Uptake of belimumab continues to outpace the use of anifrolumab among clinicians managing patients with systemic lupus erythematosus, according to a survey conducted by Spherix Global Insights.
A top-line data point from the survey suggests that, among patients with SLE currently treated with biologics by the 100 rheumatologist respondents, 62% were receiving belimumab (Benlysta, GlaxoSmithKline) as of the third quarter of 2024. Meanwhile, 18% were being treated with anifromulab (Saphnelo, AstraZeneca) and 16% were receiving rituximab (Rituxan, Genentech).
However, the increasing use and availability of both belimumab and anifromulab — no matter which ends up on top — heralds an “exciting time” in lupus, according to Allen P. Anandarajah, MBBS, MS, of the University of Rochester Medical Center.
“Lupus was traditionally behind other disease states like rheumatoid arthritis and the spondyloarthropathies,” Anandarajah, who was not involved with the Spherix survey, told Healio. “It is turning out to be an exciting time for this group we call ‘lupologists.’
“We had about a 50-year gap before we had new medications approved for lupus,” he added. “For a long time, there was only hydroxychloroquine and prednisone.”
Although Anandarajah acknowledged the “important role” prednisone has served in lupus management, he cited “huge side effects” as reasons to seek alternatives.
“While we recognized the need for steroid-sparing agents, for a long time the only one we had was hydroxychloroquine,” he said.
Enter Benlysta, which, according to Anandarajah, changed the game for SLE treatment.
“We accepted it with open arms,” he said. “There was so much excitement about the use of biologics in lupus. We are now able to potentially keep pace with management options for other rheumatic conditions, such as rheumatoid arthritis and psoriatic arthritis, where biologic use is commonplace.”
In addition to the steroid-sparing benefit, the drug’s promising efficacy data and indication for lupus nephritis are critical factors cited by rheumatologists for the high uptake of Benlysta, according to the survey results.
Anandarajah noted the challenges in managing lupus nephritis as an additional key point.
“It is no surprise that it is accepted as widely as it is,” he said.
Rheumatologists are ‘thoughtful and methodical’
Further data from the Spherix survey demonstrate that Saphnelo has yet to break through in terms of frequent use for SLE. When asked to list the last five new prescriptions they had written for a biologic to treat moderate-to-severe SLE, 65% of 100 respondents named Benlysta during the third quarter of 2024, while just 22% named Saphnelo during the same time period.
Anandarajah suggested that there might be “multiple reasons” for this trend.
“Rheumatologists are particularly thoughtful and methodical in their approach to treating patients,” he said. “Even though biologics are exciting therapies, we also realize there are potential side effects. We take our time to be comfortable with the medications.”
Given time, more rheumatologists may grow more comfortable with Saphnelo, according to Anandarajah. However, he voiced some possible reasons why this specific medication has not pulled even with Benlysta in terms of uptake among rheumatologists.
“There were some issues with the clinical trials for Saphnelo,” he said. “The first trial did not really succeed, so they changed outcomes for subsequent trials. That caused some confusion and apprehension.”
Although the increasing number of biologics in the marketplace has assuaged some of those concerns, winning the hearts and minds of rheumatologists remains a slow process for certain drugs.
“Since then, people have recognized there is a choice,” Anandarajah said. “But it just takes time. Many of us rheumatologists like to learn to use these medications on our own, and see how our colleagues use them.”
The question, then, is if or when Saphnelo will close the gap with Benlysta. Anandarajah, for his part, was loathe to make any concrete predictions.
“I wish I had a crystal ball,” he said. “It is a matter of time before people become more comfortable with it. In the meantime, I am sure there will be other medications coming, but I believe Saphnelo will find its own unique place in the lupus treatment paradigm.”
Understanding current initiation drivers for Saphnelo may provide some clues as to when that might happen.
The right drug for the right patient
“The way I look at it is there are still many patients who do not respond to traditional medications like hydroxychloroquine and low dose steroids,” Anandarajah said. “So here, in Saphnelo, is another option that has been proven.”
Rheumatologists tend to use a lot of medications — like mycophenolate, or azathioprine —without the benefit of randomized controlled trials, according to Anandarajah.
“Now we have a drug that is proven to be efficacious in controlling disease activity and equally potent steroid-sparing effects,” he said.
The steroid-sparing component is particularly important for young women to avoid long-term adverse events, Anandarajah added.
“Anything we can do to get rid of steroids is helpful,” he said.
Looking deeper into the survey findings, further information from Spherix suggests patients with depression and cutaneous lupus may not be ideal candidates for treatment with Benlysta.
“Benlysta has side effect of depression, so it should definitely be used with caution in those patients,” Anandarajah said.
He added that suicidal ideation and self-harming thoughts are not uncommon in patients treated with this medication.
“I am glad to hear it is not being used in these patients, because that shows that physicians are reading the warning labels and appropriately limiting its use.”
Meanwhile, Benlysta remains unproven and unapproved for cutaneous lupus.
“It is not proven in cutaneous lupus,” Anandarajah said. “There are potentially much safer drugs with fewer side effects in that patient population. Just because we have a new drug does not mean we have to use it for every patient.”
Overall, though, this is an “important and interesting time” for lupus management, according to Anandarajah.
“There are studies ongoing with the NIH and drug companies,” he said, noting the Accelerating Medicine Partnership, a collaboration between the NIH and 10 biopharmaceutical companies. “The NIH is working with industry to find better disease pathways for better selection of targets for treatment. We understand more about this heterogenous disease and are finding newer treatment options to target these pathways.”
