From the Guidelines
The initial treatment for Systemic Lupus Erythematosus (SLE) should always include hydroxychloroquine at a dose not exceeding 5 mg/kg real body weight, as it is recommended in all patients with lupus. This recommendation is based on the 2019 update of the EULAR recommendations for the management of SLE 1. The primary goal of treatment in SLE is to achieve remission or low disease activity and prevent flares.
Some key points to consider in the initial treatment of SLE include:
- Hydroxychloroquine is the foundation of SLE management and should be used in all patients
- Glucocorticoids (GC) should be minimized to less than 7.5 mg/day (prednisone equivalent) during chronic maintenance treatment and withdrawn when possible
- Immunomodulatory agents such as methotrexate, azathioprine, or mycophenolate can be used to expedite the tapering or discontinuation of GC
- Belimumab can be considered in persistently active or flaring extrarenal disease, while rituximab may be considered in organ-threatening, refractory disease 1.
It is essential to individualize treatment based on the specific organ systems affected, disease severity, and patient characteristics. Regular monitoring for medication side effects is necessary, and patients with SLE should be assessed for their antiphospholipid antibody status, infectious and cardiovascular diseases risk profile, and preventative strategies should be tailored accordingly 1.
From the FDA Drug Label
1 INDICATIONS AND USAGE 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, • patients 5 years of age and older with active lupus nephritis who are receiving standard therapy.
The initial treatment for Systemic Lupus Erythematosus (SLE) is not explicitly stated in the provided drug labels as the primary treatment, but rather as an addition to standard therapy.
- The drug labels mention that belimumab is indicated for patients with active SLE who are receiving standard therapy 2.
- Standard therapy is not defined in the labels, but it is implied to be the initial treatment for SLE, with belimumab being used as an additional treatment.
- The labels do not provide information on what constitutes standard therapy for SLE, so no conclusion can be drawn about the initial treatment.
From the Research
Initial Treatment for Systemic Lupus Erythematosus (SLE)
The initial treatment for SLE aims to decrease symptom severity and improve patient outcomes.
- 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 considered a mainstay in treating all patients with SLE and is the standard of care for SLE, associated with a significant reduction in mortality 4, 5, 3.
- Pharmacologic interventions are divided into four categories: antimalarials, glucocorticoids (GCs), immunosuppressants (ISs), and biological agents 4.
- Glucocorticoids are used to reduce inflammation, but their use is minimized due to potential adverse reactions 4, 5.
- Immunosuppressants, such as azathioprine and mycophenolate mofetil, are used as steroid-sparing agents and to prevent flares 4, 5, 3.
Treatment Approach
- The treatment approach for SLE is individualized, and additional immunosuppressive agents, such as cyclophosphamide, are used for moderate to severe disease 3.
- Biologic agents, such as belimumab, voclosporin, and anifrolumab, are used when other treatment options have failed due to intolerance or inefficacy 6, 3, 7.
- B cell targeting agents, such as rituximab, have been used successfully in SLE treatment 7.
- Interferon I receptor-targeting agents, such as anifrolumab, have beneficial effects on SLE 7.