Management Of Systemic Lupus Erythematosus

Management of systemic lupus erythematosus (SLE) is a challenge because no interventions can result in cure, exacerbations of disease can occur after months of stable maintenance treatment, and undesirable side effects of the therapies can be as troublesome as the disease. Careful and frequent monitoring of patients is important in selecting management plans, monitoring efficacy, and changing treatments.

Initial Therapeutic Decisions

Because most therapeutic interventions in patients with SLE are associated with significant undesirable side effects, the physician must first decide whether a patient needs treatment and, if so, whether conservative management is sufficient or aggressive immunosuppression is necessary. Figure 76-1 presents an algorithm for this decision making.

In general, patients with manifestations of SLE that are not life threatening and are unlikely to be associated with organ damage should be treated conservatively. If quality of life is mildly impaired, education and careful follow-up may be adequate. If quality of life is impaired, it is appropriate to initiate strategies listed in Figure 76-1 as conservative measures. On the other hand, if the disease is life threatening or if major organ systems are at high risk for irreversible damage, aggressive intervention is mandatory. Aggressive therapy usually consists of immunosuppression. A few clinical subsets of SLE have been recognized, however, for which immunosuppression is either not effective or alternative therapies may be preferable. The best example of this is patients who have recurring thrombosis as the major manifestation of SLE. In the subsequent sections, conservative therapies, the approach to patients with life-threatening SLE, and therapies effective in different clinical subsets are reviewed.

The pharmacology, mechanisms of action, benefits, and side effects of most of the drugs used in the management of SLE are reviewed in Section VII of this book. This chapter discusses the use of these agents in SLE.