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How essential are steroids to treating lupus nephritis?

BY RANDY DOTINGA

In Toronto, kidney physician Joanne Bargman, MD, treats a young woman who has lupus nephritis and hates the steroids used to treat flares. The patient doesn’t want to take the vital corticosteroid drugs like prednisone that calm the immune system but can cause weight gain, acne and unwanted hair growth.

Without steroids, the patient is virtually doomed to kidney failure and dialysis, according to Dr. Bargman, professor of medicine at the University of Toronto and staff nephrologist at the University Health Network. But she’s unyielding, and her dangerous decision is far from unusual.

“A lot more people aren’t taking their prednisone than their physicians realize,” Dr. Bargman said, particularly young people who are sensitive about their appearance.

Scientists are eagerly searching for alternatives to the steroids whose side effects alienate so many patients. For now, however, specialists say these drugs are still the mainstays of treatment for lupus nephritis.

Among U.S. patients with systemic lupus erythematosus (SLE) in the United States, half are estimated to have lupus nephritis. During flares, corticosteroids – especially prednisone – are prescribed to prevent the immune system from attacking the kidneys and causing inflammation.

“Prednisone is still the workhorse for getting lupus nephritis under control,” said kidney physician Roger Rodby, MD, of Rush University Medical Center in Chicago. “It is usually initially taken in high doses to ‘cool down’ the inflammation, then tapered off or down to the lowest dose possible while the lupus is kept inactive – in remission – with one of the many non-steroid drug options that are used to replace it.”

But flares can return, requiring patients to repeatedly face the side effects that prednisone and other steroids can cause.

“Side effects of prednisone include, weight gain, worsening of diabetic blood sugar control, insomnia, anxiousness, stomach irritation including ulcers, and infections as well as many other less common side effects,” Dr. Rodby said.

It’s also possible for patients who take steroids to develop acne and excess hair growth. “It is hard, especially for young people, to have your body go through the transformations that steroids can cause even if they’re reversible,” Dr. Rodby said.
Dr. Bargman said there’s another challenge: Physicians often fail to explain to patients that they can face dire consequences if they don’t treat lupus nephritis.

“If someone gets cancer, they know it’s bad, and they could die. They know they’ll need chemotherapy to get rid of the cancer, and their hair will fall out,” she said. “I don’t think a lot of physicians explain to patients with lupus nephritis that what they’ve got could kill them just as much as cancer can. Before there was prednisone, people died of lupus.”

In terms of cost, prednisone is inexpensive, at least compared to other drugs. In the U.S., a daily dose of 20 mg can cost as little as 40 cents a day for those without insurance coverage. But the immunosuppressant drugs that are often combined with prednisone can cost much more, even thousands of dollars per month, although some financial assistance may be available.

Fortunately, there is good news on lupus nephritis. “We have come a long way,” Dr. Rodby said. “If it’s caught in time, and with a little luck, patients can do very well.”
Dr. Bargman puts the likelihood of relief this way: Patients who take steroids for flares are “going to get acne and become hairy and gain weight, but there will be a light at the end of the tunnel.”

What’s next? There may come a time when steroids can be avoided entirely in lupus nephritis. Researchers are exploring whether flares of the disease can be treated with combinations of non-steroid drugs that dampen the immune system like rituximab (Rituxan).

“Medicine is becoming very sophisticated with drugs that target specific biologic functions,” Dr. Rodby said. “I believe this is the future — targeting the lupus without all the side effects of steroids.”
Dr. Bargman and Dr. Rodby report no relevant disclosures.

Randy Dotinga is a freelancer with MDedge News