Reporting a Case on Good Response of Lupus Hepatitis to Mycophenolate Mofetil and Belimumab as of Lupus Exanthema to Rituximab

Reporting a Case on Good Response of Lupus Hepatitis to Mycophenolate Mofetil and Belimumab as of Lupus Exanthema to Rituximab

We face several patients with multiple forms of systemic lupus erythematosus (SLE) in clinical practise. They are generally managed to inhibit systemic inflammatory processes with immunosuppressive drugs. Corticosteroids are often first-choice medications because they work promptly, which in emergencies such as lupus nephritis or serious neuropsychiatric disorders can be helpful. 15 years ago, a 66-year-old male patient was treated mainly for cutaneous lupus erythematosus. Local corticosteroids and the following systemic immunosuppressants were administered: methylprednisolone (MP), chloroquine (removed due to retinal bleeding), cyclosporine A and azathioprine (removed due to non-response). Methotrexate and golimumab were introduced due to polyarthralgia. In spite of a strong response, due to the production of hepatitis confirmed by liver biopsy, both drugs had to be stopped (virus serological tests were negative). A marked decrease in liver enzymes could be observed early after the start of combination therapy with 1 g mycophenolate mofetil (MMF) per day orally and 10 mg/kg belimumab intravenously at weeks 0, 2, 4, followed every 4 weeks. Hydroxychloroquine (HCQ) has been added due to insufficient lupus exanthema response.
Since it was not possible to boost skin lesions after 9 months of administration of belimumab in conjunction with MMF and HCQ, biologic therapy was moved to another Bcell inhibitor, rituximab (1000 mg intravenously at weeks 0 and 2), which is considered to be used to treat patients with lupus. Surprisingly, a rapid and marked improvement in lupus exanthema was noted following the very first infusion. Since 2003, such a change has not been seen. An excellent response to MMF and belimumab may be confirmed by systemic lupus erythematosus (SLE)-associated hepatitis, as well as arthralgia. Rituximab has been shown to be more effective (in conjunction with MMF and HCQ) in treating SLE-associated skin lesions in our patients, despite the fact that these medicines are not yet approved for SLE therapy. Of course, only after treatment failure or intolerance of approved drugs can such medicines be added. We want to encourage doctors to collect data on the off-label use of immunosuppressants in connective tissue diseases in order to broaden the likelihood of care in patients that are not sensitive or difficult to respond to.

Author(s) Details

O. Psenak
Clinic of Internal Medicine III, Department of Internal Medicine III with Haematology, Medical Oncology, Haemostaseology, Infectiology and Rheumatology Paracelsus Medical University, Salzburg, Austria, Cancer Cluster Salzburg, Austria.

A.Studnicka-Benke
Clinic of Internal Medicine III, Department of Internal Medicine III with Haematology, Medical Oncology, Haemostaseology, Infectiology and Rheumatology Paracelsus Medical University, Salzburg, Austria, Cancer Cluster Salzburg, Austria.

H.Haufe
Department of Pathology, Paracelsus Medical University, Salzburg, Austria.

R.Greil
Clinic of Internal Medicine III, Department of Internal Medicine III with Haematology, Medical Oncology, Haemostaseology, Infectiology and Rheumatology Paracelsus Medical University, Salzburg, Austria, Cancer Cluster Salzburg, Austria.

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