Dr. Loza-Santamaría has received consultancy fees, speaking fees, and/or honoraria (less than $10,000 each) from Abbott, MSD, and Roche.
Systemic Lupus Erythematosus
Efficacy and Safety of Nonbiologic Immunosuppressants in the Treatment of Nonrenal Systemic Lupus Erythematosus: A Systematic Review
Article first published online: 28 OCT 2013
Copyright © 2013 by the American College of Rheumatology
Arthritis Care & Research
Volume 65, Issue 11, pages 1775–1785, November 2013
How to Cite
Pego-Reigosa, J. M., Cobo-Ibáñez, T., Calvo-Alén, J., Loza-Santamaría, E., Rahman, A., Muñoz-Fernández, S. and Rúa-Figueroa, Í. (2013), Efficacy and Safety of Nonbiologic Immunosuppressants in the Treatment of Nonrenal Systemic Lupus Erythematosus: A Systematic Review. Arthritis Care Res, 65: 1775–1785. doi: 10.1002/acr.22035
- Issue published online: 28 OCT 2013
- Article first published online: 28 OCT 2013
- Accepted manuscript online: 22 APR 2013 03:42PM EST
- Manuscript Accepted: 12 APR 2013
- Manuscript Received: 20 FEB 2013
- Roche Spain
- European Union 7th Framework Programme. Grant Numbers: 316265 (BIOCAPS), FP7/REGPOT-2012-2013.1
To analyze the efficacy and safety of nonbiologic immunosuppressants in the treatment of nonrenal systemic lupus erythematosus (SLE).
We conducted a sensitive literature search in Medline, Embase, and the Cochrane Central Register of Controlled Trials up to October 2011. The selection criteria were studies including adult patients with SLE, a treatment intervention with nonbiologic immunosuppressants, a placebo or active comparator group, and outcome measures assessing efficacy and/or safety. Meta-analyses, systematic reviews, clinical trials, and cohort studies were included. The quality of each study was evaluated using Jadad's scale and the Oxford Levels of Evidence.
In total, 158 of the 2,827 initially found articles were selected for detailed review; 65 studies fulfilled the predetermined criteria. Overall, the studies were low quality, with only 11 randomized controlled trials (RCTs). Cyclophosphamide demonstrated efficacy for neuropsychiatric SLE, preventing relapses with an additional steroid-sparing effect, although its use was associated with cumulative damage, development of cervical intraepithelial neoplasia, and ovarian failure. Other immunosuppressants (azathioprine, methotrexate, leflunomide, mycophenolate mofetil, and cyclosporin A) demonstrated efficacy in reducing nonrenal activity and flares with a steroid-sparing effect, although only on occasion in non–placebo-controlled RCTs of small numbers of patients.
Several immunosuppressants demonstrated their safety and efficacy in nonrenal SLE. A specific drug for each particular manifestation cannot be recommended, although cyclophosphamide may be used in more severe cases, and methotrexate may be the first option in most cases of moderately active SLE. High-quality RCTs of larger numbers of patients are needed.