Rapidly deteriorating kidney function and/or severe LN on biopsy (eg, extensive crescents, capillary necrosis) | In such cases, some clinicians prefer a regimen that includes high-dose IV CYC. However, data to support this approach in this patient population are very limited as such patients were generally excluded from clinical trials. |
Higher proteinuria (≥3 g/day) | Such patients may benefit from triple therapy with glucocorticoids plus MMF and a CNI (voclosporin, tacrolimus, or cyclosporine). By contrast, belimumab may not be as effective in such patients. |
Difficulty with adherence | In such patients, regimens involving IV therapies (eg, cyclophosphamide, belimumab, rituximab) may be preferable to those without IV therapies. |
Extrarenal manifestations | The presence of extrarenal manifestations of SLE may influence the selection of therapy for LN. As examples: - Belimumab has been found to be helpful for patients with severe or refractory arthritis; thus, triple therapy with belimumab, glucocorticoids, and either MMF or CYC might be preferred over alternative regimens in that situation.
- Regimens for LN that include IV CYC may be preferable in patients who have certain severe, potentially life-threatening manifestations of SLE (eg, inflammatory or demyelinating central nervous system disease, severe diffuse alveolar hemorrhage, and/or severe myocarditis).
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