26th January 2024

Management

Treatment of SLE depends on disease activity and severity in addition to symptoms and organs affected. It requires management by a rheumatologist, and often, a multi-disciplinary approach is required. 

Non-Pharmacological/Conservative

• UV protection: This is particularly significant in those affected with cutaneous SLE where photosensitivity may occur. Sunscreens of SPF (sun protection factor) of >55 and protection against UV-A and UV-B are recommended. Medications that induce photosensitivity should also be avoided. 

Pharmacological 

• Anti-malarials: Hydroxychloroquine and Chloroquine can help relieve constitutional symptoms in addition to musculoskeletal and mucocutaneous manifestations. Can be used in mild to moderate SLE where there are manifestations that are non-organ threatening (e.g. constitutional symptoms, skin, mucosal, joint or haematological involvement)
• Oral Corticosteroids: Prednisolone 5-15mg daily can be used as a short-term therapy. This can be tapered while the hydroxychloroquine or chloroquine takes effect. 
• Intravenous Corticosteroids: Methylprednisolone IV is used in severe or life-threatening manifestations that occur secondary to major organ involvement. Patients are sometimes ‘pulsed’ on this high-dose IV corticosteroid for a short duration to rapidly reduce inflammation to achieve disease control. 
• Azathioprine: This immunosuppressant is of value in treating the manifestations of SLE in patients of childbearing age and is one of the few medications that is generally safe to use in pregnancy. 
• Adverse effects: Bone Marrow Suppression: there is an increased risk of this occurring in individuals with TPMT enzyme deficiency, which is why it is important to screen for TPMT prior to starting patients on azathioprine. Monitoring of full blood count, liver and renal function is required twice weekly for six weeks and, once the dose is stabilised, monthly for three months thereafter, which can be done at least every 12 weeks. 
• Methotrexate: MTX competitively inhibits the enzyme dihydrofolate reductase. As such, daily folic acid replacement is required. It has been shown to reduce disease activity and can be effectively used as a steroid-sparing agent. Adverse effects: Methotrexate toxicity, hepatotoxicity, nephrotoxicity, myelosuppression, teratogenic, lung fibrosis, reactivation of latent TB. Monitoring guidelines suggest full blood count and liver and renal function every 1-2 weeks until therapy is stabilised, after which patients can be monitored every 2-3 months. In the case of methotrexate toxicity, the antidote is folinic acid (calcium folinate). 
• Mycophenolate mofetil: MMF is an inhibitor of lymphocyte proliferation. It is used in combination with glucocorticoids in patients with focal or diffuse lupus nephritis. Adverse effects: Teratogenic, increased risk of infections, bone marrow suppression and rarely Progressive Multifocal Leukoencephalopathy (PML). As there is a risk of neutropenia, monitoring of full blood count is required every week for 4 weeks, then twice a month for 2 months, and then every month after that.