15. Goal and overview of therapy
• to achieve remission or low disease activity,
• prevent organ damage,
• minimize drug toxicity, and
• improve quality of life
• Pt requires monitoring at regular intervals by a rheumatologist, and
may require multidisciplinary care, including involvement of
nephrology, dermatology, and hematology.
16. • Flare –flare refers to a measurable increase in disease activity that is
clinically meaningful enough to result in a change in therapy
• Remission –Complete remission has been described as the absence
of physical and laboratory abnormalities associated with SLE without
the use glucocorticoids or immunosuppressive therapy, but is rarely
achieved
•
-
17. ASSESSMENT OF DISEASE ACTIVITY
• SLE has heterogeneity of disease presentation
• SLE must be distinguished from chronic damage, drug toxicities, and
other conditions such as infection or fibromyalgia
• History and physical examination
SLE is multisystemic disease,
potential triggers such as sun exposure, infection, or discontinuation
of therapy
• The physical examination include evaluation of the skin, lymph
nodes, respiratory, cardiovascular, abdominal, musculoskeletal, and
neurologic systems.
18. Laboratory evaluation
• used to help assess disease activity and monitor organ-specific complications (eg, lupus
nephritis)
• no single marker of disease activity, clinicians must interpret the laboratory results in the
appropriate clinical context.
19. Laboratory evaluation
CBC Leukopenia is common , Anemia and thrombocytopenia may also be
observed with active disease, Cytopenias may also result from drug
toxicities
Acute phase reactants ESR AND
CRP
elevated ESR can be associated with increased disease activity and accrued
damage
elevations in CRP can also be associated with disease activity
Urinalysis with urinary sediment Proteinuria or cellular casts and hematuria may be due to SLE involving the
kidney.
Spot urine protein-to-creatinine
ratio
Quantification of proteinuria helps assess the severity of glomerular
disease
Serum creatinine and estimated
glomerular filtration rate (eGFR)
Elevations in serum creatinine may reflect lupus nephritis
Anti-double-stranded DNA
(dsDNA)
Titers of anti-dsDNA antibodies often fluctuate with disease activity,
particularly in patients with active glomerulonephritis.
Complement levels (C3 and C4) Low C3 and C4 and/or elevated C3 and C4 activation products often
indicate active disease, particularly lupus nephritis.
20. MANAGEMENT: General measures
Photoprotection 2/3 rd pts with SLE manifests rash or reaction in sun exposed area
so avoid sunlights,
Sunscreens that block both UV-A and UV-B and have a sun protection factor
(SPF) ≥55 are suggested.
Medications that can cause photosensitivity should also be avoided in patients
with SLE
Diet and nutrition
balanced diet, Vit D supplements may be required, in lupus nephritis pt salt
restriction may be required
Exercise Inactivity causes a rapid loss of muscle mass, bone demineralization, and loss
of stamina----managed with isometric and graded exercise
Smoking cessation Smoking adds to the baseline increased risk of accelerated atherosclerosis with
coronary heart disease in those with SLE
●Immunizations Prior immunosuppressive therapies( PCV,INFLENZAE VIRUS, HEP A/B,
MENINGGOCOCCUS, COVID VACCINE ETC
21. Approach to drug therapy
• The choice of drug therapy for SLE is highly individualized and
depends on the predominant symptoms, organ involvement,
response to previous therapy, and disease activity and severity.
22. Hydroxychloroquine for all patients
• For all patients with SLE with any degree and type of disease activity,
we recommend treatment with hydroxychloroquine
• > 80 KG Hydroxychloroquine 400 MG DAILY
• < 80 KG Hydroxychloroquine 200 MG DAILY
• maximum daily dose of 5 mg/kg/day of actual body weight.
• ARDS:QTc interval prolongation
23. Escalation of therapy based on disease activity
and severity
• In addition to the use of hydroxychloroquine, the need for additional
therapy is generally guided by the predominant symptoms and organ
involvement as well as the disease severity
Mild disease predominantly skin and joint involvement,LABS –UNREMARKABLE or mild leukopenia
start with hydroxychloroquine ,alternatively short term NSAIDs or prednisolone 7.5 mg
Moderate disease Patients with moderate disease severity may be described as having significant but non-organ-
threatening disease (eg, constitutional, cutaneous, musculoskeletal, or hematologic).
Patients usually respond to hydroxychloroquine plus short-term therapy with 5 to 15 mg
of prednisone (or equivalent) daily
Severe disease A patient with organ-threatening manifestations (eg, renal and central nervous system [CNS]
involvement) generally requires an initial period of intensive immunosuppressive therapy
Patients are usually treated for a short period of time with high doses of systemic glucocorticoids
1. methylprednisolone, 0.5 to 1 g/day for three days in acutely ill patients, or
oral prednisone 1 to 2 mg/kg/day in more stable patients) used alone or in combination with
24. Treatment of specific SLE manifestations
Constitutional symptoms Fatigue; low dose glucocorticoids and hydroxychloroquine
Fever: NSAIDs PCM, low to mod dose of prednisolone
Cutaneous involvement
Raynaud phenomenon
Arthritis and musculoskeletal
manifestations
Kidney involvement
Gastrointestinal involvement
Pulmonary involvement
Cardiac involvement
Hematologic manifestations
Neurologic and
neuropsychiatric
manifestations
25. Considerations regarding specific therapies
Anifrolumab
• monoclonal antibody- type I interferon (IFN) receptor-modto severe
SLE
• Anifrolumab blocks the activity of type I IFNs, including IFN-alpha,
IFN-beta, and IFN-kappa, which are cytokines that are elevated in
many patients with SLE
• An analysis of patients enrolled in different trials indicated that
patients treated with anifrolumab achieved a lupus low disease
activity state
27. Agents under investigation
• A number of other therapeutic approaches have been tried or are
under investigation in SLE
• B-cell-targeted therapy (such as atacicept),
• anti-interleukin (IL) 6 receptor,
• iberdomide (cereblon E3 ligase modulator)
• low-dose IL-2
• obinutuzumab (anti-CD20 monoclonal antibody)
• daratumumab (anti-CD38 monoclonal antibody)
, and litifilimab (blood dendritic cell antigen 2 inhibitor)
28. Monitoring response to therapy
• It depends on prior symptoms, current disease activity status, disease
severity, and frequency and severity of prior disease flares
• monitored every three to four months
29. Pregnancy and lupus
Fetal loss -3 fold high
Risk factors : antiphopholipid syndrome, HTN, active nephritis
Suppresion of disease activities is achieved via systemic glucocorticoids,
Active SLE in preg women should be controlled with
hydroxychoroquine and if necessary prednisone/ prednisoloneat the
lowest effective dosefor short period of time
