From the Guidelines
Systemic lupus erythematosus (SLE) should be diagnosed using the American College of Rheumatology criteria, which requires at least 4 out of 11 clinical and laboratory findings, and treated based on disease severity and organ involvement, with hydroxychloroquine as the foundation of therapy for mild SLE, and systemic corticosteroids and immunosuppressants for moderate to severe disease, as recommended by the 2019 update of the EULAR recommendations for the management of SLE 1.
Diagnostic Criteria
The diagnostic criteria for SLE include:
- Malar rash
- Discoid rash
- Photosensitivity
- Oral ulcers
- Arthritis
- Serositis
- Renal disorder
- Neurologic disorder
- Hematologic disorder
- Immunologic disorder
- Positive antinuclear antibody (ANA)
Treatment Options
Treatment options for SLE depend on disease severity and organ involvement, and may include:
- Hydroxychloroquine (200-400mg daily) for mild SLE
- NSAIDs for pain and inflammation
- Topical corticosteroids for cutaneous manifestations
- Systemic corticosteroids like prednisone (0.5-1mg/kg/day) for moderate to severe disease
- Immunosuppressants such as methotrexate (7.5-25mg weekly), azathioprine (1-2.5mg/kg/day), or mycophenolate mofetil (1-3g daily)
- Biologics like belimumab (10mg/kg IV monthly) or rituximab (1000mg IV on days 1 and 15, repeated as needed) for severe organ-threatening disease
Preventive Care
Patients with SLE should receive preventive care including:
- Vaccinations
- Vitamin D supplementation
- Bone density monitoring
- Cardiovascular risk assessment
Monitoring and Follow-up
Regular monitoring of disease activity through clinical evaluation and laboratory tests is essential for adjusting therapy and preventing flares, as recommended by the American College of Rheumatology guidelines for screening, treatment, and management of lupus nephritis 1.
The use of anti-dsDNA autoantibodies is recommended for the diagnosis and follow-up of SLE, as they are relatively effective indicators for monitoring disease activity and treatment response, according to a proposal from an expert panel 1.
The 2019 update of the EULAR recommendations for the management of SLE provides guidance on the use of hydroxychloroquine, glucocorticoids, and immunosuppressive agents, as well as biologics, for the treatment of SLE, with the goal of achieving remission or low disease activity and preventing flares 1.
The Latin American Group for the Study of Lupus (GLADEL) and the Pan-American League of Associations of Rheumatology (PANLAR) also provide recommendations for the management of SLE, including the use of antimalarials, glucocorticoids, and immunosuppressive agents, as well as biologics, for the treatment of SLE, with the goal of achieving remission or low disease activity and preventing flares 1.
Overall, the treatment of SLE should be individualized and based on the severity of disease and organ involvement, with the goal of achieving remission or low disease activity and preventing flares, while minimizing medication side effects and improving quality of life.
From the Research
Diagnostic Criteria for Systemic Lupus Erythematosus (SLE)
- The American College of Rheumatology has 11 classification criteria for lupus, and if a patient meets at least four criteria, lupus can be diagnosed with 95% specificity and 85% sensitivity 2
- Antinuclear antibody (ANA) testing is positive in nearly every case of SLE, but it is not specific for this disease and must be interpreted in the appropriate clinical context 3
- Key features that warrant ANA testing include unexplained multisystem inflammatory disease, symmetric joint pain with inflammatory features, photosensitive rash, and cytopenias 3
Treatment Options for SLE
- Hydroxychloroquine is the cornerstone of treatment because it reduces disease flares and other constitutional symptoms 2, 4
- Low-dose glucocorticoids can be used to treat most manifestations of lupus 2
- The use of immunosuppressive and cytotoxic agents depends on the body systems affected 2
- Mycophenolate mofetil (MMF) is an immunosuppressive drug that may be used in patients with SLE who are refractory to other immunosuppressive agents 5
- Monoclonal antibodies have a limited role in the management of lupus 4
Management and Monitoring of SLE
- Reducing sun exposure is central to the management of lupus 4
- All patients with lupus should receive education, counseling, and support 2
- Patients with mild disease that does not involve major organ systems can be monitored by their family physician, while patients with increased disease activity, complications, or adverse effects from treatment should be referred to a rheumatologist 2