What are the prescription options and doses for a patient with possible Systemic Lupus Erythematosus (SLE)?

From the Guidelines

Hydroxychloroquine at a dose not exceeding 5 mg/kg real body weight is recommended in all patients with lupus, as it is the backbone treatment for all patients with SLE, and has been shown to have beneficial effects in preventing infections, thrombosis, and improving survival 1.

Prescription Options for SLE

Prescription options for a patient with possible Systemic Lupus Erythematosus (SLE) typically begin with hydroxychloroquine, which helps manage skin manifestations, arthritis, and fatigue while potentially preventing flares.

• For mild to moderate symptoms, NSAIDs like ibuprofen (400-800 mg three times daily) or naproxen (250-500 mg twice daily) may be used for pain and inflammation.
• Corticosteroids such as prednisone are often prescribed for acute flares, starting at 0.5-1 mg/kg/day with gradual tapering as symptoms improve, with the goal of minimizing glucocorticoids (GC) to less than 7.5 mg/day (prednisone equivalent) and, when possible, withdrawing them 1.
• For patients requiring immunosuppression, methotrexate (7.5-25 mg weekly), azathioprine (1-2.5 mg/kg/day), or mycophenolate mofetil (1-3 g daily in divided doses) may be used.
• Severe or refractory SLE might require cyclophosphamide (500-1000 mg/m² monthly IV) or biologics like belimumab (10 mg/kg IV every 2 weeks for 3 doses, then monthly) 1.

Treatment Targets and Monitoring

Treatment should be individualized based on organ involvement, disease severity, and patient factors, with the goal of reaching and maintaining remission or low-disease activity as soon as the diagnosis is made and for as long as possible 1.

• Regular monitoring of blood counts, liver and kidney function, and drug levels is essential to manage potential side effects.
• Early treatment is crucial to prevent organ damage and improve long-term outcomes in SLE patients.

Specific Considerations

• For the treatment of lupus nephritis, mycophenolic acid analogs (MPAA), low-dose intravenous cyclophosphamide, belimumab, and calcineurin inhibitors may be used, depending on the specific class of lupus nephritis and kidney function 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 1.

From the FDA Drug Label

BENLYSTA is a B-lymphocyte stimulator (BLyS)-specific inhibitor indicated for the treatment of: • patients 5 years of age and older with active systemic lupus erythematosus (SLE) who are receiving standard therapy; DOSAGE AND ADMINISTRATION • Intravenous Dosage for Adult and Pediatric Patients with SLE or Lupus Nephritis:−10 mg/kg at 2‑week intervals for the first 3 doses and at 4‑week intervals thereafter. • Subcutaneous Dosage for Adults with SLE:−200 mg once weekly. • Subcutaneous Dosage for Pediatric Patients with SLE:−weighing greater than or equal to 40 kg: 200 mg once weekly. −weighing 15 kg to less than 40 kg: 200 mg once every 2 weeks.

The prescription options for a patient with possible Systemic Lupus Erythematosus (SLE) are:

• Belimumab (IV): 10 mg/kg at 2-week intervals for the first 3 doses and at 4-week intervals thereafter.
• Belimumab (Subcutaneous):
  • Adults: 200 mg once weekly.
  • Pediatric patients weighing greater than or equal to 40 kg: 200 mg once weekly.
  • Pediatric patients weighing 15 kg to less than 40 kg: 200 mg once every 2 weeks. 2

From the Research

Prescription Options for Systemic Lupus Erythematosus (SLE)

The following prescription options are available for the treatment of SLE:

• Hydroxychloroquine: recommended for all SLE patients where no contraindication exists 3
• Aspirin: one of the three medications approved for the treatment of lupus 4
• Prednisone:
  • doses over 7.5-10 mg/day are well-recognised risk factors for infection 3
  • advisable not to exceed doses of 5 mg/day of prednisone in chronic treatment 3
• Azathioprine:
  • used for SLE patients without renal involvement who require a maintenance dose of 15 mg or higher of prednisone 5
  • effective for patients with skin lesions, pneumonitis, thrombocytopenia or hemolytic anemia 5
• Cyclophosphamide:
  • one of the two most commonly used cytotoxic agents 6
  • should be used in low-dose regimens 3
• Mycophenolate mofetil:
  • used in combination with rituximab for the treatment of lupus nephritis 7
  • has not been established whether it increases the risk of serious infections 3
• Rituximab:
  • used in combination with mycophenolate mofetil for the treatment of lupus nephritis 7
  • the first six months after rituximab treatment and the use of more than three courses are associated with an increased susceptibility for infection 3
• Methylprednisolone:
  • should be used in low-dose regimens 3
  • used in combination with rituximab for the treatment of lupus nephritis 7
• Belimumab:
  • has not been established whether it increases the risk of serious infections 3
  • one of the new therapeutic agents that hold promise for being more effective with fewer side effects than the current available agents 4

Doses

The following doses are recommended:

• Hydroxychloroquine: no specific dose mentioned in the studies
• Aspirin: no specific dose mentioned in the studies
• Prednisone:
  • 5 mg/day in chronic treatment 3
  • 7.5-10 mg/day or higher are well-recognised risk factors for infection 3
• Azathioprine: no specific dose mentioned in the studies
• Cyclophosphamide: no specific dose mentioned in the studies, but should be used in low-dose regimens 3
• Mycophenolate mofetil: no specific dose mentioned in the studies
• Rituximab: 2 doses of 1 g, on days 1 and 15 7
• Methylprednisolone: 500 mg, on days 1 and 15 7