Lupus Workup: Comprehensive Diagnostic Approach
The lupus workup must include evaluation of disease activity using validated indices, assessment of organ damage, quality of life measures, comorbidities screening, and drug toxicity monitoring as recommended by the European League Against Rheumatism (EULAR). 1
Initial Laboratory Evaluation
Core Immunologic Tests
- Antinuclear antibody (ANA) testing
- Anti-double-stranded DNA (anti-dsDNA) antibodies
- Anti-Smith (anti-Sm) antibodies
- Complement levels (C3, C4)
- Antiphospholipid antibodies (anticardiolipin, lupus anticoagulant, anti-β2 glycoprotein I)
Basic Laboratory Assessment
- Complete blood count with differential
- Comprehensive metabolic panel (liver and kidney function)
- Urinalysis with microscopy and urine protein-to-creatinine ratio
- Erythrocyte sedimentation rate (ESR)
- C-reactive protein (CRP)
Organ-Specific Evaluation
Renal Assessment
- Urinalysis with microscopy
- 24-hour urine collection for protein or spot urine protein-to-creatinine ratio
- Renal function tests (BUN, creatinine, GFR)
- Renal biopsy if significant proteinuria (>0.5g/24h), active urinary sediment, or unexplained renal insufficiency
Neuropsychiatric Assessment
- Cognitive function testing for suspected cognitive dysfunction
- MRI (T1/T2, fluid-attenuating inversion recovery, diffusion-weighted imaging) for suspected CNS involvement
- Cerebrospinal fluid analysis to exclude infection when CNS manifestations present
- EEG for seizure disorders
- Nerve conduction studies for peripheral neuropathy 1
Cardiovascular Assessment
- Blood pressure measurement
- Lipid profile
- Fasting blood glucose
- ECG and echocardiogram if cardiac symptoms present
Disease Activity and Damage Assessment
Disease Activity Monitoring
- Use validated indices such as:
- SLEDAI (SLE Disease Activity Index)
- BILAG (British Isles Lupus Assessment Group)
- SLAM (Systemic Lupus Activity Measure)
Organ Damage Assessment
- Annual evaluation using SLICC/ACR Damage Index 1
Comorbidity Screening
Cardiovascular Risk Assessment
- Annual assessment of:
- Smoking status
- Physical activity
- Family history of cardiovascular disease
- Blood pressure
- Body mass index/waist circumference
- Lipid profile
- Fasting glucose 1
Infection Risk Assessment
- HIV screening based on risk factors
- Hepatitis B and C screening
- Tuberculosis screening before immunosuppressive therapy 1
Bone Health Assessment
- Calcium and vitamin D intake
- Exercise habits
- Smoking status
- Bone density screening for patients on steroids or at risk for osteoporosis 1, 2
Cancer Screening
- Follow age-appropriate cancer screening guidelines for general population
- Special attention to cervical cancer screening 1
Special Considerations
Neuropsychiatric Lupus Evaluation
For patients with neuropsychiatric manifestations:
- Rule out non-SLE causes first
- Perform MRI, CSF analysis, EEG, and neuropsychological testing as indicated
- Evaluate for presence of antiphospholipid antibodies 1
Pregnancy Considerations
- Anti-Ro/SSA and anti-La/SSB antibodies (risk for neonatal lupus)
- Antiphospholipid antibodies (risk for pregnancy complications)
Monitoring Protocol
Frequency of Assessment
- Disease activity: at each visit
- Organ damage: annually
- Quality of life: at each visit
- Comorbidities: annually
- Drug toxicity: based on specific medications 1
Medication-Specific Monitoring
- Hydroxychloroquine: baseline and annual ophthalmologic examination
- Glucocorticoids: bone density, glucose, blood pressure monitoring
- Immunosuppressants: complete blood count, liver and kidney function tests
Common Pitfalls to Avoid
Overreliance on ANA testing: A positive ANA is not specific for SLE and can be found in other autoimmune diseases and healthy individuals.
Inadequate renal assessment: Lupus nephritis may be present without symptoms; regular urinalysis and renal function tests are essential.
Missing neuropsychiatric manifestations: Cognitive dysfunction, depression, and other neuropsychiatric symptoms may be attributed to other causes.
Neglecting cardiovascular risk: SLE patients have accelerated atherosclerosis; cardiovascular risk assessment is crucial.
Inadequate monitoring during remission: Disease activity can fluctuate; regular monitoring is necessary even during apparent remission.
By following this comprehensive approach to lupus workup, clinicians can effectively diagnose, monitor disease activity, prevent complications, and optimize outcomes for patients with SLE.