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Cyclophosphamide Versus Mycophenolate Versus Rituximab in Lupus Nephritis Remission Induction

A Historical Head-to-Head Comparative Study

Goswami, Rudra Prosad, DM; Sircar, Geetabali, MD; Sit, Hiramanik, MD; Ghosh, Alakendu, DNB; Ghosh, Parasar, DM

JCR: Journal of Clinical Rheumatology: January 2019 - Volume 25 - Issue 1 - p 28–35
doi: 10.1097/RHU.0000000000000760
Original Articles

Objective We report comparative efficacy between high-dose cyclophosphamide (HDCyC), low-dose cyclophosphamide (LDCyC), mycophenolate mofetil (MMF) and rituximab in patients with lupus nephritis (LN).

Methods We analyzed comparative efficacy of 4 induction regimens of biopsy-proven LN: LDCyC: 500 mg fortnightly, HDCyC: 750 to 1200 mg monthly, MMF: 1.5 to 3 g/d, and rituximab. Outcomes of 4 groups were analyzed at the sixth month.

Results Among a total 222 patients, 26 received LDCyC (3-g total dose), 113 received HDCyC (mean, 5.1-g total dose), 61 received MMF (mean, 2.2 g/d), and 22 received rituximab (mean, 1.9-g total dose). Relapsing/refractory LN was 11 in HDCyC, 1 in LDCyC, 10 in MMF, and 14 in the rituximab group. Overall 16.2% had no improvement of proteinuria, 18% had partial response, and 65.8% (146/222) had complete response. Renal response (RR) was higher in HDCyC (90.3%) and rituximab (90.9%) groups compared with LDCyC (73%) and MMF (72%) groups. Rituximab was effective in relapsing disease (100% RR). Infection was highest with the HDCyC, followed by LDCyC and rituximab (p = 0.15), whereas the MMF group had a higher incidence of gastrointestinal adverse effects (p < 0.001). The following predictors of RR were identified: rituximab (odds ratio [OR], 20.4; 95% confidence interval [CI], 1.9–215.7; p = 0.012), renal Baseline Systemic Lupus Erythematosus Disease Activity Index at baseline (OR, 0.86; 95% CI, 0.75–0.99; p = 0.034), and duration of disease (OR, 0.98; 95% CI, 0.97–0.99; p = 0.009).

Conclusions High-dose cyclophosphamide and rituximab were the most effective therapeutic strategies in patients with LN, especially in the Indian context. Rituximab was highly effective in relapsing disease.

From the Department of Rheumatology, Institute of Post Graduate Medical Education and Research, Kolkata, India.

The authors declare no conflict of interest.

Author contributions: Research idea and study design: R.P.G., G.S., A.G., P.G.; data acquisition: R.P.G., G.S., H.S., P.G.; data analysis: R.P.G.; interpretation: R.P.G., G.S., P.G., A.G.; statistical analysis: R.P.G.; supervision or mentorship: R.P.G., H.S.

Correspondence: Rudra Prosad Goswami, DM, SR, Abhyudoy Housing, Flat 18/14, ECTP, Ph IV, Type B, EM Bypass, Kolkata 700107, West Bengal, India. E-mail:

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