Nephrologists have long had a love-hate relationship with steroids. While effective at inducing remission in many immunologically mediated glomerular diseases, we are well aware of their multitude of side effects; be it the damage to bones and increased risk of diabetes, or, perhaps more troubling to patients in the short term, the associated weight gain and mood changes. Let’s face it, steroids are nasty drugs to take. Therefore, any strategy that allows us to reduce, or even negate their use, must be a good thing. Well, the results of the recently published MinTac study offer to achieve exactly this, a no steroid strategy for treating Minimal Change Disease (MCD).
The study randomised 50 patients with do-novo MCD to receive either prednisolone or tacrolimus monotherapy. There was no significant difference between the proportion of patients achieving complete remission by 8 weeks; 84% for prednisolone arm versus 68% in the tacrolimus arm, p = 0.32. By 26 weeks the corresponding proportions in remission were 88% and 92% respectively. Additionally, there was no significant difference in the relapse rate. A post-hoc analysis did reveal that a significantly greater proportion of patients in the steroid arm had achieved complete remission by 4 weeks, although the total number in remission (complete and partial remissions together) was no different.
Although a small study, this provides evidence that monotherapy with tacrolimus is a legitimate alternative to steroids for treating do-novo MCD. Those presenting with life threatening complications of the nephrotic syndrome, where achieving remission quickly is a priority, may still be better off with steroids, although this is arguable given the total number of remissions were no different at 4 weeks.
This is an important trial that will almost certainly influence practice. While it seems steroids still offer the fastest route to a remission, there is now good evidence that MCD can be effectively treated without them. Faced with the prospects of taking high dose steroids or a slightly slower time to remission, I know which option I would choose.
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