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Class IV lupus nephritis receiving voclosporin — SCE Rheumatology MCQ

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ModerateNephritisClass IV lupus nephritis receiving voclosporinSCE Rheumatology

A 35-year-old woman with biopsy-proven active class IV lupus nephritis starts voclosporin 23.7 mg twice daily alongside mycophenolate mofetil and a reducing glucocorticoid regimen. Her baseline estimated glomerular filtration rate (eGFR) was 68 mL/min/1.73 m². Fourteen days later, her eGFR is 51 mL/min/1.73 m²; a repeat measurement 24 hours later is 50 mL/min/1.73 m². She is euvolaemic and normotensive, with stable serum potassium and no intercurrent illness, nephrotoxic exposure or interacting CYP3A4 inhibitor. Proteinuria is beginning to fall, and urine sediment activity and anti-dsDNA titre have not worsened. Which is the most appropriate next step in managing her voclosporin treatment?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: A — Reduce voclosporin to 15.8 mg twice daily and repeat the eGFR within two weeks

Explanation lettering: C = shown as A · A = shown as B · B = shown as C · E = shown as D · D = shown as E

Her confirmed eGFR reduction is approximately 26% from baseline and the eGFR is now below 60 mL/min/1.73 m². The voclosporin SmPC specifies that a confirmed reduction of more than 20% but less than 30% requires a dose reduction of 7.9 mg twice daily. The dose should therefore fall from 23.7 mg to 15.8 mg twice daily, with reassessment for recovery within two weeks. The timing and absence of evidence for recurrent nephritic activity support the recognised early haemodynamic effect of calcineurin inhibition. A is inappropriate because maintaining the dose applies to a reduction of 20% or less, or when eGFR remains at least 60. B corresponds to a reduction of at least 30%, when voclosporin should be stopped and later restarted at 7.9 mg twice daily after recovery. D makes two dose reductions immediately; a further 7.9 mg twice-daily reduction is indicated only if renal function has not recovered after the initial reduction. E is excessive because an early eGFR fall of this magnitude is managed by protocolised dose adjustment rather than automatic permanent withdrawal, provided alternative causes have been excluded and renal function is monitored.

Reference: Lupkynis 7.9 mg soft capsules — Summary of Product Characteristics (14 November 2025) — https://www.medicines.org.uk/emc/product/14381/smpc Voclosporin with mycophenolate mofetil for treating lupus nephritis: recommendations (3 May 2023) — https://www.nice.org.uk/guidance/ta882/chapter/1-Recommendations