What is the management of Systemic Lupus Erythematosus (SLE) in primary care?

From the Guidelines

Lupus management in primary care should prioritize a collaborative approach between primary care physicians and specialists, focusing on early recognition of symptoms, individualized treatment, and regular monitoring to minimize morbidity, mortality, and improve quality of life. The most recent and highest quality study, 1, published in 2024, provides updated recommendations for the management of systemic lupus erythematosus (SLE), emphasizing the importance of hydroxychloroquine (HCQ) as the backbone treatment for all patients with SLE, with a recommended dose not exceeding 5 mg/kg real body weight. Key aspects of lupus management in primary care include:

• Early recognition of symptoms like fatigue, joint pain, rashes, photosensitivity, and unexplained fevers
• Initial workup with ANA testing, complete blood count, comprehensive metabolic panel, urinalysis, and specific antibody tests like anti-dsDNA and anti-Smith
• First-line treatments with hydroxychloroquine (200-400mg daily) to prevent flares and reduce long-term damage
• Use of NSAIDs like naproxen (500mg twice daily) or ibuprofen (400-800mg three times daily) to manage joint pain and inflammation
• Low-dose corticosteroids such as prednisone (5-10mg daily) for short-term flare management, with the goal of minimizing chronic glucocorticoid use to less than 5 mg/day, as recommended by 1
• Regular monitoring for medication side effects, particularly hydroxychloroquine-induced retinopathy with annual eye exams, and checking blood pressure, renal function, and complete blood counts every 3-6 months
• Counseling patients on sun protection, regular exercise, smoking cessation, and maintaining vaccinations (avoiding live vaccines if immunosuppressed)
• Recognizing warning signs requiring specialist referral, including severe organ involvement, pregnancy planning, or inadequate response to initial therapy, as emphasized by 1 and 1. By following these guidelines and prioritizing a collaborative approach, primary care physicians can effectively manage stable lupus patients and improve their overall quality of life, while minimizing morbidity and mortality.

From the FDA Drug Label

The co-primary endpoints were percent change in SELENA-SLEDAI score at Week 24 and time to first flare over 52 weeks. The primary efficacy endpoint was a composite endpoint (SLE Responder Index-4 or SRI-4) that defined response as meeting each of the following criteria at Week 52 compared with baseline: • ≥4‑point reduction in the SELENA‑SLEDAI score, and • no new British Isles Lupus Assessment Group (BILAG) A organ domain score or 2 new BILAG B organ domain scores, and • no worsening (<0. 30‑point increase) in Physician’s Global Assessment (PGA) score.

The management of Lupus in primary care involves the use of belimumab (IV), which has been shown to be effective in reducing disease activity in patients with SLE. The SLE Responder Index-4 (SRI-4) is a composite endpoint that measures response to treatment, and belimumab 10 mg/kg has been shown to be effective in achieving an SRI-4 response in patients with SLE 2.

• The reduction in disease activity seen in the SRI-4 was related primarily to improvement in the most commonly involved organ systems; namely, mucocutaneous, musculoskeletal, and immune.
• Belimumab 10 mg/kg is recommended for the treatment of SLE in patients who are autoantibody-positive.
• The 1-mg/kg dose is not recommended due to lack of consistent efficacy in clinical trials 2.

From the Research

Diagnosis and Management of Lupus in Primary Care

• Systemic lupus erythematosus (SLE) is an autoimmune inflammatory disorder that can be diagnosed by confirming the presence of at least 4 of 11 criteria proposed by the American College of Rheumatology 3.
• Family physicians should be familiar with the manifestations of lupus to aid in early diagnosis, monitoring patients with mild disease, and recognizing warning signs that require referral to a rheumatologist 4.
• All patients with lupus should receive education, counseling, and support, and hydroxychloroquine is the cornerstone of treatment because it reduces disease flares and other constitutional symptoms 4.

Treatment Options for Lupus

• Hydroxychloroquine (HCQ) is the mainstay long-term treatment in SLE, recommended by current guidelines in all patients unless contraindications or side effects 5.
• The daily dose of HCQ associated with the best compromise between efficacy and safety is a matter of debate, but a dose of ≤5 mg/kg/day actual body weight is currently agreed upon 5.
• Glucocorticoids (GCs) should be used more judiciously, with methyl-prednisolone pulses as the main therapy for inducing rapid remission and doses ≤5-2.5 mg/day not exceeded in long-term maintenance treatments 6.
• Immunossuppressants such as azathioprine and mycophenolate mofetil can be used in patients with persistent disease activity despite HCQ therapy or need higher dosages and/or prolonged use of GCs 7.

Monitoring and Referral

• Patients with mild disease that does not involve major organ systems can be monitored by their family physician 4.
• Patients with increased disease activity, complications, or adverse effects from treatment should be referred to a rheumatologist 4.
• It is essential to monitor patients with lupus for disease and treatment-related complications, including infection, cardiovascular disease, and osteoporosis, and treat these problems in the primary care setting 3.