From the Guidelines
The management of Systemic Lupus Erythematosus (SLE) should prioritize treatment with hydroxychloroquine in all patients, at a dose not exceeding 5 mg/kg real body weight, with the goal of achieving remission or low disease activity and preventing flares. This approach is based on the most recent and highest quality evidence from the 2019 update of the EULAR recommendations for the management of SLE 1. The treatment of SLE aims to minimize glucocorticoids (GC) to less than 7.5 mg/day (prednisone equivalent) and, when possible, withdraw them, while also considering the initiation of immunomodulatory agents such as methotrexate, azathioprine, or mycophenolate to expedite the tapering or discontinuation of GC.
Key considerations in the management of SLE include:
- Assessing patients for their antiphospholipid antibody status, infectious and cardiovascular diseases risk profile, and tailoring preventative strategies accordingly 1
- Using add-on belimumab in persistently active or flaring extrarenal disease, and considering rituximab (RTX) in organ-threatening, refractory disease 1
- Providing updated specific recommendations for cutaneous, neuropsychiatric, haematological, and renal disease 1
- Emphasizing the importance of a multidisciplinary approach to SLE care, based on a shared patient-physician decision, and considering individual, medical, and societal costs 1
The overarching principles of SLE management include:
- Recognizing SLE as a multisystem disease that requires a comprehensive approach to care 1
- Prioritizing treatment goals that include long-term patient survival, prevention of organ damage, and optimization of health-related quality of life 1
- Using a treatment strategy that includes an initial period of high-intensity immunosuppressive therapy to control disease activity, followed by a longer period of less intensive therapy to consolidate response and prevent relapses 1
From the Research
Systemic Lupus Erythematosus (SLE) Overview
- SLE is a systemic autoimmune disease characterized by extreme heterogeneity with a variable clinical course 2
- Renal involvement may be observed and affects the outcome 2
- SLE can be a severe and potentially life-threatening disease that often represents a therapeutic challenge because of its heterogeneous organ manifestations 3
Treatment Approaches
- Hydroxychloroquine should be administered to every lupus patient irrespective of organ involvement 2, 4, 5
- Conventional immunosuppressive therapy includes corticosteroids, methotrexate, cyclophosphamide, mycophenolate mofetil, azathioprine, cyclosporine, and tacrolimus 2
- Biologic agents targeting various pathogenetic paths have been applied, including B cell targeting agents such as belimumab and rituximab 2, 3
- Anifrolumab, an interferon I receptor-targeting agent, has beneficial effects on SLE 2
Synthetic Drugs
- Synthetic drugs are prescribed for nearly all patients with SLE to ameliorate symptoms and positively influence outcome 4
- Azathioprine and mycophenolate mofetil are the drugs of first choice when patients present with persistent disease activity despite hydroxychloroquine therapy or need higher dosages and/or prolonged use of glucocorticoids 4
Treatment Algorithms
- Treatment algorithms have been established for various SLE scenarios, including discoid lupus, uncomplicated cutaneous vasculitis, arthritis, pericarditis, interstitial lung disease/alveolitis, pulmonary hypertension, antiphospholipid antibody syndrome, mononeuritis multiplex, and central nervous system vasculitis 6
- Experts have variable agreement on treatment approaches, even if no randomized controlled trial data are available 6
Hydroxychloroquine
- Hydroxychloroquine has demonstrated several crucial properties for the treatment of SLE, including decreasing SLE activity, preventing disease flare, and lowering the long-term glucocorticoid need 5
- Hydroxychloroquine has a significant favorable impact on long-term outcomes such as damage accrual and mortality in SLE 5