What are the treatment options for women experiencing lupus symptoms?

Treatment Options for Women with Lupus Symptoms

Hydroxychloroquine is the cornerstone of treatment for women with lupus and should be prescribed for all patients with SLE to reduce disease activity, flares, and mortality. 1, 2

First-Line Treatments

• Antimalarials: Hydroxychloroquine (HCQ) is recommended preconceptionally and throughout pregnancy for all SLE patients, providing benefits for both maternal disease control and improved obstetrical outcomes 1
• Glucocorticoids: Can be used for disease control but should be limited to the lowest effective dose due to long-term side effects; aim to reduce doses to ≤7.5 mg/day when possible 1
• NSAIDs: May be used judiciously for short periods in patients at low risk for complications (avoid in patients with renal disease) 1

Second-Line Treatments for Non-Responsive or Organ-Threatening Disease

• Immunosuppressive agents should be considered for patients who are not responsive to first-line therapy or unable to reduce steroids below acceptable doses for chronic use 1:
  • Azathioprine: Can be used during pregnancy and for maintenance therapy 1
  • Mycophenolate mofetil: Effective for lupus nephritis but must be avoided during pregnancy 1
  • Methotrexate: Option for non-pregnant women but contraindicated during pregnancy 1
  • Cyclophosphamide: Reserved for severe manifestations (e.g., proliferative lupus nephritis) but must be avoided during pregnancy 1

Biologic Therapies

• Belimumab: FDA-approved for active SLE and lupus nephritis; shown to reduce disease activity, flares, and steroid requirements 3, 2
• Anifrolumab: Recently approved for active SLE 2, 4
• Voclosporin: Approved specifically for lupus nephritis 2, 4

Treatment Based on Organ Involvement

Lupus Nephritis

• First-line: Glucocorticoids plus mycophenolate mofetil or cyclophosphamide (induction), followed by maintenance with mycophenolate or azathioprine 1
• Newer options: Belimumab or voclosporin in combination with standard therapy 3, 2
• Regular monitoring of renal function, proteinuria, and urine sediment is essential 1

Neuropsychiatric Manifestations

• For major inflammatory neuropsychiatric manifestations (optic neuritis, acute confusional state, neuropathy, psychosis, myelitis), immunosuppressive therapy is recommended 1
• Diagnostic workup should be similar to that in the general population with the same manifestations 1

Skin Manifestations

• Photoprotection is beneficial and should be used consistently 1
• Topical treatments may be used alongside systemic therapy 1

Special Considerations for Women

Pregnancy Planning and Management

• Preconception counseling and risk stratification are essential 1
• Major risk factors for adverse pregnancy outcomes include:
  • Active/flaring SLE, especially nephritis 1
  • History of lupus nephritis 1
  • Presence of antiphospholipid antibodies 1
• Safe medications during pregnancy include:
  • Hydroxychloroquine (recommended throughout pregnancy) 1
  • Azathioprine 1
  • Low-dose aspirin (especially for those at risk of pre-eclampsia) 1
  • Prednisone (at lowest effective dose) 1
• Medications to avoid during pregnancy:
  • Mycophenolate mofetil 1
  • Cyclophosphamide 1
  • Methotrexate 1

Contraception

• IUDs can be offered to all SLE patients without gynecological contraindications 1
• Combined hormonal contraceptives can be considered in patients with stable/inactive SLE and negative antiphospholipid antibodies 1
• Progesterone-only contraception should be carefully considered in women with positive antiphospholipid antibodies due to thrombosis risk 1

Menopause Management

• Hormone replacement therapy (HRT) can be used for severe vasomotor symptoms in women with stable/inactive disease and negative antiphospholipid antibodies 1
• In patients with positive antiphospholipid antibodies, HRT should be carefully weighed against thrombotic and cardiovascular risks 1
• If needed, use HRT for the shortest possible duration 1

Adjunctive Therapies

• Lifestyle modifications are important and should be encouraged 1:

  • Smoking cessation
  • Weight control
  • Regular exercise
  • Sun protection

• Preventive medications should be considered based on individual risk factors 1:

  • Low-dose aspirin for thrombosis prevention in patients with antiphospholipid antibodies
  • Calcium and vitamin D supplementation, particularly during pregnancy or for patients on glucocorticoids 1
  • Bisphosphonates for osteoporosis prevention in long-term steroid users
  • Statins for dyslipidemia
  • Antihypertensives (including ACE inhibitors when not pregnant)

Common Pitfalls and Caveats

• Undertreatment: Failing to prescribe hydroxychloroquine to all SLE patients, which is associated with increased flares and mortality 2
• Overtreatment: Prolonged use of high-dose glucocorticoids leading to significant adverse effects 1
• Inadequate monitoring: Not regularly assessing disease activity markers (complement levels, anti-dsDNA) and organ function 1
• Pregnancy management: Not providing preconception counseling or continuing teratogenic medications during pregnancy 1
• Infection risk: Not considering infection prevention strategies in immunosuppressed patients 1

The treatment approach for women with lupus requires careful consideration of disease activity, organ involvement, pregnancy status, and individual risk factors to optimize outcomes and minimize treatment-related complications.