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Lupus Nephritis Maintenance — RACP Adult Medicine MCQ

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HardRheumatologyLupus Nephritis MaintenanceRACP Adult Medicine

A 28-year-old with class IV lupus nephritis has maintained a complete renal response for 12 months on mycophenolate, hydroxychloroquine and low-dose prednisolone. She wishes to conceive in six months. Which maintenance change is most appropriate?

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Correct answer: D — Change mycophenolate to azathioprine before conception, continue hydroxychloroquine and confirm sustained renal quiescence pre-pregnancy

The best answer is “Change mycophenolate to azathioprine before conception, continue hydroxychloroquine and confirm sustained renal quiescence pre-pregnancy”. Mycophenolate is teratogenic and should be replaced before conception. Azathioprine is pregnancy-compatible, and hydroxychloroquine should continue because withdrawal increases flare risk. Tacrolimus, cyclophosphamide and rituximab are not the appropriate planned maintenance substitution here; continuing mycophenolate until pregnancy is confirmed risks fetal exposure.

Reference: Australian Prescriber: Immunomodulatory drugs in pregnancy and lactation: https://australianprescriber.tg.org.au/articles/immunomodulatory-drugs-in-pregnancy-and-lactation.html KDIGO: Lupus nephritis guideline: https://kdigo.org/wp-content/uploads/2024/01/KDIGO-2024-Lupus-Nephritis-Guideline.pdf Australian RACP: Divisional Written Examination: https://www.racp.edu.au/trainees/examinations/divisional-written-examination