From the Guidelines
Treatment for a systemic lupus erythematosus (SLE) flare should aim at remission or low disease activity and prevention of flares in all organs, maintained with the lowest possible dose of glucocorticoids, as recommended by the 2019 EULAR guidelines 1. When managing SLE flares, it's crucial to consider the severity of organ involvement and adjust ongoing therapies accordingly.
- For mild to moderate flares, hydroxychloroquine (HCQ) is recommended for all patients with SLE, unless contraindicated, at a dose not exceeding 5 mg/kg/real BW 1.
- Glucocorticoids (GC) can be used at doses and routes of administration that depend on the type and severity of organ involvement, with pulses of intravenous methylprednisolone (usually 250–1000 mg per day, for 1–3 days) providing an immediate therapeutic effect and enabling the use of lower starting doses of oral GC 1.
- For chronic maintenance treatment, GC should be minimized to less than 7.5 mg/day (prednisone equivalent) and, when possible, withdrawn, with prompt initiation of immunomodulatory agents expediting the tapering/discontinuation of GC 1.
- Immunosuppressive therapies, such as methotrexate, azathioprine, or mycophenolate, should be considered in patients not responding to HCQ or GC, or those unable to reduce GC below acceptable doses for chronic use 1.
- Biologics, like belimumab, may be considered in patients with inadequate response to standard-of-care, defined as residual disease activity not allowing tapering of glucocorticoids and/or frequent relapses 1. Key considerations in SLE flare treatment include:
- Monitoring for medication side effects
- Addressing comorbidities
- Ensuring adequate vitamin D and calcium supplementation with steroids
- Considering antimicrobial prophylaxis when using high-dose immunosuppression By following these guidelines and tailoring treatment to the individual patient's needs, clinicians can effectively manage SLE flares and improve patient outcomes, as supported by the 2019 EULAR recommendations 1.
From the Research
Treatment Options for SLE Flare
- Traditional treatments for SLE include NSAIDs and antimalarial agents, which are the first-line therapies for mild SLE 2.
- Glucocorticoids and cytotoxic or immunosuppressive agents, such as azathioprine, mycophenolate mofetil, cyclophosphamide, cyclosporine, and methotrexate, are used for SLE with organ involvement 2.
- Hydroxychloroquine should be considered an anchor drug in SLE due to its multiple beneficial effects, and azathioprine and mycophenolate mofetil are the drugs of first choice when additional immunosuppressants are needed 3.
- Mycophenolate mofetil (MMF) has been shown to be equivalent to intravenous pulse cyclophosphamide for the induction treatment of lupus nephritis, and superior to azathioprine in decreasing the incidence of treatment failure during maintenance therapy 4.
Management of SLE Flare
- The use of hydroxychloroquine and glucocorticoids in SLE requires balancing risks and benefits, with recommendations for judicious use of these drugs to minimize toxicity 5.
- Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used to treat musculoskeletal symptoms, serositis, and headache in SLE patients, but require awareness of potential side effects and close monitoring of toxicity 6.
- Targeted immunotherapies, such as the anti-BAFF antibody belimumab, have been approved as add-on therapies for patients with active disease despite receiving standard therapy 2.