A 32-year-old woman with SLE presents with serositis, active urine sediment, and proteinuria 3.2 g/day. Anti-dsDNA is markedly elevated and complement C3/C4 are low. Renal biopsy shows diffuse proliferative nephritis. Which induction regimen is MOST appropriate per current EULAR/ACR guidelines?
- A Mycophenolate mofetil (MMF) + hydroxychloroquine + corticosteroids ✓
- B Azathioprine + low-dose prednisolone
- C Methotrexate + corticosteroids
- D Rituximab monotherapy
Correct answer: A. Mycophenolate mofetil (MMF) + hydroxychloroquine + corticosteroids
Explanation
For Class III/IV lupus nephritis (diffuse proliferative), EULAR 2023 guidelines recommend induction with either MMF (2-3 g/day) or low-dose cyclophosphamide (Euro-Lupus regimen) combined with high-dose corticosteroids. MMF plus hydroxychloroquine is now preferred as first-line for most patients due to comparable efficacy to cyclophosphamide with a more favourable safety profile. Azathioprine is used for maintenance, not induction of severe nephritis. Methotrexate is for non-renal manifestations. Rituximab is reserved for refractory disease.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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