Treatment Options for Lupus
For patients with systemic lupus erythematosus (SLE), treatment should include hydroxychloroquine as the foundation, with the addition of glucocorticoids, immunosuppressants, and biologics based on disease severity and organ involvement. 1, 2
First-Line Treatment
- Hydroxychloroquine (200-400 mg daily) is indicated for all patients with SLE unless contraindicated, as it reduces disease activity, flares, organ damage, and mortality 2, 3
- Regular ophthalmological screening should be performed at baseline, after 5 years, and yearly thereafter to monitor for retinal toxicity 1
- Topical glucocorticoids are recommended for localized cutaneous lupus manifestations 1
- NSAIDs may be used for musculoskeletal symptoms, serositis, and headache, but require close monitoring for renal, hepatic, and allergic side effects in SLE patients 4, 5, 6
Treatment for Lupus Nephritis
For active Class III or IV lupus nephritis, treatment should include glucocorticoids plus one of the following: 7
Glucocorticoid regimens typically include initial IV methylprednisolone pulses (0.25-0.5 g/day for up to 3 days) followed by oral prednisone with gradual tapering 7
After initial therapy, maintenance treatment should consist of MPAA (mycophenolate mofetil 750-1000 mg twice daily) 7, 8
Second-Line and Alternative Treatments
Azathioprine (2 mg/kg/day) may be considered as an alternative to MPAA or cyclophosphamide in selected patients without adverse prognostic factors, or when planning pregnancy 7, 8
Calcineurin inhibitors (voclosporin, tacrolimus, or cyclosporine) may be preferred in patients with preserved kidney function and nephrotic-range proteinuria 7
Rituximab should be considered for patients with persistent disease activity or inadequate response to standard therapies 7, 8
Belimumab is FDA-approved for active SLE and lupus nephritis as add-on therapy for patients with inadequate response to standard treatments 8, 9
Treatment Duration and Monitoring
The total duration of initial immunosuppression plus maintenance immunosuppression for proliferative lupus nephritis should be at least 36 months 7
Regular monitoring should include body weight, blood pressure, serum creatinine, eGFR, serum albumin, proteinuria, urinary sediment, serum C3 and C4, and anti-dsDNA antibody levels 7
Visits should be scheduled every 2-4 weeks for the first 2-4 months after diagnosis or flare, and then according to response 7
Adjunctive Therapies
Preventive measures should include: 7
- Screening for infections (HBV, HCV, HIV, tuberculosis)
- Bone mineral density assessment and calcium/vitamin D supplementation
- Broad-spectrum sunscreen and limited UV exposure
- Contraception counseling
- Cancer risk evaluation
Angiotensin-converting enzyme inhibitors or angiotensin receptor blockers are indicated for patients with proteinuria or hypertension 7
Statins are recommended for persistent dyslipidemia 7
Treatment Response Assessment
Complete response is defined as reduction in proteinuria <0.5 g/g with stable or improved kidney function within 6-12 months 8
Partial response is defined as reduction in proteinuria by at least 50% and to <3 g/g with stable or improved kidney function 8
Switching to an alternative agent is recommended for patients who fail to improve within 3-4 months 8
Common Pitfalls to Avoid
Prolonged use of high-dose glucocorticoids (>7.5 mg/day prednisone equivalent) increases risk of irreversible organ damage 4
Minimizing lifetime cyclophosphamide exposure to <36 g is recommended to reduce malignancy risk 7
Mycophenolate mofetil, cyclophosphamide, and methotrexate should be avoided during pregnancy 1
Non-adherence to hydroxychloroquine is associated with higher flare rates and should be regularly assessed 4