Comparative efficacy and safety of tacrolimus, mycophenolate mofetil, azathioprine, and cyclophosphamide as maintenance therapy for lupus nephritis

This study aimed to assess the relative efficacy and safety of tacrolimus, mycophenolate mofetil (MMF), azathioprine (AZA), and cyclophosphamide (CYC) as maintenance therapy for lupus nephritis.

Randomized controlled trials (RCTs) examining the efficacy and safety of tacrolimus, MMF, AZA, and CYC for maintenance therapy in lupus nephritis patients were included. We performed a Bayesian random-effects network meta-analysis to combine direct and indirect evidence from the RCTs.

Five RCTs including 525 patients were included. Although the difference was not statistically significant, tacrolimus showed a trend toward a lower renal relapse rate than AZA or CYC. Similarly, MMF showed a trend toward a lower relapse rate than AZA or CYC. Renal relapse tended to be lower in the AZA group than in the CYC group. Ranking probability based on the surface under the cumulative ranking curve (SUCRA) indicated that tacrolimus had the highest probability of being the best treatment based on the renal relapse, followed by MMF, AZA, and CYC. Analysis of withdrawal due to adverse events showed the same pattern. The leukopenia incidence was significantly lower in the MMF group than in the AZA group. Similarly, it tended to be lower in the tacrolimus group than in the AZA group. Ranking probability based on SUCRA indicated that MMF had the highest probability of being the safest treatment based on leukopenia incidence, followed by tacrolimus and AZA.

Lower renal relapse rates combined with a more favorable safety profile suggest that tacrolimus and MMF are superior to AZA and CYC as maintenance treatments in these patients.