Treatment approach for an SLE patient with increasing symptoms
• R/O a cause other than SLE for the patient’s symptoms: R/O infection (see Question #47); R/O thrombosis (antiphospholipid antibodies, TTP); R/O drug side effect; R/O another disease (hypothyroidism, fibromyalgia, and sleep apnea).
• Mild disease (fatigue, arthritis, rash, serositis):
• NSAIDs: may cause worsening renal function, photosensitivity, aseptic meningitis (especially ibuprofen)
• Hydroxychloroquine
• Low dose prednisone (<20 mg/day): taper to lowest effective dose
• Methotrexate: can consider leflunomide if methotrexate not tolerated
• Moderate disease (severe minor symptoms unresponsive to standard therapy, especially in patients with low complement and high anti-dsDNA antibodies):
• MMF or AZA
• Belimumab: use with other immunosuppressives
• Prednisone (20–40 mg/day): taper to lowest effective dose
• Calcineurin inhibitors (cyclosporine, tacrolimus)
• Severe disease (nephritis, CNS, pneumonitis, vasculitis, severe cytopenias):
• High dose prednisone (> 60 mg/day) including pulse methylprednisolone (1 g/day × 3–5 days) if needed
• Cytotoxic medications: induction therapy with CYC or MMF followed by maintenance therapy with AZA, MMF, calcineurin inhibitors (cyclosporine, tacrolimus), or combination of MMF and calcineurin inhibitors
• Biologics: rituximab can be considered although data is limited
• Additional therapies: plasmapheresis (diffuse alveolar hemorrhage, TTP, anti-NMO spectrum disorder, APLAS), IVIG (autoimmune cytopenias, APLAS), stem cell transplant (refractory SLE)
