Would you be comfortable combining rituximab with voclosporin in patients with lupus nephritis not responding to standard therapy?

1st: Voclosporin is standard therapy :-). I find it interesting that we often use "standard therapy" to mean "a mycophenolate analogue or cyclophosphamide (CYC)." I consider these "old therapies" that only achieve a 25% to 30% clinical remission, leaving 65% - 70% of those patients at high risk of end-stage kidney disease. I prefer the 2025 EULAR guidelines that call mycophenolate and cyclophosphamide "anchor immunosuppressants" instead. Belimumab, calcineurin inhibitors (CNI; tacrolimus, voclosporin), or obinuzumab should be considered standard therapies that should be used initially in patients as a part of quadruple therapy per the 2025 EULAR Lupus Nephritis Guidelines (announced at EULAR 2025 and included obinutuzumab).

2nd: If a patient...

I agree with Dr. @Dr. First Last' comments. I think we can use the combination of a CNI and a B-cell depleting agent safely, and this has been reported, as noted, in non-lupus membranous nephropathy. In LN, the combination of a T cell drug and a B cell drug may provide a synergistic approach to treatment. Use in refractory LN may be helpful, assuming refractory LN is not due to undertreatment or non-adherence. Of course, there are no confirmed therapies for refractory LN presently, although deep B cell depletion for refractory disease is being studied now with CAR T cells and bi-specific engineered antibodies (T cell engagers). When choosing an approach for refractory LN, it may be important to consider the clinical characteristics of the p...