Mycophenolate mofetil as induction and maintenance therapy for lupus nephritis: rationale and protocol for the randomized, controlled Aspreva Lupus Management Study (ALMS)

Mycophenolate mofetil for induction treatment of lupus nephritis: a systematic review and metaanalysis

OBJECTIVE

to systematically review the efficacy and safety of mycophenolic acid and mycophenolate mofetil (MMF) compared to cyclophosphamide (CYC) for the induction treatment of lupus nephritis (LN).

METHODS

medline, Embase, the Cochrane Center Register of Controlled Trials, and abstracts presented in major international conferences were searched for randomized controlled trials. The primary outcome was renal remission (complete, partial, and overall) and secondary outcomes were adverse events during study period and longterm followup data. Data were compared between groups and relative risk (RR) and 95% CI were calculated.

RESULTS

four trials of a total of 618 patients were included. MMF was not superior to CYC for renal remission (partial RR 0.94, 95% CI 0.80 to 1.12; complete RR 0.67, 95% CI 0.35 to 1.28, and overall RR 0.89, 95% CI 0.71 to 1.10). There was a significant reduction in alopecia (RR 5.77, 95% CI 1.56 to 21.38) and amenorrhea (RR 6.64, 95% CI 2.00 to 22.07) with the use of MMF compared to CYC. These results should be interpreted with caution given the width of the CI. There was no significant difference for infections, leukopenia, gastrointestinal symptoms, herpes zoster, endstage renal disease, and death among groups during study period and longterm followup data.

CONCLUSION

we could not show that MMF is superior to CYC for the induction treatment of LN. Patients treated with MMF showed reduced risk of certain side effects. MMF can be used as an alternative to CYC for the induction treatment of LN.

Combination therapy of mycophenolate mofetil and tacrolimus in lupus nephritis

Since most lupus nephritis patients have an incomplete response to mycophenolate mofetil, combination regimens may improve outcomes. Tacrolimus (FK506) has shown some benefit in lupus nephritis in small trials, and combined with mycophenolate mofetil is standard immunosuppression in transplant patients. We investigate the addition of FK506 to mycophenolate mofetil, in patients who were mycophenolate mofetil failures. All patients were part of a prospective cohort, but evaluated retrospectively. Seven lupus nephritis patients (mean age 27.1, 100% female, 42% Caucasian and 42% African American) were evaluated. Three patients had combined ISN class III and V, two ISN class IV, one ISN class V and II and one ISN class IV and V. Six were taking an ACE-inhibitor or angiotensin receptor blocker, 6 hydroxychloroquine and 5 prednisone (mean dose 11.5 mg; range 0-30 mg). Mean mycophenolate mofetil dose at time of tacrolimus addition was 2.8 g (range 2-3 g). Mean tacrolimus dose was 3.4 mg (range 2-8 mg) titrated to a mean level of 4.67 ng/dl (range 2.2-11.8 ng/dl) for a mean of duration of 16 months (range 2-54 months). Two patients continued both therapies, while five discontinued therapy. One patient achieved a complete renal remission, while three achieved partial remission with 82.9%, 77.1%, 55.3% reductions in proteinuria. Toxicity limited the use of combination therapy: diabetic ketoacidosis (one patient), pneumonia (two) and muscle pain (two). These data suggest that adding tacrolimus in patients refractory to mycophenolate mofetil might have some benefit, although complete responses were rare. Unfortunately, tacrolimus toxicity appeared to be prevalent in these systemic lupus erythematosus patients, limiting its long term use.

What's new in paediatric SLE?

Although more commonly presenting in adulthood, approximately 15-20% of systemic lupus erythematosus (SLE) cases occur before age 16 years. Unfortunately, SLE is usually more severe when presenting in childhood, and frequently involves vital organs such as the kidney. Over the past several decades, mortality rates have dropped, largely due to earlier diagnosis, improved management of the SLE and improved general medical care to reduce infection. Treatment strategies for nephritis in children is largely adopted from experience in adults, and the recent advances in therapeutic options for adults have brought new treatment to children. However, determining efficacy is difficult due to the absence of clinical trial data. Furthermore, determination of safety in a developing child or adolescent cannot be extrapolated from adult studies. As survival has improved, numerous secondary complications have emerged, including early atherosclerosis. As for adults with SLE, it is generally accepted that atherogenesis in SLE results from both disease- and treatment-related factors. Most surprising is that persons with childhood-onset SLE can develop myocardial ischaemia as early as 20-30 years of age. Better understanding of the pathogenesis and development of preventative strategies is needed to ensure that these young people do not succumb to atherosclerosis instead of to SLE.

Nonrenal disease activity following mycophenolate mofetil or intravenous cyclophosphamide as induction treatment for lupus nephritis: findings in a multicenter, prospective, randomized, open-label, parallel-group clinical trial

OBJECTIVE

To assess the effect of mycophenolate mofetil compared with intravenous pulses of cyclophosphamide on the nonrenal manifestations of lupus nephritis.

METHODS

Patients with active lupus nephritis (renal biopsy class III, IV, or V) were recruited for the study (n = 370) and treated with mycophenolate mofetil (target dosage 3 gm/day) or intravenous cyclophosphamide (0.5-1.0 gm/m(2)/month), plus tapered prednisone, for 24 weeks. Nonrenal outcomes were determined using measures of whole body disease activity, including the British Isles Lupus Assessment Group (BILAG) disease activity index, the Safety of Estrogens in Lupus Erythematosus: National Assessment (SELENA) version of the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI), and immunologic variables.

RESULTS

Both treatments were effective on whole body disease activity in the systems examined, as indicated by changes in the classic BILAG index. With either treatment, remission was induced, notably in the mucocutaneous, musculoskeletal, cardiovascular/respiratory, and vasculitis systems, and flares were rare, as measured by the SELENA-SLEDAI. Levels of complement C3, C4, and CH50 and titers of anti-double-stranded DNA antibodies were normalized after treatment with either mycophenolate mofetil or intravenous cyclophosphamide.

CONCLUSION

In addition to the efficacy of both treatments on the renal system, this analysis showed that remission could also be induced in other systems. There was no clear difference in efficacy between mycophenolate mofetil and intravenous cyclophosphamide in ameliorating either the renal or nonrenal manifestations. Mycophenolate mofetil is, therefore, a suitable alternative to cyclophosphamide for the treatment of renal and nonrenal disease manifestations in patients with biopsy-proven lupus nephritis.

Influence of race/ethnicity on response to lupus nephritis treatment: the ALMS study

Objective. To compare the efficacy and safety of mycophenolate mofetil (MMF) and intravenous cyclophosphamide (IVC) as induction treatment for lupus nephritis (LN), by race, ethnicity and geographical region.

Methods. A total of 370 patients with active Class III–V LN received MMF (target dose 3.0 g/day) or IVC (0.5–1.0 g/m²/month), plus tapered prednisone, for 24 weeks. Renal function, global disease activity, immunological complement (C3 and C4) and anti-dsDNA levels are the outcomes that were assessed in this study.

Results. MMF was not superior to IVC as induction treatment (primary objective). There were important pre-specified interactions between treatment and race (P = 0.047) and treatment and region (P = 0.069) (primary endpoint). MMF and IVC response rates were similar for Asians (53.2 vs 63.9%; P = 0.24) and Whites (56.0 vs 54.2%; P = 0.83), but differed in the combined Other and Black group (60.4 vs 38.5%; P = 0.03). Fewer patients in the Black (40 vs 53.9%; P = 0.39) and Hispanic (38.8 vs 60.9%; P = 0.011) groups responded to IVC. Latin American patients had lower response to IVC (32 vs 60.7%; P = 0.003). Baseline disease characteristics were not predictive of response. The incidence of adverse events (AEs) was similar across groups. Serious AEs were slightly more prevalent among Asians.

Conclusions. MMF and IVC have similar efficacy overall to short-term induction therapy for LN. However, race, ethnicity and geographical region may affect treatment response; more Black and Hispanic patients responded to MMF than IVC. As these factors are inter-related, it is difficult to draw firm conclusions about their importance.

Trial registration. National Institutes of Health, www.clinicaltrials.gov, registration number NCT00377637.

Limited sampling strategies for therapeutic drug monitoring of mycophenolate mofetil therapy in patients with autoimmune disease

Mycophenolate mofetil (MMF) is increasingly used for the treatment of autoimmune diseases (AID). In renal transplant recipients, it has been demonstrated that adjustment of the MMF dose according to the area under the plasma concentration versus time curve (AUC) of mycophenolic acid (MPA), the active moiety of MMF, improves clinical outcome. The aim of this study was to develop a maximum a posteriori Bayesian estimator (MAP-BE) to estimate MPA AUC(0-12) in patients with AID using a limited number of samples. The predictive performance of the MAP-BE was compared with a multiple linear regression method. Full MPA concentration versus time curves were available from 38 patients with AID treated with MMF. Nonlinear mixed-effect modeling was used to develop a population pharmacokinetic model. Patients were divided in an index and a validation data set. The pharmacokinetic model derived from the index data set was used to develop several MAP-BEs. The Bayesian estimators were used to predict AUC(0-12) in the validation data set on the basis of a limited number of blood samples. The bias and precision of these predictions were compared with those of limited sampling strategies developed with multiple linear regression. The absorption of MPA was described with 2 first-order processes with a short and a long lag time and a subsequent first-order elimination. The 2-compartment model accounted for the enterohepatic recirculation of MPA as well. Using 1-4 samples, MPA AUC(0-12) was adequately estimated by the MAP-BE. Bias (-5.5%) was not significantly different from zero, and precision was below 27%. The predictive performance of the multiple linear regression method was comparable. In conclusion, MAP-BEs were developed for the estimation of MPA AUC(0-12) in patients with AID. The predictive performance was good and comparable to those of the multiple linear regression method. Due to its flexibility with respect to sample times, the MAP-BE may be preferred over the multiple linear regression method.

Antioxidant effects of mycophenolate mofetil in a murine pleurisy model

Generation of oxidative stress induced by reactive oxygen species (ROS) and nitrogen (RNS) is believed to be a primary factor in the etiology of various inflammatory diseases. Although, the process of generation of oxygen species is a physiological event, in the inflammatory process this event is increased and produces large amounts of reactive species that leads to lipid peroxidation and to cell death. Mycophenolate mofetil (MMF) is a drug effective in protecting against chronic allograft failure and recently was introduced as an alternative for the treatment of various inflammatory diseases such as glomerulopathies, systemic lupus erythematosus and systemic vasculitis. Based on studies of the anti-inflammatory effect of MMF the aim of this study was to evaluate the effects of MMF on the inhibition of leukocytes and exudation, as well as myeloperoxidase and some antioxidant enzyme activities using carrageenan-induced pleurisy in mice. Our results showed that MMF significantly decreased leukocyte influx (P<0.01), exudation (P<0.01), superoxide dismutase (P<0.05), catalase (P<0.05), glutathione peroxidase (P<0.01), glutathione S-transferase (P<0.01) activities, levels of lipid peroxidation (P<0.05), as well as myeloperoxidase activity (P<0.05) on both phases (4h and 48h) of the inflammatory response induced by carrageenan into the mice pleural cavity. In conclusion, the anti-inflammatory effect of MMF may be, at least in part, via inhibition of ROS and/or NRS overgeneration, and consequently, attenuating the related oxidative stress.

Membranous nephropathy in systemic lupus erythematosus: a therapeutic enigma

Renal disease is a major cause of mortality and morbidity in systemic lupus erythematosus. Among the histological classes of lupus nephritis, membranous nephropathy comprises only one-fifth of all cases. Reported survival and rates of end-stage renal disease in membranous lupus nephropathy (MLN) vary considerably, because of substantial heterogeneity among the published studies. The risk of progression from MLN to renal failure is generally reduced in the absence of proliferative lesions, but patients are, nevertheless, at risk of thromboembolic complications. The optimal therapy for MLN remains elusive because of a lack of controlled trials; however, cardiovascular protection and blockade of the renin-angiotensin system should be instituted early in all patients. Mixed membranous and proliferative lupus nephritis should be treated in the same way as pure proliferative lupus nephritis. If MLN is not accompanied by proliferative lesions but is associated with clinically relevant proteinuria, renal insufficiency or failure to respond to supportive therapies, immunosuppressive treatment is indicated. Treatment options include glucocorticoids combined with azathioprine, calcineurin inhibitors or alkylating agents. The efficacy of mycophenolate mofetil in MLN remains to be confirmed. Controlled trials to compare existing immunosuppressive agents and experimental modalities such as sirolimus, rituximab and infliximab should be undertaken in the future.

Mycophenolate mofetil versus cyclophosphamide for induction treatment of lupus nephritis

Recent studies have suggested that mycophenolate mofetil (MMF) may offer advantages over intravenous cyclophosphamide (IVC) for the treatment of lupus nephritis, but these therapies have not been compared in an international randomized, controlled trial. Here, we report the comparison of MMF and IVC as induction treatment for active lupus nephritis in a multinational, two-phase (induction and maintenance) study. We randomly assigned 370 patients with classes III through V lupus nephritis to open-label MMF (target dosage 3 g/d) or IVC (0.5 to 1.0 g/m(2) in monthly pulses) in a 24-wk induction study. Both groups received prednisone, tapered from a maximum starting dosage of 60 mg/d. The primary end point was a prespecified decrease in urine protein/creatinine ratio and stabilization or improvement in serum creatinine. Secondary end points included complete renal remission, systemic disease activity and damage, and safety. Overall, we did not detect a significantly different response rate between the two groups: 104 (56.2%) of 185 patients responded to MMF compared with 98 (53.0%) of 185 to IVC. Secondary end points were also similar between treatment groups. There were nine deaths in the MMF group and five in the IVC group. We did not detect significant differences between the MMF and IVC groups with regard to rates of adverse events, serious adverse events, or infections. Although most patients in both treatment groups experienced clinical improvement, the study did not meet its primary objective of showing that MMF was superior to IVC as induction treatment for lupus nephritis.

Why can't we find a new treatment for SLE?

No new therapy for systemic lupus erythematosus has been approved. In the last decade, the development of several novel compounds has been pursued for lupus, but so far nothing has been proven to be effective. This review discusses some of the reasons why it may be so difficult to demonstrate that a novel therapy is effective for this disease. These include the complexity of the disease itself; the lack of reliable outcome measures; our limited understanding of the pathogenesis of the disease; the propensity of lupus patients to have bad outcomes and to react to medicines in unusual ways; the heterogeneity of the patient population; the unpredictable course of disease in individual patients; and the lack of reliable biomarkers. Although some of the tested targeted compounds that are apparently based on strong preclinical and mechanistic data may indeed not be effective therapies for SLE, it is hard not to believe that among the various specific agents now being tested that at least some of them should downregulate the abnormal immunoregulation characteristic of SLE, and thus be clinically effective. We need to be persistent and imaginative in identifying these effective agents and proving their efficacy so that they may be widely used in our lupus populations.

Beyond immunosuppression – challenges in the clinical management of lupus nephritis

Lupus nephritis remains the most common severe manifestation of SLE with increased risk of death and end-stage renal disease. Although, recent research has focused on the choice of immunosuppressive in its treatment, other factors, including the quality and delivery of healthcare, the management of glucocorticoids and co-morbidity are probably of more importance. There has been significant progress in induction regimes with the successful use of mycophenolate mofetil, low dose intravenous cyclophosphamide and development of sequential regimens whereby cyclophosphamide is followed by an alternative immunosuppressive. However, the attention on the day-to-day management of lupus nephritis in the clinic has merited less attention. In this article, we aim to address more widely the major issues which are encountered regularly in the long-term management of these patients. The overall goals are the reduction of mortality and preservation of renal function.

An update on the use of mycophenolate mofetil in lupus nephritis and other primary glomerular diseases

Mycophenolate mofetil (MMF) has been used successfully as an immunosuppressive medication in transplantation for over a decade. Owing to its efficacy and relatively benign adverse effect profile, its use has been investigated in the treatment of several glomerular diseases, as we describe in this Review. Of these, MMF has most extensively been studied in lupus nephritis. Randomized controlled trials have documented the value of MMF in both induction and maintenance therapy for severe lupus nephritis in several different geographic and ethnic populations, and have defined its potential toxicity. In minimal-change disease, focal segmental glomerulosclerosis and membranous nephropathy, promising but limited data on MMF treatment exist from small retrospective and prospective studies. Ongoing, larger, prospective trials, such as the NIH trial in focal segmental glomerulosclerosis, might clarify the value of MMF in the treatment of this disease. The efficacy of MMF in IgA nephropathy remains unclear, despite several small, controlled trials. Conflicting results might reflect differences in the disease process, differences in MMF metabolism, or varying responses to the immunosuppressive agent in different populations. Only through large, collaborative, controlled trials will the true role of MMF be defined for each glomerular disease.

Role of rituximab therapy in glomerulonephritis

B cell depletion with the monoclonal antibody rituximab is attracting increasing attention in systemic lupus erythematosus, vasculitis, and primary glomerulonephritis. Existing, uncontrolled data report high response rates in patients with refractory disease. If supported by the results of ongoing randomized trials, then rituximab and related B cell-depleting or -modulating drugs are likely to become a component in the future management of these disorders. Their use may improve patient outcomes by permitting more complete disease control and reduced exposure to glucocorticoid and traditional immunosuppressive drugs. The toxicity and infective risk of B cell-targeted agents in renal disease needs to be determined as well as their optimal dosing in combination with conventional agents.

[Treatment of lupus nephritis]

Lupus nephritis is a relevant source of morbidity and mortality in patients with systemic lupus erythematosus. The standard therapy of remission induction in severe lupus nephritis is based on the use of monthly intravenous cyclophosphamide. Recent data have established that the maintenance of remission in lupus nephritis can be achieved with azathioprine or mycophenolate mofetil, with less adverse effects than quarterly intravenous cyclophosphamide. In recent years, a number of controlled randomized clinical trials have been published, opening new therapeutic options in the induction of remission in lupus nephritis, such as less aggressive regimens of intravenous cyclophosphamide or mycophenolate mofetil. Further studies are needed for establishing the optimal therapy of lupus nephritis patients.