Belimumab: the first US FDA approved biological therapy for systemic lupus erythematosus

Towards new avenues in the management of lupus glomerulonephritis

Renal involvement in systemic lupus erythematosus (SLE) carries substantial morbidity and mortality. Conventional immunosuppressive agents (cyclophosphamide and azathioprine) have suboptimal efficacy and substantial toxicity. Mycophenolate mofetil has emerged as an alternative agent for both induction and maintenance therapy in lupus nephritis because of its reduced gonadal toxicity, despite its failure to demonstrate superiority over cyclophosphamide in pivotal studies. The calcineurin inhibitor tacrolimus has equivalent efficacy to cyclophosphamide and mycophenolate mofetil for inducing remission of lupus nephritis. Although rituximab has shown promise in refractory lupus nephritis, combining rituximab with mycophenolate mofetil as initial therapy offers no additional benefit. Considerable interethnic variation is evident in the efficacy and tolerability of the various immunosuppressive regimens, which necessitates individualized treatment and comparison of the efficacy of new regimens across different ethnic groups. For example, low-dose combinations of tacrolimus and mycophenolate mofetil seem to be more effective than pulse cyclophosphamide as induction therapy in Chinese patients. The same regimen has also been used successfully to treat refractory proliferative and membranous lupus nephritis in patients of various ethnic groups. Finally, novel serum and urinary biomarkers are being validated for diagnosis, prognostic stratification and early recognition of flares in lupus nephritis.

Update on B-cell targeted therapies for systemic lupus erythematosus

INTRODUCTION

Systemic lupus erythematosus (SLE) is a systemic autoimmune disease characterized by flares and remission, leading to accrual of organ damage over time as a result of persistent tissue inflammation and treatment-related complications. Novel therapies aiming at better treatment response and fewer adverse effects are being tested in the pipeline.

AREAS COVERED

This review summarizes the B-cell abnormalities observed in patients with SLE, and updates recent data on the efficacy and safety of B-cell targeted therapies in the treatment of SLE. The pitfalls of clinical trial design and future directions of the development of SLE therapeutics are discussed.

EXPERT OPINION

The variability of clinical response to treatment in SLE reflects the clinical and immunological heterogeneity of the disease. The treatment plan for patients with SLE should be individualized with the aim of eradicating disease activity, preventing flares and minimizing treatment-related complications. Despite the disappointment of recent clinical trials, B-cell remains the promising target of future SLE therapies. Results from ongoing clinical trials on B-cell targeted biological agents are eagerly awaited.

Emerging biological therapies for systemic lupus erythematosus

INTRODUCTION

Systemic lupus erythematosus (SLE) is a systemic autoimmune disease with unpredictable disease course, intermingled with periods of remission and exacerbation. Current therapies for SLE are not ideal in terms of efficacy and toxicity. Although the prognosis of the disease has improved in the past decades, further improvement is hindered by the occurrence of organ damage as a result of persistent disease activity and treatment-related complications. Novel biological therapies targeting at higher treatment efficacy and fewer adverse effects are being developed.

AREAS COVERED

This review summarizes recent data on novel biological therapies for SLE. The pitfalls of clinical trial design and future directions of the development of SLE therapeutics are discussed.

EXPERT OPINION

The variable therapeutic response observed in SLE reflects the clinical and immunological heterogeneity of the disease. The treatment plan of SLE patients should be individualized, with the target of quenching out disease activity, minimizing disease flares, and treatment related morbidities. Despite the disappointment of recent clinical trials, avenues are being opened for novel agents that intervene at different levels of the pathophysiological cascade of SLE. With the availability of a new treatment armamentarium, it is hoped that the survival rate and quality of life of SLE patients can continue to improve.