Treatment of Rare SARDS: Systemic Lupus Erythematous and Idiopathic Inflammatory Myopathies - Episode 4
Comprehensive insight on the treatment armamentarium for systemic lupus erythematous and nuances in selecting optimal therapy.
W. Hayes Wilson, MD: Let’s talk about treatment options for systemic lupus erythematosus, and when we’re looking at treatment options, are there guidelines, or factors that you consider when you first start treating a patient?
Kostas N. Botsoglou, MD: As we know, the cornerstone for a patient with lupus is hydroxychloroquine, all patients have been on it or are currently on it. But of course, we have corticosteroids or prednisone, which our mentor Michelle Petri, [MD, MPH,] says the P for prednisone stands for poison. Many of our patients are on a form of corticosteroids, many can be on it indefinitely. But then we move on to our DMARDs [disease-modifying antirheumatic drugs], or drugs like azathioprine and methotrexate, and so forth. Basically, it depends on how severe their disease is, the organ or organs involved, and we go off the therapeutic ladder when we assess our patients.
W. Hayes Wilson, MD: You mentioned that Michelle doesn’t like prednisone, I guess none of us do. The American College of Rheumatology says that 5 mg a day or less is safe, but lot of times we need to use higher doses than that. In addition to the oral corticosteroids and even intravenous corticosteroids that we use in our really sick patients, there is repository corticotropin injection, either IM [intramuscular] or subQ [subcutaneous]. When would you use that?
Kostas N. Botsoglou, MD: I’ve had some great success with repository corticotropin, particularly in my patients who have been unable to get below a threshold of prednisone. Typically, my cut-off, although 5 mg is preferred, if I cannot get them below 10 mg, and they are on other DEMARD therapies, they are on other immunosuppressants, or they keep requiring additional corticosteroid due to flare-ups, I have seen success with repository corticotropin, with the goal to reduce or eliminate their need for prednisone. I have seen some good outcomes in my patient population.
W. Hayes Wilson, MD: I’ve had similar success, and as we mentioned earlier we practice with our wives, and everyone once in a while my wife will come in and say, “I’ve sort of gotten to the end of my line, I’ve got this patient, she has these central nervous system features, and I have tried a lot of different things and I don’t know what to try.” I’ll say, “The repository corticotropin injection has neurological effects as well, it works on microglial cells and works in the central nervous system and has central nervous system indications, so that might be something to consider.” It’s one of those things that we use, we sometimes don’t think of it as first line. Of course, for the first line we think of the oral corticosteroids and the intravenous corticosteroids, but the repository corticotropin injection is there and helpful as well. We should always remember, that’s one of the arrows in our quiver.
Kostas N. Botsoglou, MD: Absolutely, and not to forget, it does have immunomodulatory properties.Many of our colleagues might mistake it as solely a form of corticosteroid itself, but there are data showing that even after withdrawing the medication, there are sustained effects for up to 12 weeks after. It’s more than just steroid. Yes, it is another tool in our small toolbox for these rare conditions.
W. Hayes Wilson, MD: That’s important, and we talked about central nervous system effects, but it has effects on other organ systems as well. You may have direct effects on myocytes, which we will talk about a bit in a minute. You’ve already mentioned hydroxychloroquine and chloroquine, do you use chloroquine much?
Kostas N. Botsoglou, MD: I have never used chloroquine; everyone suggests hydroxychloroquine. Unfortunately, with the shortage last year, we had to get more creative when I couldn’t obtain it.
W. Hayes Wilson, MD: I have used chloroquine myself, but only for malarial prophylaxis in Central America. But there are other immunosuppressive agents that you mentioned, mycophenolate, azathioprine, cyclophosphamide, and rituximab. Any comments you want to make on those?
Kostas N. Botsoglou, MD: Depending on if there is pulmonary involvement, ILD [interstitial lung disease], or lupus nephritis, we will select an agent like CellCept or azathioprine. For my more active and more aggressive patients, we will use rituximab. I haven’t used too much cyclophosphamide since my fellowship days, but rituximab has been a good option for our patients as well. I have seen improvements with using the RA [rheumatoid arthritis] dosing for it.
W. Hayes Wilson, MD: It’s exciting now that we have come out with new medicines that are useful in, for instance, lupus nephritis. Monoclonal antibodies are exciting in all of our diseases, but it’s nice to have steroid-sparing agents as you mentioned. We want to minimize as much as possible the steroidogenic effects, and we want to make sure we are careful about the way that we look at the potential adverse effects of our medicine. I know this probably happens to you as well, whenever I want to prescribe a medication for a patient, the first thing they say to me is, “What’s it going to do to me?” I always say, “It’s going to make you better I hope.” They say, “No, no, what kind of adverse effect am I going to have?” They are always worried about adverse effects. I was wondering how you tackle that question when you talk about disease-modifying antirheumatic drugs?
Kostas N. Botsoglou, MD: That’s a great question, and it’s a common conversation we have every day in our practice because many of our visits, the majority of time is spent educating our patients just on the disease and what our treatment goals are. And many times, is it the disease or is it the drug that is causing the adverse effects? I tell all my patients that the benefits must outweigh the risks when we select an agent. I would not select an agent that would be more detrimental than helpful. The conversation depends on the agent, if you're on glucocorticoids, our goal is to use the lowest effective dose because glucocorticoids can be your best friend and your worst enemy. But for some of our other DMARDs, these are more chronic treatments, and we need to advise them of the precautions that we need to take, to monitor for any toxicities. They need to be diligent in doing their blood work, keeping their appointments, and follow up with the respective specialists, if necessary. There is a lot of education going on, even for our stable patients.
W. Hayes Wilson, MD: Yes, I completely agree. And for instance, for somebody who is on cyclophosphamide, we want them to be hydrated. We might use mesna to decrease adverse effects. But of course, I'm sure you do this as well, people on the other DMARDs, the azathioprine, methotrexate, mycophenolate, need regular laboratory tests. We have agreements that we go into with ourpatientsto make sure that they are following up with us and following up with their labs. Yes, I completely agree.
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Transcript edited for clarity.