A 28-year-old woman with SLE on hydroxychloroquine has persistently active nephritis (24-hour urine protein 3.2 g, cellular casts). Renal biopsy shows diffuse proliferative nephritis (class IV). Which combination is now recommended as first-line induction therapy per the ACR 2019/EULAR 2019 guidelines?
- A High-dose prednisolone + cyclophosphamide (Euro-Lupus protocol)
- B Belimumab + mycophenolate mofetil
- C Rituximab + cyclophosphamide for refractory disease
- D High-dose prednisolone + mycophenolate mofetil (MMF) ✓
Explanation
For lupus nephritis class III or IV, both MMF (2–3 g/day) and cyclophosphamide (Euro-Lupus low-dose IV protocol or NIH high-dose) combined with high-dose glucocorticoids are considered equivalent first-line induction options per EULAR 2019 and ACR 2019 guidelines. MMF is preferred in Black and Hispanic patients where MMF has shown superior outcomes; it is also preferred for those wishing to preserve fertility. More recent data (BLISS-LN trial) supports addition of belimumab to standard of care for active class III/IV lupus nephritis. Rituximab is used in refractory cases, not as initial induction.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.