Background/Purpose: Current pharmacotherapy for systemic lupus erythematosus (SLE) and lupus nephritis (LN) includes combinations of nonsteroidal anti–inflammatory drugs (NSAIDs), antimalarials (AMs), glucocorticoids (GCs), and cytotoxic immune modulators (IMs). The objective of this analysis was to evaluate the use of therapies for SLE and LN in the United States and to compare these with current treatment recommendations for non–nephritis SLE (NNSLE) and LN issued by the American College of Rheumatology (ACR).

Methods:  Data were extracted from the Adelphi Real World Lupus Disease–Specific Programme^®, a cross–sectional survey of 50 rheumatologists and 25 nephrologists conducted (December 2009–May 2010) in the United States. Each physician completed a comprehensive form regarding his or her 5 most recent consulting lupus patients. Treatment history, current therapy, and other data were summarized and compared with the ACR treatment guidelines.

Results: Physicians reported data for 375 patients: 168 with NNSLE (164 treated by rheumatologists), and 207 with LN (121 treated by nephrologists). The 1999 ACR guidelines recommend the use of NSAIDs for milder NNSLE, AMs for skin and joint manifestations, corticosteroids for moderate to severe disease, and cytotoxic IMs for severe NNSLE. Survey results revealed that the proportion of all NNSLE patients (n=168) receiving NSAIDs, AMs, GCs, or IMs was 29%, 69%, 54%, and 39%, respectively. The predominant induction treatments prescribed by rheumatologists for NNSLE patients (n=164) were AMs alone (27%) or the following ± AMs: GCs (27%), IMs (15%), or IMs plus GCs (16%). In 2012, the ACR published their first set of guidelines for treating LN, recommending AM treatment for all patients, and IM plus GC induction therapy for LN classes III, IV, and V (categorized based on renal biopsy). Survey results did not include patients’ renal pathology classifications; however, the data revealed that the proportion of all LN patients (n=204) receiving AMs, GCs, NSAIDs, and IMs was 42%, 76%, 17%, and 67%, respectively. However, only 20% of LN patients (n=121) treated by nephrologists began therapy with IMs plus GCs during the survey; more LN patients began IMs without GCs (28%), or GCs without IMs (27%). The proportion of LN patients receiving IMs plus GCs increased with second and third therapies to 42% and 33%, respectively. The ACR guidelines suggest that rituximab may be used in some LN patients after 6 months of treatment with IM plus GCs if nephritis worsens or does not improve. Within the overall LN patient group (n=204), 1.5% received biologic therapy at some point.

Conclusion: Real–world surveys of NNSLE and LN treatment by rheumatologists and nephrologists revealed some differences between current ACR treatment guidelines and real–world clinical practice in the United States. Differences from guidelines were minor for NNSLE and more pronounced for LN, possibly due to publication of LN guidelines (2012) after the survey period (2009–2010). However, the guidelines summarized current expert recommendations rather than proposing radical changes in therapy, and therefore the potential gaps in both NNSLE and LN treatment warrant further investigation.

ACR Meeting Abstracts - https://acrabstracts.org/abstract/a-real-world-survey-of-clinical-practice-among-rheumatologists-and-nephrologists-in-the-united-states-reveals-differences-in-care-of-non-nephritis-systemic-lupus-erythematosus-and-lupus-nephritis-as-c/