Expert says lupus nephritis can be treated with lower doses of steroids

Q: Do therapeutic treatments differ between diseases that manifest as either glomerulonephritis (GN) or vasculitis?

Liz Lightstone, PhD, FRCP:Thus, vasculitis and lupus are different. There are manifestations of lupus that are vasculitis, often found in skin diseases, but vasculitis is a very different disease.

I have a few patients who switch between one or the other, but then I would treat according to the vasculitis or according to their lupus. There are overlaps in treatment, steroids are often used in both cases. Cyclophosphamide is used a lot in both, rituximab is used a lot in both, they were completely off-label in lupus. So there are similar mechanisms. It is an antibody-induced vascular disease. Drugs that target this part of the immune system will work, and they will in lupus.

So some overlap, but they’re really very different diseases. They affect quite different populations; the vasculitis population is generally much older than the lupus population. So, there are similar drugs used, but they are very different disease entities and there are guidelines on how to treat one and how to treat the other.

Q: How can community pharmacists make these new treatments better known?

Liz Lightstone, PhD, FRCP: It’s really difficult because, I guess you get to know the patient to come in and be on MMF, and he wouldn’t see the patients on cyclophosphamide. The drugs aren’t widely used yet – they’re licensed, and I suspect they’re used more in America than in the UK. But in the UK they are certainly expert prescribed, secondary tertiary care. I think the community pharmacist’s role would be more focused on encouraging compliance. You noticed someone not filling their prescriptions, I would go and start talking to them and see what the obstacles were. I was baring out when I was talking to them, “Are you taking your pills?” “What difficulties do you have? “

We have a particular problem in the UK because we have to prescribe generically when there is a generic. And what happens is that the credits change every time. This confuses patients. I think the community pharmacist has a big role to play in talking about adherence, problems with the drugs they’re taking, rather than necessarily promoting the new drug.

Q: Can other pharmaceutical drugs (not indicated for lupus nephritis) work simultaneously with current treatments?

Liz Lightstone, PhD, FRCP: Oh yeah! So what’s really important, I think, is that you don’t have to… there’s the immune system, which we attack with our drugs, but there’s everything else. And we know that if your blood pressure is poorly controlled, your kidneys will still get worse. There is really good evidence on this. We know that once you’ve had lupus nephritis you run with fewer nephrons (the functional units of the kidney), so we need to protect them. These patients would almost certainly all be on angiotensin blockade, so either an ACE inhibitor or sartan. Many of them are on low-dose aspirin, which is a pro-coagulant. And a lot of them have stomach symptoms, so they end up on PPIs. So they end up with polypharmacy. So encourage them and support them through this. And we should consider deprescribing when appropriate. Controlling blood pressure, I would say, is the most important. And the other thing that comes to mind is lipids, and especially if it’s uric protein. They have high lipid levels and may well be on statins.

Q: What would you like your nephrologist colleagues to understand about lupus nephritis?

Liz Lightstone, PhD, FRCP: I could talk about this for years. I really wish they understood that it can be treated with much lower doses and steroids. It is in the art that we will get them the best treatment and the fastest. So we need an early kidney biopsy. that you don’t miss the diagnosis, so you always paste the urine of your lupus patients. And if they start to get postural, if they start to have active sediment, send them to someone who is going to do a kidney biopsy and treat them appropriately and quickly to minimize their steroids. And even in high doses at the beginning, they can be weaned quite quickly.