Table 1:
Drug therapies commonly used and/or approved for the treatment of primary IgAN.
| Drug | Dose | Marker of response | Precautions | Toxicity |
|---|---|---|---|---|
| RAASi | ACEi: e.g. enalapril 5 mg OD PO uptitrated to 40 mg/day as tolerated [20]ARB: e.g. valsartan 80 mg OD PO uptitrated to 160 mg/day as tolerated [21] | Reduction in proteinuriaReduction in BPReduced eGFR slope | Hold during acute illness (e.g. dehydration, infection)Check for a rise in serum creatinine >30% or hyperkalemia 7–10 days after starting, particularly in patients with an eGFR <30 mL/min/1.73 m2 or history of hyperkalemia | HyperkalemiaHypotensionAKI (e.g. in setting of bilateral renal artery stenosis, volume depletion, sepsis) |
| SGLT2i | Dapagliflozin 10 mg OD PO (DAPA-CKD) [23]Empagliflozin 10 mg OD PO (EMPA-Kidney) [24] | Reduction in proteinuriaReduction in BPReduced eGFR slope | Hold during acute illness (e.g. dehydration, infection)Caution in patients with history of recurrent urinary tract infection or genital CandidaEfficacy and safety not formally tested in the setting of simultaneous use of immunosuppressants | Genital fungal infectionUrinary tract infectionEuglycaemic diabetic ketoacidosis |
| Dual ERA/ARB | Sparsentan 200 mg OD PO uptitrated to 400 mg OD PO as tolerated [94]Stop other ACEi/ARB | Reduction in BPReduction in proteinuria | Hold during acute illness (e.g. dehydration, infection)Check for a rise in serum creatinine >30% or hyperkalemia 7–10 days after starting | HyperkalemiaHypotensionAKI (e.g. in setting of bilateral renal artery stenosis, volume depletion, sepsis)Oedema |
| Enteric-coated budesonide | Budesonide 16 mg OD PO [95] | Reduction in proteinuria | Cautious use in patients with obesity or DM | Glucose intolerance/DMWeight gainAcneAltered appearance (moon facies/hirsutism) |
| Systemic corticosteroids | Methylprednisolone PO0.4 mg/kg/day max 32 mg/day for 2 months followed by 4 mg/day taper each month for total 6–9 months(TESTING-2 protocol) [36](or prednisolone equivalent) | Reduction in proteinuriaResolution of haematuriaReduced eGFR slope | PJP prophylaxisScreen for and treat prevalent chronic infections (e.g. TB, HBV) prior to initiationCautious use in patients with obesity or DMCautious use in patients with psychiatric historySee ‘Strategies for personalizing treatment in IgAN’ | Glucose intolerance/DMOpportunistic infectionWeight gainOsteoporosis/avascular necrosisAcneAltered appearance (stretch marks/buffalo hump/moon facies/hirsutism)Mood/psychosis |
| MMF | MMF 1.5 g/day for 12 months then taper to 0.75–1 g/day for up to 2 years (MAIN protocol) [39] | Reduction in proteinuriaResolution of haematuriaReduced eGFR slope | Screen for and treat prevalent chronic infections (e.g. TB, HBV) prior to initiationVZV vaccination | DiarrhoeaPneumoniaShinglesLeucopenia |
ACEi = angiotensin-converting enzyme inhibitor; ARB = angiotensin-II receptor blockers; OD = once per day; PO = administer orally; AKI = acute kidney injury; TB = tuberculosis; HBV = hepatitis B virus; PJP = Pneumocystis jirovecii pneumonia; VZV = Varicella-Zoster virus; M = male; F = female; BP = blood pressure; IS = immunosuppression; IV = intravenously; PCR = protein-creatinine ratio; OR = odds ratio.