Lupus Nephritis Induction Trials (revision)

OK guys. Time for lupus revision. OK we all know that the NIH protocol for INDUCTION has both short-term and long-term adverse effects of Cyclophosphamide (CYC). What else is there?

For exam purposes ;

CYCLOPHOSPHAMIDE
Euro Lupus Nephritis Trial (Houssiau et al)
(n=90)class IV LN receive either high-dose (monthly pulses x 6 followed by quarterly pulses x 2) or low-dose (500 mg biweekly × 6 pulses) IV CYC induction followed by azathioprine (AZA) maintenance in a dose of 1 mg/kg/day
Result : No difference in remissions. No difference in flares. Less infections with low dose. Limitation : milder disease, almost all causasians (no blacks)

Cellcept / MMF
Chan et al. (n=42)DPLN receive 6 months of induction with MMF (2 g/day) or oral CYC (2.5 mg/kg/day), both with concurrent prednisolone.During the maintenance phase, those in the MMF arm continued the drug at a reduced dose (1 g/day)and those in the CYC arm switched to AZA (1.5 mg/kg/day)for 6 months.
Result: At 12 months, there were no differences in CR, PR or relapse.
.... they added another 22 patients, followed up 5 years.
Result: same, no difference as above. Fewer infections with MMF arm.

Hu et al. 6 months MMF vs conventional IV CYC. Result : MMF better

Ginzler et al. (n=140) majority Class IV. MMF vs standard IV CYC (6 months). Crossover allowed at 3 months.
Result: MMF better at 6 months(CR, PR, infection rate). At 3 years, no difference (death, flare, renal failure)

... watch out for Aspreva (IV CYC vs MMF 6 months) ... but after that MMF vs Aza (i think i can predict the result ... clear winner in MMF ... but imagine if there is no difference between MMF and aza .... hehehe.