Dr Liz Lightstone on Emerging Treatment Options, Unmet Needs in Lupus Nephritis

Poor response rates and overuse of steroids are 2 issues facing the therapeutic management of lupus nephritis, with improved combination therapies warranted to better meet the needs of patients with the disease, said Liz Lightstone, MBBS, PhD, FRCP, professor of renal medicine for the faculty of medicine, Imperial College London.

Lightstone spoke during a session at the American Society of Nephrology Kidney Week 2022 meeting, titled, “Treatment of Lupus Nephritis: Beyond the Usual Suspects."

Transcript

Can you speak on the emerging treatment options for patients with lupus nephritis and any potential unmet needs addressed by these therapies?

There's really been a surge in approved drugs. We have 3 new approved drugs: belimumab, voclosporin, ​​anifrolumab not so much for lupus, [inaudible] for nephritis. And there's other drugs coming in the pipeline that look optimistic, like obinutuzumab.

Where are the unmet needs with them? Well, they all improve outcomes compared to standard of care when they’re added on. So, that's a bonus. But if you look at the absolute rates of response, there's still only a percentage responding. At 2 years in the belimumab study, 30% had a complete response.

And if we think that you need a good response, you probably don't need a stringent response or a complete response; there's data to support that. But if you think about even a response where your proteinuria is down to 0.7, it's still only a proportion of patients achieving that. So, the unmet need is the failure to achieve that in a large group of patients. And if you're not achieving that, are those patients who are losing nephrons going to end up with worse renal function over time?

So, I think we still need better combinations. We still use far too much steroids. I would like treatments that get rid of steroids rather than just a rapid taper. We've improved; the voclosporin study used a really good rapid taper. But I think the main unmet needs are the problems of not responding, though I think there's a difference between trials and the real world, because we will have better responses in the real world.

The problem of side effects of treatment. And these are all add ons, so patients end up on a lot of stuff and they don't like being on a lot of stuff. Finding the optimal combination of therapy for the right patient at the right time, I think is what we need to do and we're not there yet.