From the Guidelines
The first line treatment for lupus typically involves hydroxychloroquine (Plaquenil), which is recommended for all patients with systemic lupus erythematosus (SLE) at a dose not exceeding 5 mg/kg real body weight, unless contraindicated, as stated in the 2019 update of the EULAR recommendations for the management of SLE 1.
Key Considerations
- Hydroxychloroquine is recommended for all patients with SLE, unless contraindicated, due to its multiple beneficial effects in controlling disease activity, preventing flares, reducing organ damage, and improving survival rates 1.
- The daily dose of hydroxychloroquine should not exceed 5 mg/kg real body weight to minimize the risk of retinal toxicity, a major concern with long-term therapy 1.
- Treatment should be individualized based on disease severity, organ involvement, and patient factors, with the goal of achieving remission or low disease activity in all organ systems 1.
- Regular monitoring for medication side effects is essential, particularly eye exams every 6-12 months for patients on hydroxychloroquine to check for rare retinal toxicity 1.
Additional Treatment Options
- For patients with mild to moderate symptoms, nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen or naproxen may be added to manage pain and inflammation 1.
- Corticosteroids such as prednisone are used for more severe symptoms or during flares, with the goal of minimizing their use to less than 7.5 mg/day (prednisone equivalent) and, when possible, withdrawing them 1.
- Immunomodulatory agents like methotrexate, azathioprine, or mycophenolate may be considered for patients not responding to hydroxychloroquine or requiring high-dose corticosteroids 1.
- Biologics like belimumab or rituximab may be considered for patients with inadequate response to standard-of-care or organ-threatening disease refractory to other treatments 1.
From the FDA Drug Label
Hydroxychloroquine sulfate tablets are indicated for the treatment of systemic lupus erythematosus in adults. The recommended dosage is 200 mg given once daily, or 400 mg given once daily or in two divided doses. BENLYSTA (belimumab) is indicated for the treatment of patients 5 years of age and older with active systemic lupus erythematosus (SLE) who are receiving standard therapy
The first line treatment for lupus is hydroxychloroquine, with a recommended dosage of 200 mg given once daily, or 400 mg given once daily or in two divided doses 2. Belimumab is also an option, but it is indicated for patients who are receiving standard therapy 3.
From the Research
First Line Treatment for Lupus
- The first line treatment for lupus is hydroxychloroquine, unless contraindicated, as it is useful in almost all manifestations of lupus 4.
- Hydroxychloroquine should be administered to every lupus patient irrespective of organ involvement 5.
- The use of hydroxychloroquine and glucocorticoids in systemic lupus erythematosus requires balancing risks and benefits, with stable doses of 200 mg/day of hydroxychloroquine and doses ≤5-2.5 mg/day of glucocorticoids recommended for long-term maintenance treatments 6.
- Hydroxychloroquine is considered an anchor drug in SLE due to its multiple beneficial effects, and should be used in combination with other immunosuppressants when necessary 7.
Alternative Treatments
- Other treatments, such as monoclonal antibodies, have a limited role in the management of lupus 4.
- Biologic agents, including belimumab and rituximab, have been approved for the treatment of SLE and may be used in patients with refractory lupus 8, 5.
- Conventional immunosuppressive therapy, including corticosteroids, methotrexate, cyclophosphamide, mycophenolate mofetil, azathioprine, cyclosporine, and tacrolimus, may also be used in the treatment of SLE 5.