What is the treatment for Systemic Lupus Erythematosus (SLE)?

From the Guidelines

Lupus (LUP) treatment should prioritize a combination of medications tailored to the patient's specific symptoms and disease severity, with hydroxychloroquine (HCQ) as the foundation of treatment, aiming for remission or low disease activity, as recommended by the 2023 update of the EULAR recommendations 1.

Treatment Approach

The treatment approach for LUP involves a multi-faceted strategy, including:

• Hydroxychloroquine (200-400mg daily) as the foundation of treatment, reducing flares and organ damage while improving survival rates 1
• Topical corticosteroids like triamcinolone 0.1% cream for skin manifestations, applied to affected areas twice daily
• Oral corticosteroids such as prednisone (20-60mg daily, tapered gradually) during flares
• Immunossuppressants like mycophenolate mofetil (1-3g daily), azathioprine (1-2.5mg/kg daily), or methotrexate (7.5-25mg weekly) for maintenance therapy in more severe cases

Specific Considerations

For lupus nephritis, cyclophosphamide or mycophenolate mofetil are typically used for induction therapy, followed by maintenance with mycophenolate or azathioprine 1. Belimumab, a biologic agent, may be added for patients with active disease despite standard therapy 1. Additionally, patients should use sun protection (SPF 50+), maintain regular exercise, follow a balanced diet, and attend scheduled monitoring appointments to track disease activity and medication side effects.

Key Recommendations

• Hydroxychloroquine is recommended for all patients with SLE, at a dose not exceeding 5 mg/kg real body weight 1
• Glucocorticoids should be minimized to less than 7.5 mg/day (prednisone equivalent) and, when possible, withdrawn 1
• Immunomodulatory agents can expedite the tapering/discontinuation of glucocorticoids 1
• Belimumab should be considered for patients with inadequate response to standard-of-care treatment 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

LUP Treatment:

• Hydroxychloroquine sulfate tablets are indicated for the treatment of systemic lupus erythematosus in adults, with a recommended dosage of 200 mg given once daily, or 400 mg given once daily or in two divided doses 2.
• 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 3. Key points:
• Hydroxychloroquine can be used for LUP treatment in adults.
• Belimumab can be used for LUP treatment in patients 5 years of age and older.

From the Research

LUP Treatment Overview

• Systemic lupus erythematosus (SLE) is a complex autoimmune disease that requires a comprehensive treatment approach 4, 5.
• Synthetic drugs, such as hydroxychloroquine, are the mainstay of therapy in SLE, and are prescribed to nearly all patients to ameliorate symptoms and positively influence outcome 4.

Treatment Options

• Hydroxychloroquine is considered an anchor drug in SLE due to its multiple beneficial effects, and should be used as the backbone therapy for SLE 4, 6, 7.
• When patients present with persistent disease activity despite hydroxychloroquine therapy, additional immunosuppressants, such as azathioprine and mycophenolate mofetil, should be promptly prescribed 4.
• Glucocorticoids (GCs) should be used more judiciously, with methyl-prednisolone pulses as the main therapy for inducing rapid remission, and doses ≤5-2.5 mg/day should not be exceeded in long-term maintenance treatments 6.
• Biologic agents, such as rituximab and belimumab, are now widely used in clinical practice, particularly in patients with refractory disease 5.

Dosage and Efficacy

• The optimal dose of hydroxychloroquine is still a subject of debate, but stable doses of 200 mg/day (or 3.0-3.5 mg/kg/day) seem to accomplish good control of lupus without compromising safety 6, 7.
• A study found that 72% of patients achieved prolonged remission with a mean weight-adjusted dose of hydroxychloroquine of 2.9 mg/kg/day 7.
• The addition of mepacrine to hydroxychloroquine therapy has been shown to be safe and effective in reducing disease activity and decreasing prednisone doses in patients with refractory skin and/or joint disease 8.

Patient Response

• Smoking was found to be a predictor of complete response to combined mepacrine-hydroxychloroquine therapy in patients with refractory skin and/or joint disease 8.
• The dose of prednisone per patient did not differ according to the weight-adjusted dose of hydroxychloroquine, and the mean weight-adjusted HCQ dose during the whole follow-up was the same in patients treated or not with immunosuppressives or with mepacrine 7.