Indications for use of cyclophosphamide in SLE is: (PGI Nov 2010)
Correct Answer: Diffuse proliferative glomerulonephritis
Description: Ans: C (Diffuse,.) WHO Classification of Lupus Nephritis. Five Patterns Robbins 7th/ 231minimal or no detectable abnormalities (class I)mesangial lupus glomerulonephritis (class II)focal proliferative glomerulonephritis (class III)diffuse proliferative glomerulonephritis (class IV)membranous glomerulonephritis (class V)Proliferative Lupus Nephritis CRDT2nd/490"Several important trials conducted at the National Institutes of Health provided the rationale behind the current therapeutic regimens used to treat proliferative lupus nephritis. Key findings from these trials are as follows: (1) treatment with intravenous pulse cyclophosphamide (CYC) is superior to high-dose oral prednisone alone in preventing progression to end-stage renal disease, and (2) an extended course of CYC (six monthly pulses followed by quarterly pulses for 2 years) is more effective than pulse methylprednisolone and shorter courses of CYC in preserving renal function and preventing renal relapse. Thus the use of monthly intravenous pulse CYC (in conjunction with high-dose glucocorticoids) followed by quarterly pulse CYC became the standard of care in the community""Data suggest that cyclophosphamide is effective in most patients with severe lupus nephritis over both the short and the long term; many experts believe that it should be included in initial therapeutic regimens in most SLEpatients with severe nephritis (or other life-threatening, rapidly progressive organ involvement). IV cyclophosphamide is effective in some patients with serious extra re nai manifestations ofSLE, including diffuse CSS disease, thrombocytopenia, and interstitial pulmonary inflam motion"- Kelly Textbook of Rheumatology 7th/548SLE Harrison 17th/2080-82Cytotoxic/immunosiippressive agents added to glucocorticoids are recommended to treat serious SLE. Almost all prospective controlled trials in SLE involving cytotoxic agents have been conducted in patients with lupus nephritis, and always in combination with glucocorticoids.In patients whose renal biopsies show iSN grade HI or IV disease, early treatment with combinations of glucocorticoids and cyclophosphamide reduces progression to ESRD and improves survival. Prospective controlled trials in SLE but is nonetheless used by some clinicians.Since it has potential nephrotoxicity, but no hone marrow toxicity, the author uses it (in doses of 3-5 mg/kg per day PO) in patients with steroid-resistant cytopenias of SLE or in steroid-resistant patients who have developed bone marrow suppression from standard cytotoxic agents.it is important to note that there are few if any randomized, controlled, prospective studies of any agents in life- threatening SLE that does not include nephritis. Therefore, use of glucocorticoids plus cyclophosphamide or mycophenolate in other life-threatening conditions is based on studies in nephritis.
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