What are the treatment options for Systemic Lupus Erythematosus (SLE)?

From the Guidelines

The treatment of Systemic Lupus Erythematosus (SLE) should aim at remission or low disease activity, with hydroxychloroquine recommended for all patients at a dose not exceeding 5 mg/kg real body weight, as stated in the 2019 EULAR recommendations 1.

Overview of SLE Treatment

The management of SLE involves a combination of medications and lifestyle modifications to control symptoms, prevent flares, and minimize organ damage.

• Hydroxychloroquine is the cornerstone therapy for all SLE patients, unless contraindicated, due to its ability to reduce flares and improve long-term outcomes by modulating immune responses 1.
• Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen can help manage joint pain and inflammation.
• Corticosteroids, such as prednisone, are used to control acute flares, with the goal of minimizing their use to less than 7.5 mg/day (prednisone equivalent) and withdrawing them when possible 1.

Immunosuppressive Therapies

Immunosuppressive agents, including methotrexate, azathioprine, and mycophenolate, are used as steroid-sparing agents and can be initiated early in the treatment of SLE to expedite the tapering or discontinuation of glucocorticoids 1.

• Methotrexate (7.5-25mg weekly) and azathioprine (1-2.5mg/kg/day) are commonly used immunosuppressants.
• Mycophenolate mofetil (1-3g daily) is also effective in reducing disease activity and preventing flares.

Biologics and Organ-Specific Treatment

Newer biologics like belimumab (10mg/kg IV monthly) target B-cell activity and are beneficial for patients with high disease activity despite standard therapy 1.

• Belimumab can be considered for add-on treatment in patients with inadequate response to standard-of-care.
• Rituximab may be considered in organ-threatening disease refractory or with intolerance/contraindications to standard immunosuppressive agents.

Lifestyle Modifications and Monitoring

Sun protection, regular monitoring of disease activity and medication side effects, vaccination against preventable infections, and addressing cardiovascular risk factors are essential components of comprehensive SLE management 1.

• Patients with SLE should be assessed for their antiphospholipid antibody status, infectious and cardiovascular diseases risk profile, and preventative strategies should be tailored accordingly.

From the FDA Drug Label

1.3 Systemic Lupus Erythematosus 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 2.

• Treatment of SLE: Hydroxychloroquine sulfate tablets are indicated for the treatment of systemic lupus erythematosus in adults.
• The dosage for SLE is 200 mg given once daily, or 400 mg given once daily or in two divided doses.

From the Research

Treatment Options for SLE

• The primary goal of treatment is to achieve disease remission or quiescence, defined by minimal symptoms, low levels of autoimmune inflammatory markers, and minimal systemic glucocorticoid requirement while the patient is treated with maintenance doses of immunomodulatory or immunosuppressive medications 3.
• Hydroxychloroquine is standard of care for SLE and has been associated with a significant reduction in mortality 3, 4.
• Treatments in addition to hydroxychloroquine are individualized, with immunosuppressive agents, such as azathioprine, mycophenolate mofetil, and cyclophosphamide, typically used for treating moderate to severe disease 3, 4.
• Biologic agents, such as belimumab, voclosporin, and anifrolumab, have been approved for the treatment of SLE and may be used in refractory or organ-threatening disease 3, 5.

Management of SLE

• The management of SLE should aim at preventing organ damage accrual and drug-associated harms, improving health-related quality of life and prolonging survival 5.
• Therapy is based on combinations of antimalarials, glucocorticoids, and immunosuppressive drugs 5.
• Methylprednisolone pulses may be used for moderate-severe flares, followed by low-moderate doses of oral prednisone with quick tapering to maintenance doses of ≤5 mg/day 5.
• Immunomodulatory or immunosuppressive medications may be used as steroid-sparing agents 5.

Safety and Efficacy of Treatments

• Nonsteroidal anti-inflammatory drugs (NSAIDs) may be used to manage symptoms, but their administration should be re-evaluated on a regular basis and the patient should be closely monitored due to the risk of renal side effects, hepatotoxicity, and other adverse reactions 6, 7.
• Synthetic drugs, such as azathioprine and mycophenolate mofetil, are effective and safe for the treatment of SLE, but the determination of a 'safe' glucocorticoid dose for chronic daily use is of major importance and should be subject of further studies 4.