Management principles other than immunosuppression used in the treatment of SLE

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Management principles other than immunosuppression used in the treatment of SLE patients

  • • Photo protection:
    • • UV-A and UV-B sunscreens (sun protection factor 30 or equivalent without para-aminobenzoic acid)
    • • avoid hot part of day with most UV-B light (10:00 A.M to 4:00 P.M)
    • • camouflage cosmetics
    • • photo-protective clothing
    • • avoid smoking: can interfere with effect of antimalarials
  • • Avoid possible disease triggers:
    • • sulfa-containing antibiotics
    • • sun
    • • high-estrogen birth control pills (BCPs)
    • • alfalfa sprouts
    • • echinacea
  • • Prevent atherosclerosis:
    • • control BP (target <130/80)
    • • hyperlipidemia (target LDL cholesterol <100)
    • • stop smoking
    • • check for and treat elevated homocysteine levels
  • • Prevent osteoporosis in those taking steroids:
    • • calcium (1000 mg), vitamin D (800 IU)
    • • minimize corticosteroid dosage
    • • consider bisphosphonates (controversial in premenopausal women) if on ≥20 mg of prednisone a day for ≥3 months.
    • • R/O low testosterone in males with SLE
  • • Immunizations:
    • • Human papillomavirus (HPV; patients aged <26 years), high-dose influenza, shingrix, hepatitis B (if at risk), and pneumococcal vaccines (SLE patients at risk due to functional hyposplenism and complement deficiencies). Patients on immunosuppressive agents and/or prednisone ≥20 mg/day may not mount a satisfactory immune response.
    • • Patients should not be given live attenuated vaccines (measles, mumps, rubella, polio, Bacillus Calmette–Guérin, herpes zoster, smallpox, intranasal influenza vaccine, and yellow fever) if on prednisone >20 mg/day or immunosuppressive agents.
    • • Patients on low-dose AZA (<3 mg/kg/day) or methotrexate (<0.4 mg/kg/week) can receive live attenuated vaccines. (Immunizations do not cause flares of SLE.)
  • • Prevent infections:
    • • Consider Subacute bacterial endocarditis prophylaxis (in patients with antiphospholipid antibodies and heart murmur)
    • • A purified protein derivative or IFN-γ release assay for tuberculosis (if starting >15 mg/day prednisone)
    • • Pneumocystis jiroveci prophylaxis if on CYC and/or glucocorticoids (prednisone >15–20 mg/day).
  • • Prevent progression of renal disease in patients with nephritis:
    • • avoid NSAIDs, control BP (target 130/80)
    • • limit proteinuria (use of ACE inhibitors or ARBs decrease proteinuria by 30%)
  • • Prevent clots in patients with antiphospholipid antibodies (not on warfarin):
    • • aspirin if have lupus anticoagulant
    • • use of hydroxychloroquine (mild anticoagulant effect)
    • • avoid unnecessary surgeries and vascular catheterizations
    • • treat infections promptly
    • • avoid Cox-2 specific inhibitors
    • • avoid exogenous estrogen (BCPs, hormone replacement therapy [HRT], selective estrogen receptor modulators [raloxifene])
  • • Treat fatigue:
    • • R/O hypothyroidism, metabolic disturbances, myopathy, anemia, depression, and sleep apnea
    • • eliminate drugs that can cause fatigue
    • • antimalarials, modafinil, and DHEA (prasterone 200 mg daily) can help fatigue
  • • Cancer screens: skin, cervical, anal, breast, colon, bladder, and lymphoma.
  • • Birth control (see chapter 78 : Rheumatic Disease and the Pregnant Patient) and HRT: exogenous estrogens do not flare SLE but do increase clot risk.
    • • Low/medium dose exogenous estrogens (BCPs) safe in patients with mild to moderate SLE and no risk factors for clot (antiphospholipid antibodies, nephrotic syndrome, severe renal disease, history of thrombosis, migraine headaches)
    • • Progesterone-containing intrauterine device, progesterone implant device, or progesterone-only BCPs in SLE patients with risk factors for clot. Monitor for osteoporosis.
    • • Weigh risk/benefits of HRT. Do not use in patients with clot risk or atherosclerosis. If use for postmenopausal symptoms, use lowest dose for shortest period of time.
  • • Screen for low vitamin D and replace as needed (want 25-hydroxyvitamin D [25OH vitD] levels >30–40 ng/mL) Low vitamin d levels may be associated with lupus disease activity.
    • • R/O celiac disease if very low 25OH vitD levels, especially if associated with gastrointestinal symptoms, iron-deficiency anemia, and/or pustular skin lesions.

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