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One-third of women with systemic lupus erythematosus (SLE) develop lupus nephritis (LN), and most receive mycophenolate mofetil (MMF), which is teratogenic and needs to be switched to a pregnancy-compatible drug before conception.1 2 Azathioprine (AZA) is the immunosuppressive of choice in SLE pregnancies, but best practice guidelines in rheumatology provide recommendations on neither pharmacogenetic testing (for thiopurine methyltransferase (TPMT) and nudix hydrolase 15 (NUDT15) genes) nor therapeutic drug monitoring,2 3 likely due to lack of data in rheumatic diseases and limited indirect evidence in other populations (eg, inflammatory bowel disease).
Recent evidence in a small number of patients suggests that AZA metabolite monitoring in women with SLE during preconception and/or gestation might provide key opportunities to personalise therapy during this critical time (eg, identification of ‘shunting’, non-adherence, subtherapeutic/supratherapeutic dosing).4 Therefore, we aimed to evaluate practice patterns pertaining to management of women with LN in the preconception and gestational periods, in particular pharmacogenetic testing and drug monitoring.
In February 2022, we distributed an electronic survey via REDCap to 39 Systemic Lupus International Collaborating Clinics (SLICC) members affiliated with SLE referral centres (https://sliccgroup.org), with reminders after 2 and 6 weeks. Physicians were queried about the number of women with LN seen for pregnancy planning in the preceding year, time recommended waiting to conceive after renal response, choice of pregnancy-compatible immunosuppressive agents when switching from MMF, pharmacogenetic …
Footnotes
Handling editor Josef S Smolen
Presented at Prior conference presentation and published abstracts
1. Lee JYE, Mendel A, Askanase A, Bae S, Buyon J et al. 'Systemic lupus erythematosus Women with lupus nephritis In pregnancy Therapeutic CHallenge (SWITCH)': The Systemic Lupus International Collaborating Clinics experience. American College of Rheumatology (ACR) Convergence 2022 – Philadelphia, PA, USA. 10–14 November 2022. Arthritis & Rheumatology. 2022; 74 (suppl 9) (Abstract number 0949) (Poster Presentation, accepted 18 August 2022)
2. Lee JYE, Mendel A, Askanase A, Bae S, Buyon J et al. 'Systemic lupus erythematosus Women with lupus nephritis In pregnancy Therapeutic CHallenge (SWITCH)': The Systemic Lupus International Collaborating Clinics experience. Canadian Rheumatology Association (CRA) & Arthritis Health Professions Association (AHPA) Annual Scientific Meeting 2023 – Quebec City, QC, Canada. 8–11 February 2023. To be published (Abstract 2023–195) (Poster Presentation, accepted 25 November 2022)
3. Lee JYE, Mendel A, Askanase A, Bae S, Buyon J et al. 'Systemic lupus erythematosus Women with lupus nephritis In pregnancy Therapeutic CHallenge (SWITCH)': The Systemic Lupus International Collaborating Clinics experience. Lupus & Korean College of Rheumatology (LUPUS & KCR) – Seoul, Republic of Korea. 17–20 May 2023. To be published (Abstract LSO-083) (Short Oral Presentation, accepted 15 February 2023).
Contributors J-YEL conducted the data analysis and drafted the first version of the manuscript. AMe, AA, S-CB, JPB, AEC, NC-C, PRF, DDG, RR-G, JGH, MI, DAI, AMa, MM, MP, AR, JS-G, MU, DJW and SB contributed to the data interpretation. EV conceived and designed the study and interpreted the data.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests J-YEL, AMe, AA, S-CB, JPB, NC-C, PRF, DDG, JGH, MI, DAI, MM, AR, JS-G, MU, DJW, SB and EV all have nothing to disclose; AEC reports research funds from GSK outside the scope of this work and consulting fees (less than $10 000) from AstraZeneca, Bristol Myers Squibb and GSK outside the submitted work. RR-G reports consulting fees (less than $10 000) from Ampel Solutions, Exagen Diagnostics, Biogen and AstraZeneca, outside the submitted work. AMa is supported by the GSK’s Supported Studies Program (proposal ID 10743) and National Medical Council Clinicial Scientist-Individual Research Grant (MOH-001093), and received honoraria from Pfizer and GlaxoSmithKline for lectures/speakers (less than USD 10 000). MP received grant support from NIAMS R01-AR-069572.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.