It has been more than 40 years since a new drug was approved to treat lupus, but "if other novel therapies such as MMF [mycophenolate mofetil] and rituximab stabilize disease better than acute flares, the need for IVMP will continue to lessen over time," write study authors B.J. Parker of the Manchester Royal Infirmary and Ian N. Bruce, MD, of the University of Manchester, both in Manchester, England, in a review article in Lupus.1

Lower steroid pulses may be sufficient in acute SLE flares

The researchers conducted a literature review to help better define the risks and benefits of IVMP, especially against the changing SLE landscape. They found that IVMP can provide rapid suppression of inflammation for acute flares in patients with SLE, and the dosage needed may not be as high as previously thought. Although repeated daily infusions of 1 gram daily (≥ 10 mg/kg day) of IVMP is the accepted standard dose for most indications, "recent studies actually support lower-dose regimes, mainly to avoid potential adverse events," they write.

"Tailoring the use of IVMP to the individual situation therefore seems justified, and using lower dose pulses is especially warranted in the elderly and in those with other risk factors for steroid toxicity, eg, cardiac disease."

IVMP alone is less effective than regimens that include steroids plus other immunosuppressive agents such as cyclophosphamide for the long-term maintenance of SLE according to data in lupus nephritis patients, the authors conclude. "There is, however, a suggestion from long-term follow-up of lupus nephritis trials that the combination of IVMP and cyclophosphamide may further improve long-term renal outcomes over cyclophosphamide and oral steroids," they note.

Jury out on IVMP in nonrenal SLE manifestations

Limited evidence exists regarding the efficacy of IVMP in nonrenal lupus manifestations, but patients with haemolytic anemia, arthritis, and skin rashes related to lupus have shown good responses to IVMP. Neuropsychiatric lupus, however, is another story. When used alone, IVMP is not the ideal therapy for patients with neuropsychiatric lupus, the study authors write.

IVMP in practice today—and tomorrow

Jill P. Buyon, MD, a rheumatologist at the New York Hospital for Joint Diseases, in New York City, told CIAOMED that she uses IVMP "when I want a quick jolt of steroids and there may be gastrointestinal issues, so I cannot be confident of oral intake."

As for the changing therapeutic landscape of SLE, she predicted that "the next one on the block will be the Bristol-Myers Squibb extrarenal trial [of abatacept (Orencia)™], and after that will come rituximab (Rituxan™) for extra renal [manifestations]," she said. "Our fingers are crossed."