Tacrolimus is an effective treatment for lupus nephritis in pregnancy

Abstract

Lupus nephritis during pregnancy increases morbidity and mortality for mother and baby. Flares are difficult to treat as many therapeutic options are teratogenic or fetotoxic. Steroids alone may be unable to control disease activity and are associated with higher rates of preterm delivery, sepsis and gestational diabetes. Reports of using tacrolimus to treat lupus nephritis in pregnancy are limited. We describe the pregnancies of nine women in whom tacrolimus was successfully used to treat lupus nephritis flare (six patients) or maintain stable disease (three patients). Introduction or dose escalation of oral steroids was avoided in five of the patients who developed active disease and steroid dose was rapidly reduced in the sixth patient. All women with disease flare attained partial or complete remission after starting tacrolimus. None of the women on maintenance treatment developed active disease. We propose tacrolimus as an effective adjuvant or alternative therapy to steroids for treating lupus nephritis flare or maintaining stable disease during pregnancy.

Pregnancy and autoimmune connective tissue diseases

“…Tacrolimus is a calcineurin inhibitor that has been used successfully in both the maintenance of stable disease and treatment of lupus nephritis flare in pregnancy in several case series, in which no adverse outcomes were observed [126,127]. It is considered safe for use in pregnancy [128,129]; the lowest effective dose should be used and levels must be followed to avoid toxicity.…”

Tacrolimus versus mycophenolate mofetil for induction therapy of lupus nephritis: a randomised controlled trial and long-term follow-up

“…Therefore, MMF is contraindicated during pregnancy. On the contrary, TAC is not linked to congenital malformations in solid organ transplantation43 and has been successfully used to treat LN flares during pregnancy 44…”

Tacrolimus use in lupus nephritis: A systematic review and meta-analysis

“…MMF is contraindicated during 409 pregnancy due to a link with increased incidence of first-trimester preg- ticipants [37]. Potential problems using tacrolimus may arise from 428 the complex pharmacokinetics, which will be altered in pregnancy, 429 increasing the risk of toxicity due to higher unbound drug fractions.…”

“…review identified 1 case report, a case series of 2 pa-252 tients, and a retrospective analysis of 9 patients all successfully treated 253 with tacrolimus during pregnancy[35][36][37]. Overall five of these cases254 were already taking tacrolimus prior to pregnancy and had quiescent 255 disease throughout.…”