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Comparison of low-dose intravenous cyclophosphamide with oral mycophenolate mofetil in the treatment of lupus nephritis
clinical trial
http://www.kidney-international.org © 2015 International Society of Nephrology
Comparison of low-dose intravenous cyclophosphamide with oral mycophenolate mofetil in the treatment of lupus nephritis Manish Rathi1, Ajay Goyal1, Ajay Jaryal1, Aman Sharma2, Pramod K. Gupta3, Raja Ramachandran1, Vivek Kumar1, Harbir S. Kohli1, Vinay Sakhuja4, Vivekanand Jha1 and Krishan L. Gupta1 1
Department of Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India; 2Department of Internal Medicine, Rheumatology Wing, Post Graduate Institute of Medical Education and Research, Chandigarh, India; 3Department of Biostatistics, Post Graduate Institute of Medical Education and Research, Chandigarh, India and 4Department of Nephrology and Renal Transplant Surgery, Max Super Speciality Hospital, Mohali, India
No previous study has compared mycophenolate mofetil (MMF) with low-dose cyclophosphamide (CYC) in the treatment of lupus nephritis (LN). To do so, we recruited patients with LN (class III, IV, or V) and randomized them to receive either low-dose CYC or oral MMF. Those with crescentic LN, a serum creatinine over 265 μmol/l, and neurological or pulmonary lupus were excluded. MMF was prescribed at daily doses of 1.5–3 g for 24 weeks, while CYC was administered as six fortnightly infusions of 500 mg each. All patients received three methylprednisolone injections, followed by oral corticosteroids. Maintenance therapy with azathioprine and low-dose corticosteroid was started at end of induction therapy. The primary end point was treatment response at 24 weeks, while secondary end points were complete remission, Systemic Lupus Erythematosus Disease Activity Index and adverse events. Of the 173 patients recruited, 100 were equally randomized to receive either CYC or MMF. Baseline characteristics were similar, except for higher 24 h proteinuria in the CYC group. At 24 weeks, 37 patients in each group achieved the primary end point. The complete remission rate was 50% in CYC and 54% in MMF group. Gastrointestinal symptoms were significantly more frequent in patients receiving MMF (52 vs. 4%). However, other adverse events were similar. Thus, low-dose intravenous CYC is comparable in safety and efficacy to oral MMF in the induction treatment of less severe LN.
Lupus nephritis (LN) is a serious complication of systemic lupus erythematosus (SLE) and needs to be treated with toxic immunosuppressive therapy.1–3 Attempts have been made to reduce toxicity by altering the route of administration or dosage of drugs or substituting them with less toxic alternatives. Cyclophosphamide (CYC), the traditional standard treatment of LN,4–7 carries significant dose-dependent short- and long-term toxicity, prompting investigators to explore the effectiveness of lower doses.8,9 The Euro–lupus nephritis trial (ELNT) demonstrated a comparable efficacy and safety profile of low-dose CYC to the high-dose National Institute of Health (NIH) regimen.10 Mycophenolate mofetil (MMF), a selective lymphocyte antiproliferative agent, has also emerged as a promising drug for treatment of LN. Recent studies have established MMF as a safe and an effective alternative to full-dose CYC for LN.11–16 Both the ELNT regimen and MMF have been used successfully in subjects with less severe LN with the advantage of reduced toxicity. However, it is not clear whether low-dose ELNT CYC or oral MMF is superior, because these have not been compared in a head-to-head trial. The present study was aimed at comparing the efficacy and safety of these treatment options in subjects with less severe LN.
Kidney International advance online publication, 21 October 2015; doi:10.1038/ki.2015.318
A total of 173 subjects fulfilling the inclusion criteria were screened during the study period. Of these, 100 were randomized to receive either low-dose intravenous CYC (n = 50) or oral MMF (n = 50). The reasons for exclusion of 73 subjects are summarized in Figure 1. The baseline characteristics of the study population are described in Table 1. There were 8 males and 92 females in the cohort. All the baseline characteristics were comparable between the two groups, with the exception of urine protein/ creatinine ratio (uPCR), which was significantly higher in the CYC group (3 vs. 2.2 in the MMF group, P = 0.02). The clinical presentation, organ involvement, and the distribution
KEYWORDS: cyclophosphamide; lupus nephritis; mycophenolate mofetil
Correspondence: Manish Rathi, Department of Nephrology, Post Graduate Institute of Medical Education and Research, Sector-12, Chandigarh 160 012, India. E-mail: [email protected] Received 22 May 2015; revised 4 August 2015; accepted 20 August 2015 Kidney International
RESULTS
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M Rathi et al.: Low-dose intravenous CYC versus oral MMF in lupus nephritis
Screened (n = 173) Biopsy diagnosis of lupus nephritis class III/IV/V
Reasons for exclusion (n = 73) Crescentic LN (n = 24) Serum creatinine > 265.0 µmol/l (n = 16) Previously received CYC or MMF (n = 21) Refused consent (n = 5) Pregnant (n = 1) CNS or pulmonary lupus (n = 6)
Randomized (n = 100)
50: Low fixed dose intravenous CYC
50: Oral MMF
Withdrawn (n = 9)
Withdrawn (n = 8)
Death (n = 2) Adverse events (n = 3) Lost to follow-up (n = 3) Deviated from protocol (n = 2)
Death (n = 5) Adverse events (n = 1) Lost to follow-up (n = 2)
Completed 24 weeks of follow-up (n = 41)
Completed 24 weeks of follow-up (n = 42)
Figure 1 | Flow chart depicting patient enrollment and follow-up. CNS, central nervous system; CYC, cyclophosphamide; LN, lupus nephritis; MMF, mycophenolate mofetil.
of various biopsy classes were also similar in the two groups (Table 1). Of the 50 subjects in CYC group, 40 (80%) received the target cumulative dose of 3 g, whereas 48 (96%) subjects in the MMF group received the target dose of 1.5–3.0 g/day with a mean dose of 2.22 ± 0.39 g/day. Study outcomes
The primary, as well as the secondary outcome measures were assessed at 12 and 24 weeks according to the original assigned groups (intention-to-treat (ITT) analysis), as well as the completed follow-up groups (as-per-protocol (APP) analysis). The rates of treatment response and complete renal remission at these time points as per the two analyses are summarized in Table 2. The serum creatinine, serum albumin, uPCR, and the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) score improved significantly in both the groups over the study period, and there were no differences between the treatment groups (Figure 2). The median (interquartile 2
range) SLEDAI score at the end of 24 weeks was 6 (4, 8) and 4 (2, 6) in the CYC and the MMF group, respectively (P = 0.17). The delta estimated glomerular filtration rate improved by 14.0 ml/min (95% confidence interval: 4.3, 23.7) in the CYC group (P = 0.005) and 16.5 ml/min (95% confidence interval: 4.9, 28.0) in the MMF group (P = 0.006) over 24 weeks, with no significant intergroup difference (P = 0.74). The anti-double– stranded deoxyribonuclease antibody positivity rate declined from 90 to 58% in the CYC group (Po0.001) and 88 to 62% in the MMF group (P = 0.01) over 24 weeks, with no significant intergroup difference (P = 0.84). The prevalence of hypocomplementemia (low C3 or C4) declined from 92 to 32% in the CYC group (Po0.001) and from 76 to 40% in the MMF group (Po0.001), without any significant difference between the two treatment groups (P = 0.53). The response rate for different pathological classes of LN according to the treatment group was also analyzed. Using ITT analysis, the treatment response rate in class IV was 76.7% in the CYC group compared with 70.4% in the MMF group (P = 0.59); in class III it was 66.7% in the CYC group Kidney International
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M Rathi et al.: Low-dose intravenous CYC versus oral MMF in lupus nephritis
compared with 90.9% in the MMF group (P = 0.21), whereas in class V it was 71.4% in the CYC group compared with 66.7% in the MMF group (P = 0.79). The treatment response rate did not differ significantly in the two treatment groups even after the exclusion of subjects with pure class-V LN (75.0 and 76.3% in CYC and MMF groups, respectively, P = 0.91). The median time to response was 10 (4, 20) weeks in the CYC group as compared with 12 (6.5, 12) weeks in the MMF group (P = 0.90). Similarly, there was no difference in the median time to complete remission in the two groups (9 (7.5, 21) weeks and 12 (8, 20) weeks in the CYC and MMF group, respectively; P = 0.88). The probability of response, as well as remission was also not different between the treatment groups Figure 3). Adverse events
During the study period, 25 (50%) subjects in the CYC group and 32 (64%) subjects in the MMF group reported at least one adverse event (P = 0.32). The reported adverse events are Table 1 | Baseline characteristics of the study population Variable Gender, n (%) Female Male
CYC
MMF
n = 50
n = 50
45 (90) 5 (10)
47 (94) 3 (6)
P-value
0.715
Kidney biopsy class, n (%) III/III+V 6 (12) 11 (22) IV/IV+V 30 (60) 27 (54) V 14 (28) 12 (24) Age (years) 30.6 ± 9.5 28.3 ± 9.5 2 Body mass index (kg/m ) 22.3 ± 3.1 22.5 ± 3.6 18.1 ± 6.2 17.9 ± 5.6 SLEDAI scorea Anti-dsDNA positive, n (%) 45 (90) 44 (88) Hypocomplementemia 46 (92) 38 (76) (↓ C3 or C4), n (%) Hemoglobin (g/l) 89 ± 18 94.4 ± 24 Leukocyte count (×109/l)b 6.5 (4, 8) 6.8 (4.8, 9.1) 9 b Platelet count (×10 /l) 143.5 (108, 264.8) 220 (133.8, 269) 6.7 (5.5, 10) 6.0 (4.5, 8.5) Blood urea nitrogen (mmol/l)b b Serum creatinine (μmol/l) 77.3 (70.7, 123.8) 79.6 (70.7, 123.8) b Urine protein/creatinine ratio 3.0 (1.9, 4.4) 2.2 (1.6, 3.4) 75.8 ± 31.2 78.3 ± 32.9 eGFR (ml/min)c Serum albumin (g/l) 24.7 ± 7.0 27.4 ± 8.0
0.414 0.237 0.85 0.866 1 0.056 0.203 0.311 0.177 0.178 0.942 0.024 0.693 0.082
Abbreviations: CYC, cyclophosphamide; dsDNA, double-stranded DNA; eGFR; estimated glomerular filtration rate; MMF, mycophenolate mofetil; SLEDAI, Systemic Lupus Erythematosus Disease Activity Index. Value in bold is statistically significant. a Scoring done according to the Safety of Exogenous Estrogens in Lupus Erythematosus National Assessment (SELENA) modification. b Measure of central tendency values indicated as median (interquartile range), others as mean ± s.d. c eGFR calculated using the Modified MDRD (Modification of Diet in Renal Disease) equation.
summarized in Table 3. Both the groups had an equal number of infection episodes. However, more patients receiving MMF experienced gastrointestinal (GI) symptoms (P o0.001). There was no difference in the incidence of infertility or menstrual abnormalities between the two groups. Three subjects in the CYC group and one subject in the MMF group required discontinuation of treatment because of adverse events. There were five deaths in the MMF group and two in the CYC group (P = 0.43). Of the five deaths in the MMF group, two were due to severe neuropsychiatric lupus, one due to lupus enteritis and septic shock, whereas the cause was not clear in the other two cases. The cause of death in two subjects in the CYC group was unknown. Economics of the therapy
The cost of monthly therapy with MMF was fourfold higher than the CYC therapy (8500 vs. 2200 INR or 100 vs. 20 Euros). Over a period of 6 months, the cumulative cost of MMF therapy was almost seven times that of 3-month CYC and 3 months of azathioprine therapy (52,000 INR (618 Euros) vs. 7700 INR (90 Euros)). DISCUSSION
In this randomized trial, we compared low-dose intravenous CYC with oral MMF in the induction treatment of mild to moderately severe LN. We observed that the treatment response and complete remission rates, as well as adverse event rates were comparable in the two groups. Many observational and randomized trials were conducted to identify the most effective and safe therapy for patients with LN. Studies have shown that both the low-dose intravenous CYC and oral MMF are equally efficacious and safe alternatives compared with the conventional NIH regimen of high-dose intravenous CYC. The ELNT trial had compared six fortnightly injections of CYC at a fixed dose of 500 mg with high-dose monthly injections.10 Follow-up for up to 10 years showed that there were no differences in the outcomes parameters or the side effects between high- and low-dose intravenous CYC.17 Similarly, the Aspreva Lupus Management Study (ALMS) trial had compared oral MMF with monthly high-dose intravenous CYC and noted equal rates of complete and partial remission in the two treatment groups.15 However, to date there have been no studies directly comparing the low-dose CYC regimen with oral MMF.
Table 2 | Outcome variables in the two groups as per the ITT and APP analysis ITT
Outcome measures CYC (n = 50) Response12 weeks Remission12 weeks Response24 weeks Remission24 weeks
31 16 37 25
(62%) (32%) (74%) (50%)
MMF (n = 50) 29 21 37 27
(58%) (42%) (74%) (54%)
APP
Odds ratio (95% CI) 0.85 1.54 1.0 1.17
(0.35–2.03) (0.63–3.79) (0.37–2.70) (0.50–2.77)
P-value 0.84 0.41 1.0 0.84
CYC 26/41 13/41 33/41 20/41
(63.4%) (31.7%) (80.5%) (49.0%)
MMF 29/44 17/44 34/42 25/42
(65.9%) (38.6%) (80.9%) (59.5%)
Odds ratio (95% CI) 1.12 1.36 0.93 1.47
(0.42–2.98) (0.51–3.67) (0.25–3.22) (0.56–3.86)
P-value 0.99 0.65 1.0 0.52
Abbreviations: APP, as-per-protocol; CI, confidence interval; CYC, cyclophosphamide; ITT, intention-to-treat; MMF, mycophenolate mofetil.
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40 MMF CYC
95
Serum albumin
Serum creatinine
105
90 85 80 75
MMF CYC
35 30 25
0
12 Time
24
0
12 Time
24
3.5 CYC MMF
15 SLEDAI
uPCR
CYC MMF
2.5
10
1.5 5
0.5 0
12 Time (weeks)
24
0
12 Time (weeks)
24
Figure 2 | Changes in serum creatinine, serum albumin, uPCR, and disease activity (SLEDAI) score over the 24-week induction period. Within each treatment group, the biochemical parameters and uPCR all showed significant improvement over time (Po0.05). Comparisons of each variable between treatment groups showed no significant differences (P40.05). CYC, cyclophosphamide; MMF, mycophenolate mofetil; SLEDAI, Systemic Lupus Erythematosus Disease Activity Index; uPCR, urine protein/creatinine ratio.
Survival for response
Survival for remission
1.0
1.0
CYC MMF
0.6 0.4 0.2
0.8 Survival probability
Survival probability
0.8
0.6 0.4 0.2
0.0
CYC MMF
0.0 0
5
10 15 Time
20
0
5
10 15 Time
20
Figure 3 | Kaplan–Meier analysis of probability of response (P = 0.833) and probability of remission (P = 0.921) in the two treatment groups. CYC, cyclophosphamide; MMF, mycophenolate mofetil.
At the end of 24 weeks, we noted similar treatment response of 74% in both the groups, whereas complete renal remission was achieved in 50% in the CYC group and 54% in the MMF group. Chan et al.11 compared MMF with oral CYC for LN induction in Chinese subjects and noted a comparable complete remission in each treatment arm (81% in the MMF group vs. 76% in the CYC group). These remission rates were higher as compared with those seen in our study. This may be in part due to the fact that the results in the Chinese study were analyzed at the end of 12 months in contrast to 6 months in our study. Achievement of remission is cumulative over a period of time after completion of the 4
induction phase.18 On the other hand, the response and remission rates achieved in our study are better than those seen in the ALMS trial, which showed response rates of 56.2% and 53.0% and complete remission rates of 8.6% and 8.1% in the MMF and high-dose intravenous CYC groups, respectively.15 This difference may be due to various reasons. In contrast to the ALMS trial, the present study excluded subjects with estimated glomerular filtration rate of o30 ml/ min. Second, the percentage of subjects with different biopsy classes in the two studies is different, with more subjects with pure class-V LN in our study. Finally, the racial background of subjects in the two studies is different. The ALMS trial Kidney International
M Rathi et al.: Low-dose intravenous CYC versus oral MMF in lupus nephritis
Table 3 | Adverse events during 24-week induction phase Adverse events Death Patients with at least one AE
CYC
MMF
n = 50 2 (4.0) 25 (50)
n = 50 5 (10) 32 (64)
Infections (total) Pneumonia Urinary tract infection Esophageal candidiasis Breast abscess Gluteal abscess Herpes zoster Pulmonary tuberculosis Acute parotitis Shock
13 4 3 0 0 1 5 0 0 1
GI symptoms Gastric ulcer Transaminitis Cytopenia Leg ulcers Steroid induced diabetes Deep vein thrombosis
2 (4.0) 1 0 5 3 1 2
Neurological Headache Seizures Stroke Psychosis Worsened GFR Menorrhagia Amenorrhea Alopecia Diffuse alveolar hemorrhage
0 3 0 1 1 1 1 1 0
10 4 1 1 1 0 3 1 1 1 26 (52)* 0 1 7 0 2 1
1 1 1 0 1 0 2 0 1
Abbreviations: AE, adverse event; CYC, cyclophosphamide; GFR, glomerular filtration rate; GI, gastrointestinal; MMF, mycophenolate mofetil. The bold and asterisk mark indicate significant difference in the two groups. *P o 0.001.
included subjects with different racial backgrounds, and 12.5% were Black, whereas in our study all subjects were Asians. The rate of remission in the CYC arm of our study is also better than that reported in the multicenter study by Ginzler et al.13, which showed significantly higher rates of complete remission with MMF compared with high-dose intravenous CYC (22.5 vs. 5.8%, P = 0.005). The high response rate with MMF in our study occurred despite a lower received MMF dose. Only 40% subjects were able to achieve to receive the target 2.5–3.0 g dose. This is less than that achieved by Ginzler et al. (63%),13 or the ALMS trial (91.3%).15 The mean dosage of MMF in our study population (2.22 ± 0.39 g/day) was also less than that in the other two trials (2.68 and 2.47 ± 0.58 g/day, respectively).13,15 Compared with the ELNT trial,10 the dose of steroid used in our treatment protocol was high, and it is possible that steroids may have driven a significant part of the beneficial effects of the induction therapy at week 24. However, the steroid dose used in our study was close to the one used in the ALMS trial,15 where a dose of 0.75–1 mg/kg per day was used for unspecified period followed by taper to 10 mg/day. Kidney International
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As compared with low-dose CYC, there were more adverse events in the MMF group; however, the differences were not significant. The commonest adverse event was GI intolerance and infections. GI symptoms were more frequent in the MMF group. Although the GI manifestations are known complications of MMF therapy,19,20 no previous studies have reported any difference in GI symptoms between MMF and CYC groups.11–13,15 In our study, the dose of CYC was less as compared with previous studies, and majority of GI symptoms like nausea and vomiting with CYC are dose related. The ELNT trial did not provide details regarding GI side effects in the low-dose CYC group,10 but no one withdrew from the study for GI toxicity. Another possible reason could be a direct increase in the dose of MMF from 1000 mg bid to 1500 mg bid without a stepwise increase (e.g., 2500 mg in divided doses); however, we did not notice any particular trend of increased GI upset during the hike to this dose at 4-week duration. The number of infection episodes was similar in both groups in this investigation. Earlier studies that have compared MMF with either oral or high-dose intravenous CYC have also found similar rates of infections.11–15 The rate and severity of infections were similar in the two groups on CYC in the ELNT trial.10 The menstrual abnormalities were also not different in the two groups in our study. The side effect rate of alopecia in our study was lower in both the treatment groups as compared with the ALMS trial (11% in MMF and 36% in CYC).15 Although the exact reasons for this difference are unclear, it may be due to lower doses of the drugs used in our study as compared with ALMS. Genetic differences in the drug metabolism and cultural differences in the concern about body image when faced with a potentially serious illness may also be responsible for this difference. The mortality rate in our study was 10% in the MMF group and 4% in the CYC group, compared with 4.9 and 2.8%, respectively, in the ALMS study.15 Close follow-up, regular dose adjustments, and a timely switch to monthly CYC regimen in cases of non-responsive patients may help in reducing the mortality rate. Similarly, understanding how MMF blood levels correlate with response and toxicity may also permit more careful monitoring of the drug and decrease adverse outcomes. Although we observed no difference in the treatment outcomes in the MMF and CYC groups, low-dose intravenous CYC appeared to have some advantages over MMF. These include a better GI tolerability and shorter course of induction treatment. The CYC was given in the day care setting, avoiding hospitalization and ensuring that the drug was received. The total treatment cost over 6-month period was almost sevenfold lower in the CYC group as compared with the MMF group. Ours is a public sector hospital that does not charge patients for infusion, nursing, or day care treatment, and this cost difference was despite using generic MMF. The cost of therapy is a major factor driving treatment decisions in economically deprived countries. Considering 5
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M Rathi et al.: Low-dose intravenous CYC versus oral MMF in lupus nephritis
these advantages, it is reasonable to choose low-dose CYC over MMF for the treatment of less severe LN, particularly when the cost of therapy is met by out-of-pocket expenditure. However, it is worth pointing out that the cost difference is related to the way the health-care system is structured, and the cost advantage of CYC therapy may be lost if payment is needed for extra visits, infusion, or nursing care. These results should be interpreted in the light of several limitations of our study. This was a single-center study with subjects belonging to a single ethnicity. Thus, the results need validation in a large multicenter study involving different races and ethnicities. Moreover, 25% patients in our study had pure class-V lesion, which is considered to be more benign disease, and results may have been different had we included only proliferative LN. Another important limitation is that the dose of MMF was not concentration controlled. There may be some differences in the metabolism of this drug by race leading to higher exposure and toxicity in our subjects despite receiving relatively low dose. Our study also had a short follow-up; thus, we cannot predict the durability of response over the long term. The study was not blinded, and this might have led to biases in recruitment of subjects or analysis of results. Finally, patients with severe LN and crescentic LN were excluded by design, and thus it remains to be seen how each of these treatment regimens performs in that situation. In conclusion, our study demonstrates low-dose intravenous CYC to be as effective as oral MMF, with fewer GI side effects, and thus is a good induction treatment option for patients with moderately severe LN in the Indian population. Larger multicenter studies with a longer follow-up are required to extrapolate these results to lupus populations in other parts of the world. MATERIALS AND METHODS Study design and subjects This was an open-label, prospective, randomized, non-inferiority, parallel group study conducted at a single center with the hypothesis that the low-dose intravenous CYC is similar to oral MMF in terms of efficacy and safety in subjects with less severe LN. Subjects were enrolled from the Nephrology and Rheumatology departments of the Post Graduate Institute of Medical Education and Research, Chandigarh, between June 2011 and March 2014. Patients of either sex between the ages of 12 and 65, diagnosed to have SLE as per American College of Rheumatology (ACR) criteria,21 and biopsyproven class III, IV, V, III+V, or IV+V LN based on the International Society of Nephrology/Renal Pathology Society classification were included.22 Those with crescentic LN (450% crescents in biopsy), serum creatinine of 4265.0 μmol/l, neurological or pulmonary lupus, ongoing infection, pregnancy, and prior treatment with CYC or MMF were excluded. The study was approved by the Institute Ethics Committee and was registered with Clinical Trial Registry– India (CTRI/2013/12/004179). An informed consent was obtained from all study participants or their parents/legal guardians, and the procedures followed were in accordance with the ethical standards of the responsible committees on human experimentation (institutional 6
and national) and with the Declaration of Helsinki Principles 1975, as revised in 2000. Study treatment and drug dosing MMF was initiated at a dose of 500 mg twice a day and increased every 2 weeks to achieve a target dose of 1.5–3.0 g/day, depending on the leukocyte count and tolerability. At 2 weeks, the dose was increased to 1000 mg twice a day, whereas it was increased to a maximum dose of 1500 mg twice a day at 4 weeks. In case of GI intolerance, the frequency of drug was changed to thrice daily, followed by a change to mycophenolate sodium formulation if required. In case of persistence of symptoms, the dose of MMF was reduced stepwise by 25%. CYC was administered as six fortnightly intravenous infusions at a fixed dose of 500 mg each. In addition, all subjects received three daily intravenous injections of methylprednisolone (750 mg each) at the beginning of treatment followed by oral prednisolone (1 mg/kg per day) for 8 weeks and subsequent tapering. All subjects were given hydroxychloroquine (6 mg/kg, single daily dose) as well as either angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. At the end of induction treatment, that is, 6 months in the MMF group and 3 months in the CYC group, all subjects were shifted to maintenance treatment with azathioprine (2 mg/kg) and steroids (5–7.5 mg/day). The treatment protocol remained the same with no change during the trial period. Follow-up visits Subjects in the CYC group were followed-up every 2 weeks for 12 weeks and then every 4 weeks through week 24. Those in the MMF group were followed-up at week 2, week 4, and subsequently every 4 weeks through week 24. A monthly telephonic contact was made throughout the study period to collect safety and concomitant medication information. Baseline investigations included complete blood counts, renal function tests, serum albumin, urine examination, uPCR in a 24 h urine sample, anti-nuclear antibodies, anti-double– stranded deoxyribonuclease antibody, and complement levels. At each follow-up, complete blood counts, renal function tests, and uPCR were performed, whereas complement levels and antidouble–stranded deoxyribonuclease antibody were checked at the end of 12 and 24 weeks. The disease activity was assessed by SLEDAI scoring according to Safety of Exogenous Estrogens in Lupus Erythematosus National Assessment modification (SELENA–SLEDAI) at baseline, 12 weeks, and 24 weeks.23,24 The estimated glomerular filtration rate was calculated using modified ‘Modification of Diet in Renal Disease (MDRD)’ equation at baseline, 12 weeks, and 24 weeks.25 Study end points The primary outcome measure was ‘treatment response’, defined as a decrease in the uPCR to o3 in subjects with a baseline ratio ⩾ 3 or a decrease in uPCR by ⩾ 50% in those with a baseline ratio o3, along with stabilization or improvement in serum creatinine (a 24-week serum creatinine level within 25% of baseline). The secondary outcome measures were as follows: (i) ‘complete renal remission’, defined as return to normal serum creatinine along with proteinuria ⩽ 0.5 g/day and inactive urine sediment, (ii) SELENA–SLEDAI score, and (iii) adverse events. The sample size was determined using the Sealed Envelope sample size calculator to determine the sample size for a 2 arm, Kidney International
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M Rathi et al.: Low-dose intravenous CYC versus oral MMF in lupus nephritis
randomized, parallel group trial with the outcome variable being binary and the objective of showing non-inferiority. Assuming a response rate of 56% with MMF (as per the ALMS trial),15 and 71% with low-dose CYC (as per the ELNT study)10 and the noninferiority criteria of 10%, it was estimated that to achieve 80% power with one-sided confidence interval of 95%, 45 subjects per group would be required, thus giving a sample size of 90. Further, accounting for a withdrawal rate of 10%, 50 subjects per group needed to be recruited, leading to a total sample size of 100 subjects. The randomization was performed with an in-center computergenerated random number table by an authorized study coordinator, and the subjects were randomized in a 1:1 ratio to receive either intravenous low-dose CYC or oral MMF. Statistical analysis Analyses were performed by considering all observations pertaining to each variable. Hence, the data set was not adjusted by omitting all missing variables globally. The results under APP analysis thus have different sample sizes (n), depending on the missing observations therein. Missing observations were imputed under a multivariate setting, where other variables were taken as predictors for imputing missing observations of the individual variables for ITT analysis. Continuous data are presented as mean ± s.d. or median and interquartile range, as appropriate. Normality of the quantitative data was checked by the Kolmogorov–Smirnov test. For normally distributed data, means for the two groups were compared using Student’s t-test, whereas non-normal data were tested by the Mann– Whitney’s U-test. With in-patient–related variables were compared using a paired t-test or analysis of variance. Change in the SLEDAI score was assessed by the Wilcoxon signed-rank test. Qualitative or categorical variables were described as frequencies and proportions. Proportions were compared using χ2 or Fisher’s exact test as applicable. The McNemar test was applied to compare between pre- and post-treatment values. A two-sided P-value of o0.05 was considered significant. All calculations were performed using SPSS version 21 (Statistical Packages for the Social Sciences, Chicago, IL) on a Windows platform.
patient management and end point assessment; MR, AG, and AJ have drafted the manuscript; RR, AS, and VK have helped in data acquisition, data analysis, and literature search; VJ and HSK have supervised the patient management, edited the manuscript, and provided intellectual support; and KLG and VS have supervised the study, provided intellectual support, critically reviewed, and edited the manuscript.
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DISCLOSURE
All the authors declared no competing interests. 14.
ACKNOWLEDGMENTS
We thank Dr Brad H Rovin (Professor and Director, Division of Nephrology, Department of Internal Medicine, The Ohio State University, OH, USA) for reviewing the manuscript. He has performed language editing and provided valuable feedback to improve the quality of paper.
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AUTHOR CONTRIBUTIONS
All the authors meet the four criteria defined by ICMJE. They have made substantial contributions to the conception or design of the work or the acquisition, analysis, or interpretation of data for the work. The authors have contributed to the draft preparation and revising it critically for important intellectual content. All the authors have approved the final version of the draft and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. In addition, MR has conceptualized and designed the study; AG and AJ have recruited the patients and randomized them; MR, AG, and PKG have performed the data acquisition and statistical analysis; MR and AS have supervised the randomization and patient recruitment and contributed to Kidney International
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21.
Contreras G, Roth D, Pardo V et al. Lupus nephritis: a clinical review for practicing nephrologists. Clin Nephrol 2002; 57: 95–107. Bomback AS, Appel GB. Update on the treatment of lupus nephritis. J Am Soc Nephrol 2010; 21: 2028–2035. Waldman M, Appel GB. Update on the treatment of lupus nephritis. Kidney Int 2006; 70: 1403–1412. Austin HA 3rd, Klippel JH, Balow JE et al. Therapy of lupus nephritis: controlled trial of prednisone and cytotoxic drugs. N Engl J Med 1986; 314: 614–619. Boumpas DT, Austin HA 3rd, Vaughan EM et al. Controlled trial of pulse methylprednisolone versus two regimens of pulse cyclophosphamide in severe lupus nephritis. Lancet 1992; 340: 741–745. Gourley MF, Austin HA 3rd, Scott D et al. Methylprednisolone and cyclophosphamide, alone or in combination, in patients with lupus nephritis. A randomized, controlled trial. Ann Intern Med 1996; 125: 549–557. Illei GG, Austin HA, Crane M et al. Combination therapy with pulse cyclophosphamide plus pulse methylprednisolone improves long-term renal outcome without adding toxicity in patients with lupus nephritis. Ann Intern Med 2001; 135: 248–257. Urowitz MB. Is “aggressive” therapy necessary for systemic lupus erythematosus? Rheum Dis Clin North Am 1993; 19: 263–270. Ponticelli C. Treatment of lupus nephritis: the advantages of a flexible approach. Nephrol Dial Transplant 1997; 12: 2057–2059. Houssiau FA, Vasconcelos C, D’Cruz D et al. Immunosuppressive therapy in lupus nephritis: the Euro-Lupus Nephritis Trial, a randomized trial of lowdose versus high-dose intravenous cyclophosphamide. Arthritis Rheum 2002; 46: 2121–2131. Chan TM, Li FK, Tang CS et al. Efficacy of mycophenolate mofetil in patients with diffuse proliferative lupus nephritis. xHong KongGuangzhou Nephrology study group. N Engl J Med 2000; 343: 1156–1162. Chan TM, Tse KC, Tang CS et al. Long-term study of mycophenolate mofetil as continuous induction and maintenance treatment for diffuse proliferative lupus nephritis. J Am Soc Nephrol 2005; 16: 1076–1084. Ginzler EM, Dooley MA, Aranow C et al. Mycophenolate mofetil or intravenous cyclophosphamide for lupus nephritis. N Engl J Med 2005; 353: 2219–2228. Walsh M, James M, Jayne D et al. Mycophenolate mofetil for induction therapy of lupus nephritis: a systematic review and meta-analysis. Clin J Am Soc Nephrol 2007; 2: 968–975. Appel GB, Contreras G, Dooley MA et al. Mycophenolate mofetil versus cyclophosphamide for induction treatment of lupus nephritis. J Am Soc Nephrol 2009; 20: 1103–1112. Lee Y, Woo JH, Choi S et al. Induction and maintenance therapy for lupus nephritis: a systematic review and meta-analysis. Lupus 2010; 19: 703–710. Houssiau FA, Vasconcelos C, D’Cruz D et al. The 10-year follow-up data of the Euro-Lupus Nephritis Trial comparing low-dose and high-dose intravenous cyclophosphamide. Ann Rheum Dis 2009; 69: 61–64. Kidney Disease: Improving Global Outcomes (KDIGO) Glomerulonephritis Work Group. KDIGO Clinical Practice Guideline for Glomerulonephritis. Kidney Int 2012; 2 Suppl 2 S139–S274. Riskalla MM, Somers EC, Fatica RA et al. Tolerability of mycophenolate mofetil in patients with systemic lupus erythematosus. J Rheumatol 2003; 30: 1508–1512. Oglesby A, Shaul AJ, Pokora T et al. Adverse event burden, resource use, and costs associated with immunosuppressant medications for the treatment of systemic lupus erythematosus: a systematic literature review. Int J Rheumatol 2013; 2013: 347520. Hochberg MC. Updating the American College of Rheumatology revised criteria for the classification of systemic lupus erythematosus. Arthritis Rheum 1997; 40: 1725.
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22.
23.
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Weening JJ, D’Agati VD, Schwartz MM et al. The classification of glomerulonephritis in systemic lupus erythematosus revisited. J Am Soc Nephrol 2004; 15: 241–250. Bombardier C, Gladman DD, Urowitz MB et al. Derivation of the SLEDAI. A disease activity index for lupus patients. The Committee on Prognosis Studies in SLE. Arthritis Rheum 1992; 35: 630–640.
24. Isenberg D, Ramsey-Goldman R. Assessing patients with lupus: towards a drug responder index. Rheumatology 1999; 38: 1045–1049. 25. Levey AS, Bosch JP, Lewis JB et al. A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Ann Intern Med 1999; 130: 461–470.
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Comparison of low-dose intravenous cyclophosphamide with oral mycophenolate mofetil in the treatment of lupus nephritis Manish Rathi1, Ajay Goyal1, Ajay Jaryal1, Aman Sharma2, Pramod K. Gupta3, Raja Ramachandran1, Vivek Kumar1, Harbir S. Kohli1, Vinay Sakhuja4, Vivekanand Jha1 and Krishan L. Gupta1 1
Department of Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India; 2Department of Internal Medicine, Rheumatology Wing, Post Graduate Institute of Medical Education and Research, Chandigarh, India; 3Department of Biostatistics, Post Graduate Institute of Medical Education and Research, Chandigarh, India and 4Department of Nephrology and Renal Transplant Surgery, Max Super Speciality Hospital, Mohali, India
No previous study has compared mycophenolate mofetil (MMF) with low-dose cyclophosphamide (CYC) in the treatment of lupus nephritis (LN). To do so, we recruited patients with LN (class III, IV, or V) and randomized them to receive either low-dose CYC or oral MMF. Those with crescentic LN, a serum creatinine over 265 μmol/l, and neurological or pulmonary lupus were excluded. MMF was prescribed at daily doses of 1.5–3 g for 24 weeks, while CYC was administered as six fortnightly infusions of 500 mg each. All patients received three methylprednisolone injections, followed by oral corticosteroids. Maintenance therapy with azathioprine and low-dose corticosteroid was started at end of induction therapy. The primary end point was treatment response at 24 weeks, while secondary end points were complete remission, Systemic Lupus Erythematosus Disease Activity Index and adverse events. Of the 173 patients recruited, 100 were equally randomized to receive either CYC or MMF. Baseline characteristics were similar, except for higher 24 h proteinuria in the CYC group. At 24 weeks, 37 patients in each group achieved the primary end point. The complete remission rate was 50% in CYC and 54% in MMF group. Gastrointestinal symptoms were significantly more frequent in patients receiving MMF (52 vs. 4%). However, other adverse events were similar. Thus, low-dose intravenous CYC is comparable in safety and efficacy to oral MMF in the induction treatment of less severe LN.
Lupus nephritis (LN) is a serious complication of systemic lupus erythematosus (SLE) and needs to be treated with toxic immunosuppressive therapy.1–3 Attempts have been made to reduce toxicity by altering the route of administration or dosage of drugs or substituting them with less toxic alternatives. Cyclophosphamide (CYC), the traditional standard treatment of LN,4–7 carries significant dose-dependent short- and long-term toxicity, prompting investigators to explore the effectiveness of lower doses.8,9 The Euro–lupus nephritis trial (ELNT) demonstrated a comparable efficacy and safety profile of low-dose CYC to the high-dose National Institute of Health (NIH) regimen.10 Mycophenolate mofetil (MMF), a selective lymphocyte antiproliferative agent, has also emerged as a promising drug for treatment of LN. Recent studies have established MMF as a safe and an effective alternative to full-dose CYC for LN.11–16 Both the ELNT regimen and MMF have been used successfully in subjects with less severe LN with the advantage of reduced toxicity. However, it is not clear whether low-dose ELNT CYC or oral MMF is superior, because these have not been compared in a head-to-head trial. The present study was aimed at comparing the efficacy and safety of these treatment options in subjects with less severe LN.
Kidney International advance online publication, 21 October 2015; doi:10.1038/ki.2015.318
A total of 173 subjects fulfilling the inclusion criteria were screened during the study period. Of these, 100 were randomized to receive either low-dose intravenous CYC (n = 50) or oral MMF (n = 50). The reasons for exclusion of 73 subjects are summarized in Figure 1. The baseline characteristics of the study population are described in Table 1. There were 8 males and 92 females in the cohort. All the baseline characteristics were comparable between the two groups, with the exception of urine protein/ creatinine ratio (uPCR), which was significantly higher in the CYC group (3 vs. 2.2 in the MMF group, P = 0.02). The clinical presentation, organ involvement, and the distribution
KEYWORDS: cyclophosphamide; lupus nephritis; mycophenolate mofetil
Correspondence: Manish Rathi, Department of Nephrology, Post Graduate Institute of Medical Education and Research, Sector-12, Chandigarh 160 012, India. E-mail: [email protected] Received 22 May 2015; revised 4 August 2015; accepted 20 August 2015 Kidney International
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Screened (n = 173) Biopsy diagnosis of lupus nephritis class III/IV/V
Reasons for exclusion (n = 73) Crescentic LN (n = 24) Serum creatinine > 265.0 µmol/l (n = 16) Previously received CYC or MMF (n = 21) Refused consent (n = 5) Pregnant (n = 1) CNS or pulmonary lupus (n = 6)
Randomized (n = 100)
50: Low fixed dose intravenous CYC
50: Oral MMF
Withdrawn (n = 9)
Withdrawn (n = 8)
Death (n = 2) Adverse events (n = 3) Lost to follow-up (n = 3) Deviated from protocol (n = 2)
Death (n = 5) Adverse events (n = 1) Lost to follow-up (n = 2)
Completed 24 weeks of follow-up (n = 41)
Completed 24 weeks of follow-up (n = 42)
Figure 1 | Flow chart depicting patient enrollment and follow-up. CNS, central nervous system; CYC, cyclophosphamide; LN, lupus nephritis; MMF, mycophenolate mofetil.
of various biopsy classes were also similar in the two groups (Table 1). Of the 50 subjects in CYC group, 40 (80%) received the target cumulative dose of 3 g, whereas 48 (96%) subjects in the MMF group received the target dose of 1.5–3.0 g/day with a mean dose of 2.22 ± 0.39 g/day. Study outcomes
The primary, as well as the secondary outcome measures were assessed at 12 and 24 weeks according to the original assigned groups (intention-to-treat (ITT) analysis), as well as the completed follow-up groups (as-per-protocol (APP) analysis). The rates of treatment response and complete renal remission at these time points as per the two analyses are summarized in Table 2. The serum creatinine, serum albumin, uPCR, and the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) score improved significantly in both the groups over the study period, and there were no differences between the treatment groups (Figure 2). The median (interquartile 2
range) SLEDAI score at the end of 24 weeks was 6 (4, 8) and 4 (2, 6) in the CYC and the MMF group, respectively (P = 0.17). The delta estimated glomerular filtration rate improved by 14.0 ml/min (95% confidence interval: 4.3, 23.7) in the CYC group (P = 0.005) and 16.5 ml/min (95% confidence interval: 4.9, 28.0) in the MMF group (P = 0.006) over 24 weeks, with no significant intergroup difference (P = 0.74). The anti-double– stranded deoxyribonuclease antibody positivity rate declined from 90 to 58% in the CYC group (Po0.001) and 88 to 62% in the MMF group (P = 0.01) over 24 weeks, with no significant intergroup difference (P = 0.84). The prevalence of hypocomplementemia (low C3 or C4) declined from 92 to 32% in the CYC group (Po0.001) and from 76 to 40% in the MMF group (Po0.001), without any significant difference between the two treatment groups (P = 0.53). The response rate for different pathological classes of LN according to the treatment group was also analyzed. Using ITT analysis, the treatment response rate in class IV was 76.7% in the CYC group compared with 70.4% in the MMF group (P = 0.59); in class III it was 66.7% in the CYC group Kidney International
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compared with 90.9% in the MMF group (P = 0.21), whereas in class V it was 71.4% in the CYC group compared with 66.7% in the MMF group (P = 0.79). The treatment response rate did not differ significantly in the two treatment groups even after the exclusion of subjects with pure class-V LN (75.0 and 76.3% in CYC and MMF groups, respectively, P = 0.91). The median time to response was 10 (4, 20) weeks in the CYC group as compared with 12 (6.5, 12) weeks in the MMF group (P = 0.90). Similarly, there was no difference in the median time to complete remission in the two groups (9 (7.5, 21) weeks and 12 (8, 20) weeks in the CYC and MMF group, respectively; P = 0.88). The probability of response, as well as remission was also not different between the treatment groups Figure 3). Adverse events
During the study period, 25 (50%) subjects in the CYC group and 32 (64%) subjects in the MMF group reported at least one adverse event (P = 0.32). The reported adverse events are Table 1 | Baseline characteristics of the study population Variable Gender, n (%) Female Male
CYC
MMF
n = 50
n = 50
45 (90) 5 (10)
47 (94) 3 (6)
P-value
0.715
Kidney biopsy class, n (%) III/III+V 6 (12) 11 (22) IV/IV+V 30 (60) 27 (54) V 14 (28) 12 (24) Age (years) 30.6 ± 9.5 28.3 ± 9.5 2 Body mass index (kg/m ) 22.3 ± 3.1 22.5 ± 3.6 18.1 ± 6.2 17.9 ± 5.6 SLEDAI scorea Anti-dsDNA positive, n (%) 45 (90) 44 (88) Hypocomplementemia 46 (92) 38 (76) (↓ C3 or C4), n (%) Hemoglobin (g/l) 89 ± 18 94.4 ± 24 Leukocyte count (×109/l)b 6.5 (4, 8) 6.8 (4.8, 9.1) 9 b Platelet count (×10 /l) 143.5 (108, 264.8) 220 (133.8, 269) 6.7 (5.5, 10) 6.0 (4.5, 8.5) Blood urea nitrogen (mmol/l)b b Serum creatinine (μmol/l) 77.3 (70.7, 123.8) 79.6 (70.7, 123.8) b Urine protein/creatinine ratio 3.0 (1.9, 4.4) 2.2 (1.6, 3.4) 75.8 ± 31.2 78.3 ± 32.9 eGFR (ml/min)c Serum albumin (g/l) 24.7 ± 7.0 27.4 ± 8.0
0.414 0.237 0.85 0.866 1 0.056 0.203 0.311 0.177 0.178 0.942 0.024 0.693 0.082
Abbreviations: CYC, cyclophosphamide; dsDNA, double-stranded DNA; eGFR; estimated glomerular filtration rate; MMF, mycophenolate mofetil; SLEDAI, Systemic Lupus Erythematosus Disease Activity Index. Value in bold is statistically significant. a Scoring done according to the Safety of Exogenous Estrogens in Lupus Erythematosus National Assessment (SELENA) modification. b Measure of central tendency values indicated as median (interquartile range), others as mean ± s.d. c eGFR calculated using the Modified MDRD (Modification of Diet in Renal Disease) equation.
summarized in Table 3. Both the groups had an equal number of infection episodes. However, more patients receiving MMF experienced gastrointestinal (GI) symptoms (P o0.001). There was no difference in the incidence of infertility or menstrual abnormalities between the two groups. Three subjects in the CYC group and one subject in the MMF group required discontinuation of treatment because of adverse events. There were five deaths in the MMF group and two in the CYC group (P = 0.43). Of the five deaths in the MMF group, two were due to severe neuropsychiatric lupus, one due to lupus enteritis and septic shock, whereas the cause was not clear in the other two cases. The cause of death in two subjects in the CYC group was unknown. Economics of the therapy
The cost of monthly therapy with MMF was fourfold higher than the CYC therapy (8500 vs. 2200 INR or 100 vs. 20 Euros). Over a period of 6 months, the cumulative cost of MMF therapy was almost seven times that of 3-month CYC and 3 months of azathioprine therapy (52,000 INR (618 Euros) vs. 7700 INR (90 Euros)). DISCUSSION
In this randomized trial, we compared low-dose intravenous CYC with oral MMF in the induction treatment of mild to moderately severe LN. We observed that the treatment response and complete remission rates, as well as adverse event rates were comparable in the two groups. Many observational and randomized trials were conducted to identify the most effective and safe therapy for patients with LN. Studies have shown that both the low-dose intravenous CYC and oral MMF are equally efficacious and safe alternatives compared with the conventional NIH regimen of high-dose intravenous CYC. The ELNT trial had compared six fortnightly injections of CYC at a fixed dose of 500 mg with high-dose monthly injections.10 Follow-up for up to 10 years showed that there were no differences in the outcomes parameters or the side effects between high- and low-dose intravenous CYC.17 Similarly, the Aspreva Lupus Management Study (ALMS) trial had compared oral MMF with monthly high-dose intravenous CYC and noted equal rates of complete and partial remission in the two treatment groups.15 However, to date there have been no studies directly comparing the low-dose CYC regimen with oral MMF.
Table 2 | Outcome variables in the two groups as per the ITT and APP analysis ITT
Outcome measures CYC (n = 50) Response12 weeks Remission12 weeks Response24 weeks Remission24 weeks
31 16 37 25
(62%) (32%) (74%) (50%)
MMF (n = 50) 29 21 37 27
(58%) (42%) (74%) (54%)
APP
Odds ratio (95% CI) 0.85 1.54 1.0 1.17
(0.35–2.03) (0.63–3.79) (0.37–2.70) (0.50–2.77)
P-value 0.84 0.41 1.0 0.84
CYC 26/41 13/41 33/41 20/41
(63.4%) (31.7%) (80.5%) (49.0%)
MMF 29/44 17/44 34/42 25/42
(65.9%) (38.6%) (80.9%) (59.5%)
Odds ratio (95% CI) 1.12 1.36 0.93 1.47
(0.42–2.98) (0.51–3.67) (0.25–3.22) (0.56–3.86)
P-value 0.99 0.65 1.0 0.52
Abbreviations: APP, as-per-protocol; CI, confidence interval; CYC, cyclophosphamide; ITT, intention-to-treat; MMF, mycophenolate mofetil.
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40 MMF CYC
95
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Serum creatinine
105
90 85 80 75
MMF CYC
35 30 25
0
12 Time
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0
12 Time
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15 SLEDAI
uPCR
CYC MMF
2.5
10
1.5 5
0.5 0
12 Time (weeks)
24
0
12 Time (weeks)
24
Figure 2 | Changes in serum creatinine, serum albumin, uPCR, and disease activity (SLEDAI) score over the 24-week induction period. Within each treatment group, the biochemical parameters and uPCR all showed significant improvement over time (Po0.05). Comparisons of each variable between treatment groups showed no significant differences (P40.05). CYC, cyclophosphamide; MMF, mycophenolate mofetil; SLEDAI, Systemic Lupus Erythematosus Disease Activity Index; uPCR, urine protein/creatinine ratio.
Survival for response
Survival for remission
1.0
1.0
CYC MMF
0.6 0.4 0.2
0.8 Survival probability
Survival probability
0.8
0.6 0.4 0.2
0.0
CYC MMF
0.0 0
5
10 15 Time
20
0
5
10 15 Time
20
Figure 3 | Kaplan–Meier analysis of probability of response (P = 0.833) and probability of remission (P = 0.921) in the two treatment groups. CYC, cyclophosphamide; MMF, mycophenolate mofetil.
At the end of 24 weeks, we noted similar treatment response of 74% in both the groups, whereas complete renal remission was achieved in 50% in the CYC group and 54% in the MMF group. Chan et al.11 compared MMF with oral CYC for LN induction in Chinese subjects and noted a comparable complete remission in each treatment arm (81% in the MMF group vs. 76% in the CYC group). These remission rates were higher as compared with those seen in our study. This may be in part due to the fact that the results in the Chinese study were analyzed at the end of 12 months in contrast to 6 months in our study. Achievement of remission is cumulative over a period of time after completion of the 4
induction phase.18 On the other hand, the response and remission rates achieved in our study are better than those seen in the ALMS trial, which showed response rates of 56.2% and 53.0% and complete remission rates of 8.6% and 8.1% in the MMF and high-dose intravenous CYC groups, respectively.15 This difference may be due to various reasons. In contrast to the ALMS trial, the present study excluded subjects with estimated glomerular filtration rate of o30 ml/ min. Second, the percentage of subjects with different biopsy classes in the two studies is different, with more subjects with pure class-V LN in our study. Finally, the racial background of subjects in the two studies is different. The ALMS trial Kidney International
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Table 3 | Adverse events during 24-week induction phase Adverse events Death Patients with at least one AE
CYC
MMF
n = 50 2 (4.0) 25 (50)
n = 50 5 (10) 32 (64)
Infections (total) Pneumonia Urinary tract infection Esophageal candidiasis Breast abscess Gluteal abscess Herpes zoster Pulmonary tuberculosis Acute parotitis Shock
13 4 3 0 0 1 5 0 0 1
GI symptoms Gastric ulcer Transaminitis Cytopenia Leg ulcers Steroid induced diabetes Deep vein thrombosis
2 (4.0) 1 0 5 3 1 2
Neurological Headache Seizures Stroke Psychosis Worsened GFR Menorrhagia Amenorrhea Alopecia Diffuse alveolar hemorrhage
0 3 0 1 1 1 1 1 0
10 4 1 1 1 0 3 1 1 1 26 (52)* 0 1 7 0 2 1
1 1 1 0 1 0 2 0 1
Abbreviations: AE, adverse event; CYC, cyclophosphamide; GFR, glomerular filtration rate; GI, gastrointestinal; MMF, mycophenolate mofetil. The bold and asterisk mark indicate significant difference in the two groups. *P o 0.001.
included subjects with different racial backgrounds, and 12.5% were Black, whereas in our study all subjects were Asians. The rate of remission in the CYC arm of our study is also better than that reported in the multicenter study by Ginzler et al.13, which showed significantly higher rates of complete remission with MMF compared with high-dose intravenous CYC (22.5 vs. 5.8%, P = 0.005). The high response rate with MMF in our study occurred despite a lower received MMF dose. Only 40% subjects were able to achieve to receive the target 2.5–3.0 g dose. This is less than that achieved by Ginzler et al. (63%),13 or the ALMS trial (91.3%).15 The mean dosage of MMF in our study population (2.22 ± 0.39 g/day) was also less than that in the other two trials (2.68 and 2.47 ± 0.58 g/day, respectively).13,15 Compared with the ELNT trial,10 the dose of steroid used in our treatment protocol was high, and it is possible that steroids may have driven a significant part of the beneficial effects of the induction therapy at week 24. However, the steroid dose used in our study was close to the one used in the ALMS trial,15 where a dose of 0.75–1 mg/kg per day was used for unspecified period followed by taper to 10 mg/day. Kidney International
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As compared with low-dose CYC, there were more adverse events in the MMF group; however, the differences were not significant. The commonest adverse event was GI intolerance and infections. GI symptoms were more frequent in the MMF group. Although the GI manifestations are known complications of MMF therapy,19,20 no previous studies have reported any difference in GI symptoms between MMF and CYC groups.11–13,15 In our study, the dose of CYC was less as compared with previous studies, and majority of GI symptoms like nausea and vomiting with CYC are dose related. The ELNT trial did not provide details regarding GI side effects in the low-dose CYC group,10 but no one withdrew from the study for GI toxicity. Another possible reason could be a direct increase in the dose of MMF from 1000 mg bid to 1500 mg bid without a stepwise increase (e.g., 2500 mg in divided doses); however, we did not notice any particular trend of increased GI upset during the hike to this dose at 4-week duration. The number of infection episodes was similar in both groups in this investigation. Earlier studies that have compared MMF with either oral or high-dose intravenous CYC have also found similar rates of infections.11–15 The rate and severity of infections were similar in the two groups on CYC in the ELNT trial.10 The menstrual abnormalities were also not different in the two groups in our study. The side effect rate of alopecia in our study was lower in both the treatment groups as compared with the ALMS trial (11% in MMF and 36% in CYC).15 Although the exact reasons for this difference are unclear, it may be due to lower doses of the drugs used in our study as compared with ALMS. Genetic differences in the drug metabolism and cultural differences in the concern about body image when faced with a potentially serious illness may also be responsible for this difference. The mortality rate in our study was 10% in the MMF group and 4% in the CYC group, compared with 4.9 and 2.8%, respectively, in the ALMS study.15 Close follow-up, regular dose adjustments, and a timely switch to monthly CYC regimen in cases of non-responsive patients may help in reducing the mortality rate. Similarly, understanding how MMF blood levels correlate with response and toxicity may also permit more careful monitoring of the drug and decrease adverse outcomes. Although we observed no difference in the treatment outcomes in the MMF and CYC groups, low-dose intravenous CYC appeared to have some advantages over MMF. These include a better GI tolerability and shorter course of induction treatment. The CYC was given in the day care setting, avoiding hospitalization and ensuring that the drug was received. The total treatment cost over 6-month period was almost sevenfold lower in the CYC group as compared with the MMF group. Ours is a public sector hospital that does not charge patients for infusion, nursing, or day care treatment, and this cost difference was despite using generic MMF. The cost of therapy is a major factor driving treatment decisions in economically deprived countries. Considering 5
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these advantages, it is reasonable to choose low-dose CYC over MMF for the treatment of less severe LN, particularly when the cost of therapy is met by out-of-pocket expenditure. However, it is worth pointing out that the cost difference is related to the way the health-care system is structured, and the cost advantage of CYC therapy may be lost if payment is needed for extra visits, infusion, or nursing care. These results should be interpreted in the light of several limitations of our study. This was a single-center study with subjects belonging to a single ethnicity. Thus, the results need validation in a large multicenter study involving different races and ethnicities. Moreover, 25% patients in our study had pure class-V lesion, which is considered to be more benign disease, and results may have been different had we included only proliferative LN. Another important limitation is that the dose of MMF was not concentration controlled. There may be some differences in the metabolism of this drug by race leading to higher exposure and toxicity in our subjects despite receiving relatively low dose. Our study also had a short follow-up; thus, we cannot predict the durability of response over the long term. The study was not blinded, and this might have led to biases in recruitment of subjects or analysis of results. Finally, patients with severe LN and crescentic LN were excluded by design, and thus it remains to be seen how each of these treatment regimens performs in that situation. In conclusion, our study demonstrates low-dose intravenous CYC to be as effective as oral MMF, with fewer GI side effects, and thus is a good induction treatment option for patients with moderately severe LN in the Indian population. Larger multicenter studies with a longer follow-up are required to extrapolate these results to lupus populations in other parts of the world. MATERIALS AND METHODS Study design and subjects This was an open-label, prospective, randomized, non-inferiority, parallel group study conducted at a single center with the hypothesis that the low-dose intravenous CYC is similar to oral MMF in terms of efficacy and safety in subjects with less severe LN. Subjects were enrolled from the Nephrology and Rheumatology departments of the Post Graduate Institute of Medical Education and Research, Chandigarh, between June 2011 and March 2014. Patients of either sex between the ages of 12 and 65, diagnosed to have SLE as per American College of Rheumatology (ACR) criteria,21 and biopsyproven class III, IV, V, III+V, or IV+V LN based on the International Society of Nephrology/Renal Pathology Society classification were included.22 Those with crescentic LN (450% crescents in biopsy), serum creatinine of 4265.0 μmol/l, neurological or pulmonary lupus, ongoing infection, pregnancy, and prior treatment with CYC or MMF were excluded. The study was approved by the Institute Ethics Committee and was registered with Clinical Trial Registry– India (CTRI/2013/12/004179). An informed consent was obtained from all study participants or their parents/legal guardians, and the procedures followed were in accordance with the ethical standards of the responsible committees on human experimentation (institutional 6
and national) and with the Declaration of Helsinki Principles 1975, as revised in 2000. Study treatment and drug dosing MMF was initiated at a dose of 500 mg twice a day and increased every 2 weeks to achieve a target dose of 1.5–3.0 g/day, depending on the leukocyte count and tolerability. At 2 weeks, the dose was increased to 1000 mg twice a day, whereas it was increased to a maximum dose of 1500 mg twice a day at 4 weeks. In case of GI intolerance, the frequency of drug was changed to thrice daily, followed by a change to mycophenolate sodium formulation if required. In case of persistence of symptoms, the dose of MMF was reduced stepwise by 25%. CYC was administered as six fortnightly intravenous infusions at a fixed dose of 500 mg each. In addition, all subjects received three daily intravenous injections of methylprednisolone (750 mg each) at the beginning of treatment followed by oral prednisolone (1 mg/kg per day) for 8 weeks and subsequent tapering. All subjects were given hydroxychloroquine (6 mg/kg, single daily dose) as well as either angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. At the end of induction treatment, that is, 6 months in the MMF group and 3 months in the CYC group, all subjects were shifted to maintenance treatment with azathioprine (2 mg/kg) and steroids (5–7.5 mg/day). The treatment protocol remained the same with no change during the trial period. Follow-up visits Subjects in the CYC group were followed-up every 2 weeks for 12 weeks and then every 4 weeks through week 24. Those in the MMF group were followed-up at week 2, week 4, and subsequently every 4 weeks through week 24. A monthly telephonic contact was made throughout the study period to collect safety and concomitant medication information. Baseline investigations included complete blood counts, renal function tests, serum albumin, urine examination, uPCR in a 24 h urine sample, anti-nuclear antibodies, anti-double– stranded deoxyribonuclease antibody, and complement levels. At each follow-up, complete blood counts, renal function tests, and uPCR were performed, whereas complement levels and antidouble–stranded deoxyribonuclease antibody were checked at the end of 12 and 24 weeks. The disease activity was assessed by SLEDAI scoring according to Safety of Exogenous Estrogens in Lupus Erythematosus National Assessment modification (SELENA–SLEDAI) at baseline, 12 weeks, and 24 weeks.23,24 The estimated glomerular filtration rate was calculated using modified ‘Modification of Diet in Renal Disease (MDRD)’ equation at baseline, 12 weeks, and 24 weeks.25 Study end points The primary outcome measure was ‘treatment response’, defined as a decrease in the uPCR to o3 in subjects with a baseline ratio ⩾ 3 or a decrease in uPCR by ⩾ 50% in those with a baseline ratio o3, along with stabilization or improvement in serum creatinine (a 24-week serum creatinine level within 25% of baseline). The secondary outcome measures were as follows: (i) ‘complete renal remission’, defined as return to normal serum creatinine along with proteinuria ⩽ 0.5 g/day and inactive urine sediment, (ii) SELENA–SLEDAI score, and (iii) adverse events. The sample size was determined using the Sealed Envelope sample size calculator to determine the sample size for a 2 arm, Kidney International
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randomized, parallel group trial with the outcome variable being binary and the objective of showing non-inferiority. Assuming a response rate of 56% with MMF (as per the ALMS trial),15 and 71% with low-dose CYC (as per the ELNT study)10 and the noninferiority criteria of 10%, it was estimated that to achieve 80% power with one-sided confidence interval of 95%, 45 subjects per group would be required, thus giving a sample size of 90. Further, accounting for a withdrawal rate of 10%, 50 subjects per group needed to be recruited, leading to a total sample size of 100 subjects. The randomization was performed with an in-center computergenerated random number table by an authorized study coordinator, and the subjects were randomized in a 1:1 ratio to receive either intravenous low-dose CYC or oral MMF. Statistical analysis Analyses were performed by considering all observations pertaining to each variable. Hence, the data set was not adjusted by omitting all missing variables globally. The results under APP analysis thus have different sample sizes (n), depending on the missing observations therein. Missing observations were imputed under a multivariate setting, where other variables were taken as predictors for imputing missing observations of the individual variables for ITT analysis. Continuous data are presented as mean ± s.d. or median and interquartile range, as appropriate. Normality of the quantitative data was checked by the Kolmogorov–Smirnov test. For normally distributed data, means for the two groups were compared using Student’s t-test, whereas non-normal data were tested by the Mann– Whitney’s U-test. With in-patient–related variables were compared using a paired t-test or analysis of variance. Change in the SLEDAI score was assessed by the Wilcoxon signed-rank test. Qualitative or categorical variables were described as frequencies and proportions. Proportions were compared using χ2 or Fisher’s exact test as applicable. The McNemar test was applied to compare between pre- and post-treatment values. A two-sided P-value of o0.05 was considered significant. All calculations were performed using SPSS version 21 (Statistical Packages for the Social Sciences, Chicago, IL) on a Windows platform.
patient management and end point assessment; MR, AG, and AJ have drafted the manuscript; RR, AS, and VK have helped in data acquisition, data analysis, and literature search; VJ and HSK have supervised the patient management, edited the manuscript, and provided intellectual support; and KLG and VS have supervised the study, provided intellectual support, critically reviewed, and edited the manuscript.
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DISCLOSURE
All the authors declared no competing interests. 14.
ACKNOWLEDGMENTS
We thank Dr Brad H Rovin (Professor and Director, Division of Nephrology, Department of Internal Medicine, The Ohio State University, OH, USA) for reviewing the manuscript. He has performed language editing and provided valuable feedback to improve the quality of paper.
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AUTHOR CONTRIBUTIONS
All the authors meet the four criteria defined by ICMJE. They have made substantial contributions to the conception or design of the work or the acquisition, analysis, or interpretation of data for the work. The authors have contributed to the draft preparation and revising it critically for important intellectual content. All the authors have approved the final version of the draft and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. In addition, MR has conceptualized and designed the study; AG and AJ have recruited the patients and randomized them; MR, AG, and PKG have performed the data acquisition and statistical analysis; MR and AS have supervised the randomization and patient recruitment and contributed to Kidney International
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