For the treatment of Class III or Class IV LN, alone or in combination with Class V features, members of the ALNN agreed on the following: It is important to expedite the investigative and diagnostic process to aim for starting treatment early, since delay of effective LBH589 in vivo treatment implies continuous attrition of nephron mass, renal reserve, and a negative impact on renal survival. Initial (induction) treatment should be combination immunosuppression comprising high-dose corticosteroids
and an immunosuppressive agent. The latter can be intravenous pulse CYC, MMF, or oral CYC for a limited duration, and the choice INCB024360 cost takes into consideration cost, compliance, geographical access, and reimbursement policy. The duration of this ‘induction’ phase lasts four to six months. There was consensus that intravenous pulse corticosteroid treatment, at a dose of 250–1000 mg methylprednisolone daily for three days, should be administered to patients with crescentic involvement of 10% or more of the glomeruli
on renal biopsy, or those with deteriorating renal function attributed to the nephritic process. There were diverse opinions on the use of pulse corticosteroid in patients with lesser degrees of disease severity. Following
pulse corticosteroid therapy, oral prednisolone is commenced at a dose of 0.5–0.6 mg/kg daily, while the starting dose is 0.8–1.0 mg/kg daily when not preceded by intravenous pulses. The dose of oral corticosteroids next is thereafter tapered to target a dose of prednisolone below 20 mg daily after 3 months, and below 10 mg daily at 6 months from baseline. Combination immunosuppression with corticosteroids and MMF is considered a standard-of-care treatment option, in view of the published data demonstrating its efficacy and tolerability in the majority of Asian patients treated with this regimen.[31-33, 35] However, it should be noted that patients with crescentic LN and rapidly deteriorating renal function were often excluded from prior clinical trials. Also, the results of a post-hoc analysis of pooled data suggest that while the short-term efficacy was similar between MMF or CYC based induction treatment in patients with Class III/IV LN and renal impairment, CYC induction may be associated with more sustained remission and more favorable long-term renal outcome. It is therefore important to monitor the responsiveness when MMF is used to treat patients with very severe disease.