• FACTS: There is no cure & complete
sustained remissions are rare.
Principles of Therapy
• Patients require individualized therapy
depending on disease manifestations,
activity & severity
• Control disease manifestations
• Allow the patient to have a good quality
of life w/o major exacerbations
• Prevent serious organ damage that
adversely affect function or life span
• Prevent adverse effects of the drugs
used
Therapeutic choices depend on :
( 1 ) whether disease manifestations
are life-threatening or likely to cause
organ damage
(2) whether manifestations are
potentially reversible
(3) the best approaches to
preventing complications of disease
and its treatments.

• Analgesic+A/malarial
+/- belimumab.
Activity Index [SLEDAI] score of >10, positive
anti-DNA, and low serum complment.
SLEDAI is a widely used measure of SLE
disease activity; scores >3 reflect clinically
active disease.
systemic glucocorticoids (0.5-1mg/kg per day PO)/ 500-1000 mg
of methyl prednisolone sodium succinate IV daily for 3 days
followed by 0.5- 1 mg/kg of daily prednisone or equivalent). +
Immunosuppressive agent
low doses of cyclophosphamide (500 mg every 2 weeks for six total
doses, followed by azathioprine or mycophenolate maintenance)
are as effective as standard high doses, with less toxicity.
High-dose cyclophosphamide (500-1000 mg/m2 body surface area
given monthly IV for 6 months, followed by azathioprine or
mycophenolate maintenance)
The number of SLE flares is reduced by maintenance therapy
with myιophenolate mofetil ( 1 .5-2 g daily) or azathioprine (1-
2.5 mg/kg per day).
Cyclophosphamide and mycophenolate responses begin
3-16 weeks after treatment is initiated, whereas
glucocorticoid responses may begin within 24 h.
• Inhibit inflammatory reactions & pain by
decreasing prostaglandin synthesis
• These drugs provide symptomatic relief of
fever, arthritis & mild serositis
• SLE patients have a high incidence of NSAID-
induced hepatotoxicity
Non-Pharmacological Therapy
• Patients w/ systemic lupus
erythematosus (SLE) should apply sunscreen
w/ at least an sun protection factor (SPF) of
30 to prevent dermal or systemic disease
flares upon exposure to ultraviolet light
• Used for skin & joint manifestations
• Useful for patients with skin disease that are
unresponsive to topical corticosteroids & in
patients with arthritis that does not respond
to NSAID
• Recommended as background treatment for Class
III/IV SLE patients with nephritis
• Patients with continuing treatment with
Hydroxychloroquine showed less renal
damage as compared to those on placebo
• Also used for preventing flares, reducing CV risk &
recurrent infection, & other constitutional
symptoms
 Topical corticosteroids
Oral corticosteroids
• Patients w/ mild (SLE) do not normally require use of • for discoid lesions
especially on the scalp
systemic corticosteroids but there are patients who has
low quality of life if not given low-dose corticosteroids
• Used as initial therapy for severe discoid lupus Parenteral
erythematosus or lupus vasculitis Corticosteroids
• Low-dose corticosteroids may be added to • Pulse therapy w/ IV
Hydroxychloroquine for fatigue & fever corticosteroids in
combination w/
• High-dose corticosteroids are necessary for refractory immunosuppressive
manifestations of SLE & for severe organ involvement therapy is
especially CNS, renal & hematologic manifestations recommended for Class
• Corticosteroid use should be tapered as soon as desired III/IV SLE patients w/
response is observed (control of inflammatory confirmed
manifestations) to avoid toxicity glomerulonephritis
Choice of immunosuppressant will depend on nature & severity of disease
manifestation
• These agents act as immunosuppressive, cytotoxic & anti-inflammatory agents
• In the treatment of severe CNS & severe glomerulonephritis, thrombocytopenia & hemolytic
anemia, high-dose glucocorticoids & immunosuppressants are used
• Concomitant use w/ corticosteroids allows lower doses of immunosuppressants
 Lifelong monitoring is required for systemic
lupus erythematosus (SLE) patients. Frequency
of visits depends on disease activity, severity &
extent; response to treatment, type of
treatment & monitoring of toxicity
The most important tool in the management of
SLE is careful, frequent clinical & laboratory
evaluation to detect disease flares, appearance
of infections & to tailor management based on
patient response

Patients w/ severe SLE, complications & toxicity

will require more frequent follow-up

• Results of laboratory tests that may precede a disease flare:

• Decrease in serum complement levels
• Increase in anti-dsDNA
• Increase in erythrocyte sedimentation rate (ESR)
• Decrease in hemoglobin level, leukocyte or platelet counts
• Increase in creatine phosphokinase (CPK) levels
• Appearance of microscopic hematuria or proteinuria
• A rheumatologist is an integral part of the medical
team managing an SLE patient
• Referral to a rheumatologist is indicated for: • life-threatening or serious organ system
• Confirmation of diagnosis involvement
• Management plan for patient • requiring high-dose corticosteroid
• Periodic evaluation of disease activity & severity • needing chemotherapy
• Management of uncontrolled disease • with severe hypertension
• Management of organ involvement or life-threatening • with unexplained fever to rule out sepsis
disease
• Prevention &/or management of treatment toxicities
• Special situations (eg pregnancy, antiphospholipid
syndrome, life-threatening disease, concomitant infection
& surgery)
• SLE patients should be referred to a psychologist,
psychiatrist, physical &/or occupational therapist,
ophthalmologist, dermatologist, nephrologist,
cardiologist, orthopedic surgeon & other specialists
when necessary
• If there are signs of renal involvement, patient should be
referred to a nephrologist for management

• Lupus does not affects fertility.
• Rate of fetal loss increased.
• Demise is higher in mothers with
– high disease activity , APLA,
active nephritis
• Women with AntiRo need
additional monitoring, high risk
for neonatal Lupus.
• APLA with SLE treated with
heparin and low dose Asprin.
• Glucocorticoids are Category A
• Cyclosporin, Tacrolimus Rituximab in
Category C
• AZA, HCQs, MMF, CPM as category D
(benefits outweighs risk)
• MTX is Cat X (risk outweighs benefits)
• Mx : HCQ + prednisone (lowest dose
• for short time)
• AZA may be added.
• Breast feeding should be avoided
( glucocorticoids and
immunosuppressants get into breast
milk).