What is the recommended treatment for lupus?

Treatment for Lupus

Hydroxychloroquine is the cornerstone medication recommended for all patients with systemic lupus erythematosus (SLE), regardless of disease severity, due to its ability to reduce disease flares, morbidity, and mortality. 1, 2

First-Line Treatment

• Hydroxychloroquine (HCQ): 200-400 mg daily, taken with food or milk 1, 3
  • Requires baseline and periodic ophthalmologic examinations to screen for retinal toxicity
  • Should not exceed 5 mg/kg/day of actual body weight to minimize risk of retinopathy 3
  • Should be continued during pregnancy 1

Treatment Based on Disease Manifestations

Mild Disease (Constitutional, Mucocutaneous, Musculoskeletal)

1. Hydroxychloroquine 200-400 mg daily 1, 3
2. Low-dose glucocorticoids (0.25-0.5 mg/kg/day) for acute flares, targeting the lowest effective dose (≤5 mg/day) for shortest duration 1
3. NSAIDs for symptomatic relief of joint pain and inflammation 4

Moderate-Severe Disease

For patients with more severe manifestations or organ involvement:

1. Methylprednisolone pulses for acute flares (more effective and less toxic than high-dose oral prednisone) 4
2. Immunosuppressive agents based on organ involvement:
   • Methotrexate (5-15 mg weekly) for persistent arthritis 1
   • Azathioprine (1-2.5 mg/kg daily) for various manifestations 1
   • Mycophenolate mofetil (0.5-1 g twice daily) for various manifestations 1

Lupus Nephritis

Treatment should be guided by renal biopsy classification 5, 1:

• Class III/IV lupus nephritis: Methylprednisolone pulses followed by oral prednisone with mycophenolate mofetil or cyclophosphamide 1
• Class V lupus nephritis: Prednisone with mycophenolate mofetil 1
• High-risk lupus nephritis: High-dose intravenous cyclophosphamide 1

Treatment goal: Complete renal response (proteinuria <0.5 g/24h with normal or near-normal renal function) 5

Biologic Therapies for Refractory Disease

For patients who fail standard therapy:

1. Belimumab: FDA-approved for active SLE in patients 5 years and older who are receiving standard therapy; also approved for active lupus nephritis 6, 2
2. Rituximab: Consider for refractory cases 1
3. Voclosporin: FDA-approved for lupus nephritis 2
4. Anifrolumab: FDA-approved for active SLE 2

Maintenance Therapy

• After initial treatment response, continue immunosuppression with mycophenolate mofetil or azathioprine for at least 3 years 5
• If initial treatment was with mycophenolate mofetil, continue with mycophenolate mofetil for maintenance 5

Treatment Monitoring

• Disease activity should be assessed at each visit using validated indices (SLEDAI-2K) 1
• Laboratory monitoring should include:
  • Complete blood count every 1-3 months during active disease
  • Anti-dsDNA antibodies and complement levels
  • Renal function tests, urinalysis, and urine protein/creatinine ratio for renal involvement 1

Preventive Care

• Annual cardiovascular risk assessment (blood pressure, lipid profile, blood glucose, BMI) 1
• Target blood pressure <130/80 mmHg 1
• Osteoporosis prevention with calcium and vitamin D supplementation 1
• Photoprotection to prevent flares 1
• Vaccination with inactivated vaccines when SLE is inactive 1

Special Considerations

• Pregnancy: Continue hydroxychloroquine; add low-molecular-weight heparin and low-dose aspirin in women with recurrent losses 1
• Antiphospholipid antibodies: Consider anticoagulation or antiplatelet therapy 1

Common Pitfalls to Avoid

1. Discontinuing hydroxychloroquine (increases risk of flares)
2. Using high-dose glucocorticoids for prolonged periods (increases damage accrual and mortality) 4
3. Delaying immunosuppressive therapy in severe organ involvement
4. Inadequate monitoring for medication toxicity
5. Neglecting preventive care for cardiovascular disease and osteoporosis

The treatment approach should be guided by disease severity, organ involvement, and individual patient factors, with the primary goal of achieving remission or low disease activity while minimizing treatment-related complications.