Efficacy and Safety of Belimumab in Lupus Nephritis Patients: A Real-World Observational Study in China

Background

This study aimed to describe disease activity, clinical outcome, and overall patterns of lupus nephritis care in patients who received belimumab in a real-world clinical setting in China.

Materials and Methods

This observational cohort study included lupus nephritis patients who received belimumab as adjunct therapy. We deeply investigated the characteristics of those patients including clinical response to belimumab and safety.

Results

All 61 lupus nephritis patients were included with a median follow-up period of 9 months (6, 19). Prevalence of proteinuria (52.5-24.6%) and hematuria (33.3-9.8%) was decreased with a stable level of eGFR at last visit. The percentage of patients achieved complete or partial renal response increased from 47.5% to 78.7% and the proportion of complete or partial renal response in patients with proliferative lupus nephritis was higher than those with membranous lupus nephritis (75 vs. 50%) at last visit. The median SLEDAI score decreased from 6 to 2, and there was an increase in patient of LLDAS from 17 to 33 at last visit. A notable dose reduction was seen for glucocorticosteroid dose, with a median change from 10 to 5 mg/d. The proportion of patients receiving >7.5 mg/d steroids reduced from 52.5% at baseline to 23.0% at last visit. The discontinuation of belimumab was rare (3/61) for drug-induced fever, hyperthyroidism, and uveitis.

Conclusions

Lupus nephritis patients with belimumab demonstrated improvements in clinical response and a reduction in glucocorticosteroids, which provided evidence of effectiveness and safety in real-world clinical practice in China.

Steroid sparing in vasculitis: Myth or reality?

Glucocorticoids are the cornerstone of therapy for all forms of vasculitis. However, glucocorticoid treatment carries with it the risk of glucocorticoid toxicity. Recent research efforts in vasculitis have emphasized investigation into strategies that reduce glucocorticoid exposure. These strategies include the adoption of rapid-acting steroid-sparing agents, reduced-dose glucocorticoid induction regimens, the early introduction of steroid-sparing agents for maintenance therapy, and the extension of maintenance therapy to minimize glucocorticoid exposure associated with disease relapse. These are critical advances to move us toward the goal of glucocorticoid-free treatment of vasculitis. The evidence supporting each of these strategies and directions for future research are explored.

Chronic low-dose intravenous immunoglobulins as steroid-sparing therapy in myasthenia gravis

INTRODUCTION

Intravenous immunoglobulin (IVIg) has been proven beneficial in myasthenic crisis, but their role as maintenance therapy is unclear. The aim of this study was to determine if maintenance therapy with low-dose IVIg improves clinical outcome and may be used as a steroid-sparing agent in myasthenia gravis (MG).

METHODS

We retrospectively reviewed charts of all MG patients treated with IVIg from January 2006 to December 2019. Long-term treatment response to IVIg was assessed by improvement in the Myasthenia Gravis Foundation of America (MGFA) clinical classification scale as primary end point, as well as the ability to reduce the time-weighted average required dose of prednisone as secondary end-point, in a follow-up period of 36 months.

RESULTS

109 patients were treated with IVIg. The mean follow-up time was 34.03 ± 5.5 months. Sixty-seven patients (61.4%) responded to therapy with at least one-point improvement of the MGFA scale. There was no statistical difference in demographic and clinical characteristics between IVIg responders and non-responders. The mean prednisone dose decreased significantly from 33.1 ± 14.5 mg at baseline to 7.2 ± 7.8 mg after 36 months of IVIg treatment (P < 0.0001), with the greatest effect after 6 months (33.1 ± 14.5 mg Vs. 17.9 ± 11.7 mg; P < 0.0001). In the follow-up period of 36 months, most patients (92.5%) remained clinically and pharmacologically stable under chronic IVIg treatment.

CONCLUSION

This retrospective study demonstrates that chronic low-dose IVIg treatment in patients with MG improves clinical outcomes and has a prolonged and significant steroid-sparing effect over a period of 3 years.

Clinical and therapeutic features of pediatric Vogt-Koyanagi-Harada disease

PURPOSE

To analyze clinical, therapeutic and prognostic features of pediatric Vogt-Koyanagi-Harada (VKH) disease.

MATERIAL AND METHODS

This retrospective study included 16 eyes of 8 children diagnosed with VKH disease followed at a teaching hospital over a 10 year period. Diagnosis was based on the revised criteria of VKH disease. All data were analyzed using SPSS® software.

RESULTS

There were 62.5% girls and 37.5% boys. The mean age (years) was 14.6±4.4. The mean follow-up (months) was 38.7±28.7. The mean initial visual acuity (VA) (LogMAR) was 1.4 with 68.8% of eyes presenting with severe visual loss at admission. The median time (days) required for resorption of the serous retinal detachment was 10 [8.25-25]. Extraocular signs were present in 62.5% of cases. The mean time until initiation of treatment was 25.6 days. 62.5% of patients received corticosteroids alone, and 37.5% of patients received a combination of corticosteroids and immunosuppressive therapy. Final VA was 0.4 [0.1-2.3]. In our study, the time until consultation, low initial VA and recurrences were statistically associated with severe visual loss (P≤0.05).

CONCLUSION

Life expectancy in pediatric cases of VKH disease justifies the early initiation of immunosuppressive treatment or even biological therapy to achieve better steroid sparing and preserve visual function.

Knowing when to use steroids, immunosuppressants or biologics for the treatment of sarcoidosis

Introduction: Care of patients with sarcoidosis requires familiarity with its natural history as well as of various immunosuppressants employed in its treatment. We would like to share our approach to management based on our experience and understanding of the relevant literature.Areas covered: Asymptomatic patients with pulmonary sarcoidosis ought to be managed conservatively. Systemic sarcoidosis with burdensome symptoms usually responds to corticosteroids, but one needs to consider the risk of long-term steroid toxicity as well as relapse. Rapidly tapering steroids can decrease cumulative exposure without compromising efficacy. Steroid-sparing anti-sarcoidosis (SSAS) agents take longer to act and are associated with unique but mostly reversible toxicities. Used judiciously and with careful monitoring, they effectively suppress granulomatous inflammation. Patients intolerant of or failing to improve with a particular drug can be switched to another, and occasionally combination therapy with two SSAS agents might prove effective. A small proportion of patients are refractory, but often achieve control and sometimes remission with stepping up to biologic therapy.Expert opinion: Adopting a strategy of early SSAS therapy ought to effectively control sarcoidosis and avoid harm from prolonged corticosteroid dosing.

[The pentoxifylline, a corticosteroid sparing in the treatment of sarcoidosis: A case report]

INTRODUCTION

The pentoxifylline seems to have some effects on immune cells by inhibiting tumor necrosis factor alpha (TNFα). Its role as a sparing corticosteroids in the treatment of sarcoidosis remains to be defined.

CLINICAL CASE

We present the case of a patient with sarcoidosis corticodependent despite the use of azathioprine. It was finally improved clinically, functionally and by a thoracic computed tomography with addition of pentoxifylline.

CONCLUSION

When the tolerance of the pentoxifylline is good and there is not a bleeding risk, the benefit-risk in the long term might be interesting in some patients with sarcoidosis corticodependent.

Steroid sparing effects of doxofylline

Glucocorticosteroids are widely used in the treatment of asthma and chronic obstructive pulmonary disease (COPD). However, there are growing concerns about the side effect profile of this class of drug, particularly an increased risk of pneumonia. Over the last two decades there have been many attempts to find drugs to allow a reduction of glucocorticosteroids, including xanthines such as theophylline. Use of xanthines has been shown to lead to a reduction in the requirement for glucocorticosteroids, although xanthines also have a narrow therapeutic window limiting their wider use. Doxofylline is another xanthine that has been shown to be of clinical benefit in patients with asthma or COPD, but to have a wider therapeutic window than theophylline. In the present study we have demonstrated that doxofylline produces a clear steroid sparing effect in both an allergic and a non-allergic model of lung inflammation. Thus, we have shown that concomitant treatment with a low dose of doxofylline and a low dose of the glucocorticosteroid dexamethasone (that alone had no effect) significantly reduced both allergen-induced eosinophil infiltration into the lungs of allergic mice, and lipopolysaccharide (LPS)-induced neutrophil infiltration into the lung, equivalent to a higher dose of each drug. Our results suggest that doxofylline demonstrates significant anti-inflammatory activity in the lung which can result in significant steroid sparing activity.

Risk factors and outcomes of delayed graft function in renal transplant recipients receiving a steroid sparing immunosuppression protocol

AIM

To analyse the risk factors and outcomes of delayed graft function (DGF) in patients receiving a steroid sparing protocol.

METHODS

Four hundred and twenty-seven recipients of deceased donor kidney transplants were studied of which 135 (31.6%) experienced DGF. All patients received monoclonal antibody induction with a tacrolimus based, steroid sparing immunosuppression protocol.

RESULTS

Five year patient survival was 87.2% and 94.9% in the DGF and primary graft function (PGF) group respectively, P = 0.047. Allograft survival was 77.9% and 90.2% in the DGF and PGF group respectively, P < 0.001. Overall rejection free survival was no different between the DGF and PGF groups with a 1 and 5 year rejection free survival in the DGF group of 77.7% and 67.8% compared with 81.3% and 75.3% in the PGF group, P = 0.19. Patients with DGF who received IL2 receptor antibody induction were at significantly higher risk of rejection in the early post-transplant period than the group with DGF who received alemtuzumab induction. On multivariate analysis, risk factors for DGF were male recipients, recipients of black ethnicity, circulatory death donation, preformed DSA, increasing cold ischaemic time, older donor age and dialysis vintage.

CONCLUSION

Alemtuzumab induction may be of benefit in preventing early rejection episodes associated with DGF. Prospective trials are required to determine optimal immunotherapy protocols for patients at high risk of DGF.

Treatment of Sarcoidosis

Treatment of sarcoidosis is not required in all patients with the diagnosis. The decision to treat and the strategy for how to treat usually require input and shared decision making by the patient. Some common consequences of sarcoidosis are not caused by granulomatous inflammation, but may be the dominant disease manifestation and should be actively considered when formulating a treatment plan. The medication regimen should be tailored to each patient. Steroid-sparing medications should be prescribed early as part of a long-term strategy.

Maintenance of remission with infliximab in inflammatory bowel disease: Efficacy and safety long-term follow-up

AIM: To evaluate the safety and efficacy of a long-term therapy with infliximab in Crohn’s disease (CD) and ulcerative colitis (UC) patients retrospectively.

METHODS: The medical charts of 50 patients (40 CD and 10 UC), who received after a loading dose of 3 infliximab infusions scheduled re-treatments every 8 wk as a maintenance protocol, were reviewed.

RESULTS: Median (range) duration of treatment was 27 (4-64) mo in CD patients and 24.5 (6-46) mo in UC patients. Overall, 32 (80%) CD and 9 (90%) UC patients showed a sustained clinical response or remission throughout the maintenance period. Three CD patients shortened the interval between infusions. Eight (20%) CD patients and 1 UC patient underwent surgery for flare up of disease. Nine out of 29 CD and 4 out of 9 UC patients, who discontinued infliximab scheduled treatment, are still relapse-free after a median of 16 (5-30) and 6.5 (4-16) mo following the last infusion, respectively. Ten CD patients (25%) and 1 UC patient required concomitant steroid therapy during maintenance period, compared to 30 (75%) and 9 (90%) patients at enrolment. Of the 50 patients, 16 (32%) experienced at least 1 adverse event and 3 patients (6%) were diagnosed with cancer during maintenance treatment.

CONCLUSION: Scheduled infliximab strategy is effective in maintaining long-term clinical remission both in CD and UC and determines a marked steroid sparing effect. Long-lasting remission was observed following infliximab withdrawal.