26th February 2025

Management of SLE

Conservative measures such as wearing sun cream, preventing sun exposure, staying hydrated and regular exercise are very important.

Pharmacological treatment may include the following:

• Glucocorticoids can help in achieving remission and treating flares. 
• Hydroxychloroquine is used as a disease-modifying agent to prevent flares, maintain remission, and is particularly useful to treat joint symptoms and malar rash. It is generally well tolerated and does not require blood monitoring. Retinal toxicity is a rare but important side effect, and patients should have ophthalmology review 5 yearly and stop taking the drug straight away if any visual symptoms develop.
• Mycophenolate mofetil (MMF) is an immunosuppressive agent which helps to prevent flares, and is particularly effective in lupus nephritis.
• Azathioprine is another immunosuppressive drug which is effective in the management of SLE. It is generally less commonly used than MMF. However, it is safe to use throughout pregnancy and, therefore, is commonly seen in this cohort. Thiopurine methyltransferase enzyme should be tested prior to initiation, as those with a low level of this are at higher risk of side effects.
• Cyclophosphamide is used in severe flares that do not respond to conventional therapy, particularly with lupus nephritis. It has side effects, including haemorrhagic cystitis and risk of developing transitional cell carcinoma of the bladder if used long-term. Mesna is given concomitantly to prevent bladder irritation. 
• Rituximab is an anti-CD20 monoclonal antibody that has recently started to be used in SLE for patients who do not respond to conventional treatments. It depletes B cells, which are key inflammatory mediators in SLE. Serum sickness, a type III hypersensitivity reaction which causes fever, maculopapular rash and arthralgia, can occur 7-10 days following administration, and first-dose infusion reactions with fevers are not uncommon. Progressive multifocal leukoencephalopathy (PML) is the most important side effect to be aware of, although this is extremely rare. This is a progressive and often fatal demyelinating disease caused by reactivation of the JC virus.
• Belimumab is a recently approved monoclonal antibody against B-cell activating factor (BAFF), a B-cell differentiation factor. This has been shown to decrease severe flares and decrease cumulative steroid exposure.