Karen Costenbader, MD: Data Supports Belimumab as Treatment in Early Lupus

In the second part of an interview with HCPLive, Karen Costenbader, MD, director of the Lupus Program at Brigham and Women’s Hospital, discusses the 2 post hoc analyses that demonstrated treatment with belimumab reduces flares and increases response rates among patients with early active systemic lupus erythematosus (SLE). Findings were presented at the 2024 European Congress of Rheumatology (EULAR) conference.

Initially, some providers may have been hesitant to use belimumab early in the treatment of lupus. However, Costenbader was not and regularly prescribed the drug early in very sick patients. The recent data shows that belimumab is equally effective when used upfront, even in patients who haven't received other immunosuppressants. This is significant because it suggests rheumatologists don't need to cycle through less effective and more toxic medications first. One of the main outcomes of this approach is a reduction in flares, which decreases organ damage and improves quality of life.

These findings are crucial for clinicians. The latest American College of Rheumatology (ACR) guidelines, which are still in development, may reflect this shift. However, the EULAR guidelines already suggest using biologics much earlier in the disease course. This paradigm shift means treating lupus aggressively from the start, especially for patients with a poor prognosis due to their presentation, autoantibodies, or organ involvement.

Belimumab has been shown to be less immunosuppressive compared to other immunosuppressants, resulting in fewer infections, which is particularly important during the COVID-19 era. And studies like these are helping providers become more comfortable using it early, supported by these data demonstrating its effectiveness in reducing flares.

Costenbader suggests rheumatologists and patients should adapt to this new approach, avoiding the traditional slow, stepwise treatment. Recognizing patients who might have a worse prognosis and treating them more aggressively from the start is crucial.

Exploring prognostic biomarkers for patients at risk of developing lupus nephritis, but who don't yet have it, is another important area of study. Belimumab is now approved for treating lupus nephritis, so starting treatment early in high-risk patients could prevent the development of nephritis.

Costenbader emphasized the safety profile of belimumab is very favorable. Unlike steroids and other immunosuppressants, belimumab has shown fewer long-term risks of infections or malignancies. With over a decade of experience using belimumab, rheumatologists can now feel more confident in its early use, knowing it works well and prevents long-term damage with a good safety profile.

Disclosures: Costenbader is associated with GSK, BMS, AstraZeneca, Cabaletta Bio, Exagen Diagnostics, Merck, and Gilead.