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Lupus Nephritis (LN)
A major cause of morbidity and mortality; regular screening with
urinalysis (hematuria, pyuria, casts) and urine protein-to-creatinine ratio
(UPCR) is vital in all SLE patients. Induction regimens for proliferative
LN (Class III/IV) have typically included MMF or cyclophosphamide,
often combined with glucocorticoids. Voclosporin (with MMF) and
belimumab (with standard therapy) are newer approved induction
options that have rapidly eclipsed cyclophosphamide in utilization
because of both lower toxicity and better results. Maintenance therapy
usually involves MMF or AZA (and now belimumab). Achieving rapid
and complete renal response is the goal to preserve long-term kidney
function.

Comorbidity Management
Non-rheumatologists are central here.
• Cardiovascular Disease: SLE confers a significantly elevated risk
of accelerated atherosclerosis, which is independent of traditional
risk factors. Aggressive management of hypertension, dyslipidemia,
diabetes and smoking cessation is paramount as are inflammatory
disease control and steroid dosing limitation.
• Infections: Increased risk due to both underlying immune dys-
regulation and immunosuppressive therapies. Ensure appropriate
vaccinations (pneumococcal, influenza, COVID-19, HPV, Zoster;
avoid live vaccines in significantly immunosuppressed patients).
• Osteoporosis: Screen and manage risk, especially with cumulative
glucocorticoid exposure.
• Mental Health: Depression and anxiety are common; screen and
facilitate appropriate care. The most common neuropsychiatric
manifestation of SLE is mood disorder (generally depression and/
or anxiety). This level of central nervous system involvement is
present in more than half of all SLE patients in some studies.

Conclusion
SLE management is increasingly nuanced, moving towards targeted
therapies based on pathogenic pathways and more personalized
approaches. While HCQ remains central, biologics like belimumab and
anifrolumab, along with voclosporin for LN, offer valuable additions.
More targeted therapies including biologics are expected to be approved
in the next few years. Vigilant screening for organ involvement (especially
renal) and aggressive management of comorbidities, particularly
cardiovascular risk, are essential components of care.

Pendleton Wickersham, MD, graduated from Rice University
in 1996, attended Baylor College of Medicine in Houston and
earned his medical degree with honors in 2000. He completed
his internship, residency and fellowship at University of Colorado
Health Sciences Center in Denver where he worked in a basic sciences lab
as part of his research training. Dr. Wickersham moved to San Antonio
in early 2006 to join a large rheumatology practice. He is a partner in the
San Antonio-based Arthritis Associates, PA, where he has created a Lupus
Center of Excellence to care for over 500 active lupus patients. A frequent
national and international speaker and consultant, he has invented several
medical devices, a molecule for pain, and a nutraceutical for arthritis. He
is a principal investigator for clinical trials with Flourish Research.
Dr. Wickersham is a member of the Bexar County Medical Society.