Systemic%20lupus%20erythematosus Treatment

Patients require individualized therapy depending on disease manifestations, activity and severity

Goals of Therapy

• Control disease manifestations, ie aim for remission or low disease activity and flare prevention
  • Complete remission is no clinical activity (SLEDAI = 0) without use of corticosteroids and immunosuppressants
  • Low disease activity is SLEDAI ≤4, PGA ≤1, corticosteroid use of ≤7.5 mg/day of Prednisone, and well-tolerated immunosuppressants in stable doses
• Allow the patient to have a long-term survival and good quality of life without major exacerbations
• Prevent serious organ damage that adversely affects function or life span
• Prevent adverse effects of the drugs used

Corticosteroids

Oral Corticosteroids

• Patients with mild SLE do not normally require use of systemic corticosteroids but there are patients whose quality of life is not improved if not given low-dose corticosteroids
  • Patients on remission or with low disease activity should be maintained with the lowest possible glucocorticoid dose
• Decrease inflammation by suppressing the immune system
  • Decrease lymphocyte volume and activity, PMN migration, capillary permeability
• Used as initial therapy for severe lupus erythematosus or lupus vasculitis
• Low-dose corticosteroids may be added to Hydroxychloroquine for fatigue and fever
• High-dose corticosteroids are necessary for refractory manifestations of SLE and for severe organ involvement especially CNS, renal and hematologic manifestations
  • Show improved survival in patients with severe forms of SLE nephritis
  • May also be useful in severe, life-threatening thrombocytopenia and hemolytic anemia
  • May also be useful in pleuritis or pericarditis
• Corticosteroid use should be <7.5 mg/day (Prednisone equivalent) during chronic maintenance therapy and tapered (and if possible withdrawn) as soon as desired response is observed (control of inflammatory manifestations) to avoid toxicity
  • Tapering or withdrawing of corticosteroids may be hastened with the prompt initiation of immunosuppressants 
  • High doses over periods of >2-3 weeks suppress adrenal function

Topical Corticosteroids

• Helpful for mild cutaneous involvement or discoid lesions especially on the scalp
• Use a less potent steroid on the face because it is more prone to atrophy

Parenteral Corticosteroids

• IV pulse dosing of Methylprednisolone gives immediate therapeutic effect and allows the initiation of oral corticosteroids at a lower dose  
• Pulse therapy with IV corticosteroids with or without immunosuppressive therapy can be given to patients with severe organ or life-threatening manifestations

Disease-Modifying Anti-Rheumatic Drug (DMARD) 

Hydroxychloroquine 

• A 4-aminoquinolone antimalarial, it has immunomodulatory and anti-inflammatory effects in the treatment of SLE
• Inhibits chemotaxis of eosinophils and locomotion of neutrophils and impairs complement-dependent antigen-antibody reactions
• Recommended for all SLE patients unless contraindicated
• Used for skin and joint manifestations
  • Useful for patients with skin disease that is unresponsive to topical corticosteroids and in patients with arthritis that does not respond to NSAID
• Recommended as background treatment for class III/IV SLE patients with nephritis
  • Patients with continuing treatment with Hydroxychloroquine showed less renal damage as compared to those on placebo
• Also used for preventing flares, reducing cardiovascular risk and recurrent infection, and other constitutional symptoms

Immunosuppressants

Choice of immunosuppressant will depend on nature and severity of disease manifestation 

• These agents act as immunosuppressive, cytotoxic and anti-inflammatory agents
• Consider the addition of immunosuppressants in patients unresponsive to Hydroxychloroquine therapy (with or without corticosteroids) or unable to decrease corticosteroid doses below that acceptable for chronic use
• Can be included in the initial treatment of organ- or life-threatening SLE wherein an initial course of high-intensity immunosuppressive therapy is given followed by a longer course of less intensive treatment to consolidate patient’s response and prevent relapses
  
  • In the treatment of severe CNS and severe glomerulonephritis, thrombocytopenia and hemolytic anemia, high-dose glucocorticoids and immunosuppressants are used
  • Concomitant use with corticosteroids allows lower doses of immunosuppressants

Azathioprine 

• Antagonizes purine metabolism and inhibits synthesis of DNA, RNA and proteins
• May decrease proliferation of immune cells resulting in lower autoimmune activity
• Used for mild to moderate SLE-related organ involvements (ie renal, neurological, hematological) and prevents flares
• May be used as the initial immunosuppressant for SLE nephritis

Calcineurin Inhibitors

• Eg Ciclosporin, Tacrolimus, Voclosporin
• Can be considered in patients with moderate to severe SLE with arthritis, cutaneous disease, cytopenias, serositis, or vasculitis if Hydroxychloroquine treatment is insufficient 
• Can also be considered in the subsequent treatment of pure class V nephritis

Cyclophosphamide 

• As an alkylating agent, it may involve cross-linking of DNA which may interfere with growth of normal and neoplastic cells
• Used as an initial immunosuppressant for severe SLE nephritis
  • Concomitant use with Prednisone is the standard treatment for lupus nephritis as it helps preserve renal function
• Useful for severe organ- or life-threatening SLE (eg severe CNS, cardiopulmonary or renal involvement) and as rescue therapy for non-major organ manifestations unresponsive to other immunosuppressants 
• Prevents lupus flares 

Methotrexate

• Blocks purine synthesis and increases anti-inflammatory adenosine concentration at sites of inflammation
• Used for mild to moderate non-renal SLE and prevents flares 
• May be used as the initial immunosuppressant for severe arthritis 

Mycophenolate mofetil

• A reversible inhibitor of inosine monophosphate dehydrogenase which is the rate-limiting step in de novo purine synthesis
• Effective for both renal and non-renal lupus and certain neuropsychiatric diseases
  • Used for moderate to severe non-renal SLE and prevents flares
  • Recommended as induction and maintenance therapy for patients with lupus nephritis and has shown better results (less adverse effects and infections) as compared to IV Cyclophosphamide

Biologic Agents

• Consider giving monoclonal antibodies to patients who are unresponsive to treatment with maximum tolerable doses of immunosuppressants

Anifrolumab  

• A human IgG1 kappa monoclonal antibody that inhibits signaling of type I interferon by binding to subunit 1 of the type I interferon receptor resulting in improvement of SLE symptoms   
• Used for the treatment of moderate to severe SLE in adult patients who are receiving standard therapy, eg NSAIDs, corticosteroids, antimalarials, and/or immunosuppressants (Azathioprine, Methotrexate or Mycophenolate) 
• Not recommended for patients with severe active CNS lupus or severe active lupus nephritis

Belimumab

• A human monoclonal antibody that binds to soluble B-lymphocyte stimulator (BLyS/BAFF) to reduce disease activity
• Used as an add-on therapy for patients with active, autoantibody-positive SLE with a high degree of disease activity (eg positive anti-dsDNA and low complement) despite standard therapy (Hydroxychloroquine and corticosteroid combinations with or without immunosuppressants) 
• Considered as an add-on therapy to extrarenal disease that is persistently active or flaring, or to patients with frequent relapses and/or residual disease activity preventing corticosteroid tapering 
• Studies have shown that patients on Belimumab therapy experienced reduced risk of severe flares, improved health-related quality of life and reduced steroid use as compared to those on placebo
• Not recommended for patients with severe active CNS lupus 

Rituximab 

• A biologic, it is a chimeric monoclonal antibody to CD20 antigen which regulates cell cycle initiation
• Used as rescue therapy for SLE patients with organ-threatening disease refractory or with intolerance or contraindications to standard immunosuppressive therapy

Intravenous Immunoglobulin (IVIg)

• Neutralizes circulating myelin antibodies through anti-idiotypic antibodies
  • Down-regulates proinflammatory cytokines, including interferon-gamma
  • Blocks receptors on macrophages, suppresses inducer T and B cells, and augments suppressor T cells
  • Blocks complement cascade, promotes remyelination and may increase colony stimulating factor lgG
• Used in serious SLE flares and refractory severe lupus
• May be considered in the acute phase of lupus thrombocytopenia if there is an inadequate response to high-dose corticosteroids or to prevent infectious complications from corticosteroid therapy

Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

• Inhibit inflammatory reactions and pain by decreasing prostaglandin synthesis
• These drugs provide symptomatic relief of fever, arthritis and mild serositis, ie control symptoms in mild non-renal lupus
• SLE patients have a high incidence of NSAID-induced hepatotoxicity

Specific Manifestations of SLE

Lupus Nephritis 

• Patients suspected to have lupus nephritis should immediately undergo renal biopsy to confirm diagnosis, evaluate severity, determine prognosis and therapy
• Indications for renal biopsy in SLE patients:
  • Unexplained increase in serum creatinine in the absence of alternative causes (eg sepsis, hypovolemia, medications)
  • Confirmed proteinuria of ≥1 g/24 hr or reproducible proteinuria of ≥0.5 g/24 hr plus glomerular hematuria and/or cellular casts
• Goal of treatment is to achieve proteinuria <0.5-0.7 g/24 hr by 12-24 months, with improvement seen at 3 months and at least 50% reduction in proteinuria by 6 months 
• For induction of treatment, Mycophenolate and low-dose IV Cyclophosphamide are the recommended 1st-line treatment in patients with class III-IV disease
  • Consider giving the same regimens or use high-dose IV Cyclophosphamide in those at high risk of renal failure or those with adverse prognostic factors
• For patients with pure class V disease, Mycophenolate is the recommended 1st-line induction treatment
  • Alternative options include Cyclophosphamide and calcineurin inhibitors (eg Tacrolimus, Ciclosporin, Voclosporin) in combination with Mycophenolate
  • Rituximab may also be considered for nonresponders to 1st-line agents 
• Initial combination of treatment regimens with 3 consecutive pulses of IV Methylprednisolone then followed by oral Prednisone helps increase efficacy and decrease cumulative corticosteroid dose
• Patients with severe nephrotic syndrome or incomplete renal response without a decreased GFR, uncontrolled hypertension and/or kidney biopsy with a high chronicity index can be given Mycophenolate combined with low-dose calcineurin inhibitor
• Hydroxychloroquine may also be considered as initial therapy, with regular ophthalmological screening
• Belimumab may be used for the treatment of active lupus nephritis in combination with standard immunosuppressive therapies 
  • Should be used in combination with corticosteroids and Mycophenolate or Cyclophosphamide for induction, or Azathioprine or Mycophenolate for maintenance
• Azathioprine or Mycophenolate should be used for maintenance treatment 
  • Mycophenolate maintenance therapy is recommended for patients given Mycophenolate during the treatment induction
  • Azathioprine or Mycophenolate is the recommended maintenance therapy for patients given Ciclosporin as initial treatment agent
  • Maintenance treatment with a calcineurin inhibitor may also be considered in class V lupus nephritis at its lowest effective dose
• For treatment of refractory disease, Mycophenolate, Ciclosporin, calcineurin inhibitors as monotherapy or combination therapy are recommended
  • Studies showed that Rituximab, Obinutuzumab, Belimumab/Mycophenolate, Belimumab/Rituximab and high-dose IVIg are viable alternative treatment options 
• Monitoring of lupus nephritis includes a blood pressure check and lab tests such as urinalysis, protein/creatinine ratio, serum creatinine, C3/C4 and anti-DNA levels
• Please see Lupus Nephritis disease management chart for further information

Neuropsychiatric SLE (NPSLE) 

• Monitor SLE patients for neurological and/or psychiatric manifestations as in non-NPSLE patients
• Usually appears within 1 year from the time of diagnosis; may also appear before or at the time of diagnosis
• Diagnostic work-up may include the following: 
  • Lumbar puncture
  • Nerve conduction studies (NCS)
  • Neuropsychological assessment of cognitive function
  • Cerebrospinal fluid analysis
  • Electroencephalography (EEG)
  • Neuroimaging: T1/T2 MRI, diffusion-weighted imaging, gadolinium-enhanced T1 sequences
• Manifestations indicating an inflammatory process are treated with corticosteroids and/or immunosuppressants while atherothrombotic or antiphospholipid-related manifestations are treated with antiplatelets/anticoagulants  
• Patients found to have NPSLE should be referred to a team of psychiatrists, psychologists, neurologist and rheumatologist

Skin Disease

• Initial management includes use of topical agents (corticosteroids, calcineurin inhibitors), antimalarials (Hydroxychloroquine, Quinacrine) with or without systemic corticosteroids 
• Consider adding Methotrexate, Mycophenolate, Dapsone or retinoids to unresponsive patients or those who need high-dose corticosteroids 

Hematological Disease

• Lupus thrombocytopenia can be acutely treated with moderate to high doses of corticosteroids (including IV pulse dosing of Methylprednisolone) in combination with immunosuppressants and/or IVIg 
• Azathioprine, Mycophenolate or Ciclosporin can be used for maintenance therapy 
• Refractory patients can be given Rituximab or Cyclophosphamide 

Comorbidities of SLE

Cardiovascular Disease

• Regularly evaluate SLE patients for traditional and disease-related risk factors for cardiovascular disease, eg persistently active disease, increased disease duration, chronic use of corticosteroids, persistent proteinuria and/or GFR <60 mL/min and medium/high titers of antiphospholipid 
• Vascular events may be reduced with a blood pressure maintained at <140/90 mmHg in patients with SLE
• SLE patients may be given low-dose Aspirin and/or lipid-lowering agents based on their individual cardiovascular risk profile 

Infectious Diseases

• Evaluate SLE patients for general and disease-related risk factors for infection, eg advanced age, frailty, renal disease, diabetes mellitus, use of corticosteroid and immunosuppressive therapy 
• Early diagnosis and treatment of infection or sepsis and general preventive measures, eg immunizations, are recommended 

Antiphospholipid Syndrome

• Antiplatelet agents as primary prophylaxis may be given to SLE patients with a high-risk antiphospholipid profile, especially if with other atherosclerotic or thrombophilic factors, after considering potential for bleeding 
• Management for secondary prevention (thrombosis, pregnancy loss/complication) should be the same as for primary antiphospholipid syndrome 

Malignancies    

• May include non-Hodgkin's lymphoma, thyroid, lung, liver, cervical and vulval cancer  
• Perform cancer screening and manage according to established guidelines for the specific condition