November 02, 2021
New Drugs and Evolving Treatment Patterns in Lupus Nephritis: How Nephrologists and Rheumatologists Are Responding Differently to New Treatment Options
Authors: Ryan Rex, Tucker Hurtado, and Jennifer Robinson
Early uptake and experience with recently approved lupus nephritis (LN) drugs belimumab and voclosporin reveal different perceptions, comfort levels, and prescribing intentions between nephrologists and rheumatologists.
Data were collected over four waves of research between February and May 2021 via online surveys with 50 US nephrologists and 50 US rheumatologists who are actively treating LN patients, followed-up with a subset of qualitative interviews.
In a notable trend, rheumatologists deem more of their LN patients as candidates for belimumab, while nephrologists increasingly see their patients as better suited for voclosporin.
Rheumatologists tend to rate belimumab higher overall than voclosporin, particularly on safety and tolerability, thanks to long term history with the product in SLE patients. Both physician types generally use belimumab as later-line therapy in mild-to-moderate LN, often to reduce steroid burden. It is generally used with at least one other advanced agent like an antimalarial, steroid, or MMF. Recently initiated patients are most often in CKD Stage 3, with proteinuria and fatigue.
Nephrologists favor voclosporin, likely due to their familiarity with the CNI drug class. Both physician-types are using voclosporin even later-line than belimumab for moderate-to-severe LN patients given the drug’s perceived quicker onset of action, efficacy, and steroid-sparing effect. Voclosporin is nearly always used concomitantly with advanced drugs like antimalarials, steroids, or MMFs. Rheumatologists appear to be initiating voclosporin most often in CKD Stage 2, while nephrologists are initiating most often in CKD Stage 3.
Rheumatologists are the leading prescribers of belimumab, and currently have a slight edge with voclosporin patient initiations as well. Nephrologists are tending to wait longer to initiate, due to cost- and risk-benefit uncertainty compared to other options like tacrolimus.
Rheumatologists currently view both drugs as a greater treatment advance than nephrologists; nephrologists believe voclosporin is more of an advance in LN treatment than belimumab.
Physician understanding and comfort level with belimumab and voclosporin MOAs are driving early use and perceptions of the two new LN drugs.