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SLE Nephritis Drug Avoidance — RACP Adult Medicine MCQ

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HardRheumatologySLE Nephritis Drug AvoidanceRACP Adult Medicine

A 42-year-old with SLE has persistent class III/IV lupus nephritis activity despite adherent mycophenolate, hydroxychloroquine, glucocorticoid optimisation and control of blood pressure and proteinuria. Infection has been excluded and kidney function is preserved. Which escalation is supported as add-on therapy rather than substitution for induction treatment?

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Correct answer: A — Add belimumab to current nephritis induction therapy after reassessing adherence, chronicity, infection and drug exposure

The best answer is “Add belimumab to current nephritis induction therapy after reassessing adherence, chronicity, infection and drug exposure”. Belimumab can be added to standard therapy for selected active lupus nephritis with inadequate response; it does not replace induction. Cyclophosphamide is an alternative induction strategy, while calcineurin inhibitors require renal, blood-pressure and interaction assessment. Rituximab is generally reserved for refractory disease rather than automatic substitution.

Reference: Kidney Health Australia: Lupus nephritis: https://kidney.org.au/wp-content/uploads/2025/10/KHA-Factsheet-Lupus-Nephritis-2025.pdf 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