A 32-year-old woman with SLE on hydroxychloroquine has worsening lupus nephritis class III confirmed on biopsy. Her creatinine has risen from 0.8 to 1.4 mg/dL. Per EULAR/ERA-EDTA 2019 guidelines, what is the recommended induction regimen?
- A Mycophenolate mofetil 2–3 g/day plus low-dose glucocorticoids, or IV cyclophosphamide (Euro-Lupus protocol) plus glucocorticoids ✓
- B High-dose prednisolone alone
- C Azathioprine plus high-dose prednisolone
- D Rituximab monotherapy as first-line induction
Correct answer: A. Mycophenolate mofetil 2–3 g/day plus low-dose glucocorticoids, or IV cyclophosphamide (Euro-Lupus protocol) plus glucocorticoids
Explanation
Current EULAR 2019 guidelines recommend either mycophenolate mofetil (MMF, 2–3 g/day) or low-dose IV cyclophosphamide (Euro-Lupus regimen: 500 mg every 2 weeks for 6 doses) combined with glucocorticoids as first-line induction for class III/IV lupus nephritis. MMF and Euro-Lupus cyclophosphamide have comparable efficacy with less toxicity than the original NIH high-dose cyclophosphamide regimen. Hydroxychloroquine should be continued throughout. Azathioprine is the preferred maintenance agent, not induction.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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