Combination therapy with pulse cyclophosphamide plus pulse methylprednisolone improves long-term renal outcome without adding toxicity in patients with lupus nephritis.
BACKGROUND
Controlled trials in lupus nephritis have demonstrated that cyclophosphamide therapy is superior to corticosteroid therapy alone. The long-term effectiveness and side-effect profiles of pulse immunosuppressive regimens warrant further study.


OBJECTIVE
To define the long-term risk and benefit of monthly treatment with boluses of methylprednisolone, cyclophosphamide, or both.


METHODS
Extended follow-up (median, 11 years) of a randomized, controlled trial.


METHODS
U.S. government research hospital.


METHODS
82 patients with proliferative lupus nephritis.


METHODS
Rates of treatment failure (defined as need for supplemental immunosuppressive therapy or doubling of serum creatinine concentration, or death) and adverse events.


RESULTS
In an intention-to-treat survival analysis, the likelihood of treatment failure was significantly lower in the cyclophosphamide (P = 0.04) and combination therapy (P = 0.002) groups than in the methylprednisolone group. Combination therapy and cyclophosphamide therapy alone did not differ statistically in terms of effectiveness or adverse events. Of patients who completed the protocol (n = 65), the proportion of patients who had doubling of serum creatinine concentration was significantly lower in the combination group than in the cyclophosphamide group (relative risk, 0.095 [95% CI, 0.01 to 0.842]).


CONCLUSIONS
With extended follow-up, pulse cyclophosphamide continued to show superior efficacy over pulse methylprednisolone alone for treatment of lupus nephritis. The combination of pulse cyclophosphamide and methylprednisolone appears to provide additional benefit over pulse cyclophosphamide alone and does not confer additional risk for adverse events.
Illei
G G
GG
Arthritis and Rheumatism Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, 10 Center Drive, Building 10, Room 9S-205, Bethesda, MD 20892, USA. illeig@exchange.nih.gov
Austin
H A
HA
Crane
M
M
Collins
L
L
Gourley
M F
MF
Yarboro
C H
CH
Vaughan
E M
EM
Kuroiwa
T
T
Danning
C L
CL
Steinberg
A D
AD
Klippel
J H
JH
Balow
J E
JE
Boumpas
D T
DT
D000328:Adult; D000893:Anti-Inflammatory Agents / Q000008:administration & dosage* / Q000009:adverse effects; D003404:Creatinine / Q000097:blood; D003520:Cyclophosphamide / Q000008:administration & dosage* / Q000009:adverse effects; D004334:Drug Administration Schedule; D004359:Drug Therapy, Combination; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007166:Immunosuppressive Agents / Q000008:administration & dosage* / Q000009:adverse effects; D007262:Infusions, Intravenous; D008181:Lupus Nephritis / Q000097:blood / Q000188:drug therapy* / Q000401:mortality; D008297:Male; D008775:Methylprednisolone / Q000008:administration & dosage* / Q000009:adverse effects; D011241:Prednisone / Q000627:therapeutic use; D012074:Remission Induction; D016019:Survival Analysis; D017211:Treatment Failure
D000893:Anti-Inflammatory Agents; D007166:Immunosuppressive Agents; D003520:Cyclophosphamide; D003404:Creatinine; D011241:Prednisone; D008775:Methylprednisolone