Recurrent Palpitation in a Young Man with Systemic Lupus Erythematosus Undergoing Belimumab with Resolution After Switching to Telitacicept

Abstract

Background Cardiovascular disease is a significant complication of SLE patients, leading to high risk of morbidity and mortality. Atherosclerosis is a major contributor. Belimumab can reduce disease relapses and indicated to be atheroprotective. As a new biologic agent telitacicept targets both BLys and APRIL and inhibits both B cells and plasma cells. It may become a better option. Methods This case report describes a male patient with SLE combined with refractory lupus nephritis. Belimumab was given on the basis of corticosteroids and MMF. His condition was partially improved but recurrent palpitation occurred. Coronary artery atherosclerosis was confirmed. After switching from belimumab to telitacicept, palpitation disappeared and the patient’s condition gradually improved. Results A 40-year-old man presented recurrent fatigue for 8 years. He is a non-smoker, BMI 24.07kg/m2, without family history of CAD. In October 2015, pancytopenia was found, with ANA, anti-dsDNA and U1-nRNP/Sm antibody positive. C3 decreased obviously. Coombs test was positive. 24h proteinuria was 11895 mg. SLE complicated with lupus nephritis was diagose and he was treated with pulse steroid, IVIG and CTX. Condition was improved, and he maitained steroid, MMF and hydroxychloroquine. In May 2023, he stopped MMF himself for fear of COVID-19 infection. Soon lower limbs edema developed. C3 0.37g/L, C4 0.02g/L, dsDNA 675.3 IU/ml, 24h-P 8444 mg was documented. SLEDAI score was 12. Renal pathology indicated ISN/RPS 2003 Class IV-G(A)+V Lupus Nephritis. He received pulse steroid (MP 500 mg per day) for 3 days, belimumab 720mg once and with MMF 750mg twice per day. Belimumab was regularly given after disease was controlled. Proteinuria decreased and remained about 3g. In August,2023, the patient began to feel palpitation repeatedly. LDH, HBDH and LDL increased. Holter showed sinus rhythm, accidental supraventricular premature beat, but no ST-T change. Coronary CTA showed non-calcified plaques in local section of RCA and the proximal section of branch of LAD, with slight stenosis. Rosuvastatin was prescribed. But palpitation reoccured after belimumab was given. Belimumab was stopped and changed to telitacicept 160mg every 4 weeks from 12 November, 2023. Till now, palpitation doesn’t occure. Prednisolone was tapered down to 7.5mg per day and MMF maintained 750mg twice a day. Complements rised. Proteinuria decreased to 1164.34mg. Conclusion Telitacicept is supposed to be a choice for refractory active SLE patient with atherosclerosis who has poor response to conventional therapy.