Reporting a Case on Good Response of Lupus Hepatitis to Mycophenolate Mofetil and Belimumab as of Lupus Exanthema to Rituximab

In clinical practice we face many patients with different manifestations of systemic lupus
erythematosus (SLE). Usually, they are being treated with immunosuppressive drugs to suppress
systemic inflammatory processes. Corticosteroids are often drugs of first choice, since they act
promptly, which may be beneficial in emergency cases, such as lupus nephritis or severe
neuropsychiatric conditions. A 66-year-old male patient had been primarily treated for cutaneous
lupus erythematosus 15 years ago. He received local corticosteroids and following systemic
immunosuppressants: methylprednisolone (MP), chloroquine (removed due to retinal haemorrhage),
cyclosporine A and azathioprine (both removed due to non-response). Due to polyarthralgia
methotrexate as well as golimumab were started. Despite good response, both drugs had to be
stopped due to development of hepatitis confirmed by liver biopsy (virus serological tests were
negative). Early after onset of a combination treatment with 1 g mycophenolate mofetil (MMF) per day
orally and 10 mg/kg belimumab intravenously at weeks 0, 2, 4, followed by every 4 weeks, a marked
decrease in liver enzymes could be detected. Due to insufficient response of lupus exanthema,
hydroxychloroquine (HCQ) was added.
Since we could not achieve an improvement of skin lesions after 9 months of belimumab
administration on combination with MMF and HCQ, the biologic therapy was switched to another Bcell
inhibitor - rituximab (1000 mg intravenously at weeks 0 and 2) known to be used to treat lupus
patients. Surprisingly, after the very first infusion a rapid and marked improvement of lupus
exanthema was noticed. Such an improvement had not been experienced since 2003.
We could confirm an excellent response of systemic lupus erythematosus (SLE)-associated hepatitis
as well as arthralgias to MMF and belimumab. Rituximab turned out to be more efficacious (in
combination with MMF and HCQ) for SLE-associated skin lesions in our patient, despite the fact that
these drugs are still not approved for treatment of SLE. Naturally, such medications should be
introduced after treatment failure or intolerance of approved drugs only. We want to encourage
physicians to collect data from off-label use of immunosuppressants in connective tissue diseases to
extend treatment possibilities in non-response or difficult patients.