LSO-083 ‘Systemic lupus erythematosus women with lupus nephritis in pregnancy therapeutic challenge (SWITCH)’: the systemic lupus international collaborating clinics experience
Bibliographic record
Abstract
Background Many SLE patients develop lupus nephritis (LN) and receive mycophenolate mofetil (MMF), a teratogenic drug. Guidelines recommend azathioprine (AZA) in SLE pregnancy without providing guidance on pharmacogenetic testing and therapeutic monitoring although these may help personalize therapy (e.g., identifying ‘shunters’, non-adherence). We evaluated practice patterns pertaining to SLE women with LN in preconception and gestational periods, focusing on pharmacogenetic testing and drug monitoring. Methods In 02/2022, we distributed an electronic survey to 39 Systemic Lupus International Collaborating Clinics (SLICC) members. Physicians were queried about number of LN patients seen for pregnancy planning, wait time physicians recommend preconception after renal response, choice of pregnancy-compatible immunosuppressive when switching from MMF, pharmacogenetic testing before AZA initiation, and therapeutic monitoring. Results Response rate was 74%. On average, respondents saw 7.2 (standard deviation 6.6) LN patients in the preceding year for pre-pregnancy counselling. Most (93%) recommended waiting for a minimal time after achieving renal response on MMF before transitioning to a pregnancy-compatible immunosuppressive (19% suggested ≤ 6 months, 44% 6–11 months, 30% 12–23 months). In patients with inactive LN for ≥ 2 years, 86% switched immunosuppressives, while 14% discontinued MMF without switching. First choice of pregnancy-compatible immunosuppressive was AZA (90%). Tacrolimus (TAC) was preferred over cyclosporine (CsA) by 96% as second option. When initiating AZA, 38% never assessed thiopurine methyltransferase (TPMT) genotype and/or phenotype and 97% never tested for nudix hydrolase 15 (NUDT15) gene. When switching MMF to AZA preconception, 14% measured 6-mercaptopurine (6-MP) levels. Most (56%) faced barriers to 6-MP testing related to access, cost, and wait times. When patients were on TAC or CsA, 48% monitored drug each trimester, while 44% never did. Conclusions There is low use of pharmacogenetic testing and therapeutic monitoring when transitioning MMF to a pregnancy-compatible drug preconception. We identified potential care gaps, which could be addressed by future pragmatic trials.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.002 | 0.003 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.000 | 0.000 |
| Bibliometrics | 0.000 | 0.001 |
| Science and technology studies | 0.002 | 0.001 |
| Scholarly communication | 0.001 | 0.001 |
| Open science | 0.000 | 0.001 |
| Research integrity | 0.001 | 0.001 |
| Insufficient payload (model declined to judge) | 0.007 | 0.001 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".