Management of systemic lupus erythematosus (SLE) spans a quite broad spectrum of items including: patient assessment and monitoring, patient education, life style recommendations, treatment strategies, and others. For this reason is difficult to cover all these aspects in only one session and therefore the present review will be focused on therapeutic aspects, trying to raise the most relevant ones from a practical point of view.
Thus, I will discuss specific issues regarding to the general management of the disease, treatment of specific manifestations and finally recommendations for prevention of cardio-vascular complications.
Firstly, regarding to the general management, antimalarial use in lupus will be considered. Nowadays, antimalarials should be indicated as soon as the diagnosis of lupus is done, given that they have shown beneficial effects on clinical activity, damage prevention, thrombosis or lipid levels. Among them efficacy-toxicity trade off favours the use of hydroxichloroquine but other agents as chloroquine or quinacrine are potential options in some circumstances. Sun protection is another common general measure in lupus patients but correct sun protector indication and usage and tailored patient selection should be considered. Glucocorticoids are used also very often in these patients; however potential side effects should not be forgotten and for this reason optimization of its use must be always borne in mind using sparing agents when needed and trying to use the lowest possible dose from the beginning. Furthermore, recent off-glucocorticoid protocols for the management of lupus nephritis have been proposed with good preliminary results. Finally, recommendations about vaccination and vitamin D monitoring and supplementation are reviewed.
With respect to specific clinical scenarios, refractory lupus nephritis, skin manifestations, arthritis, thrombocytopenia and CNS involvement are discussed.
General management of lupus nephritis (LN) has been clarified in the recently published EULAR and ACR guidelines for the treatment of LN. However, no definitive rules are given for refractory cases. To this regard two principal options come out: rituximab and anti-calcineurins and main literature data of both alternatives are discussed.
Sun protection, antimalarials and topical steroids are the mainstay of treatment of cutaneous lupus, but in refractory cases multiple types of treatments are used without a definitive consensus about which are the best options in each situation. An effort is performed to give the clues to individualize the therapeutic place of each agent (when possible) as well as the role of biologics, mainly Belimumab, in this scenario.
Unresponsive lupus arthritis is another common situation. If methotrexate or leflunomide fail, biologics would be the option. To this regard, either rituximab and belimumab seem to be effective but not head to head comparisons exist. Rituximab accumulates more clinical experience but belimumab offers a higher level of scientific evidence and it has not to be used off-label.
Regarding to the case of thrombocytopenia not responding to standard care, recent data for not forgetting the option of splenectomy, the evidence of the efficacy of Rituximab and the potential utility of the new thrombopoetin stimulating agents, are discussed.
The last specific scenario considered is CNS involvement. In this case the standard of care consists on high dose of GC usually in combination with immunosupresants (mainly iv ciclophosphamide) and in selected cases adjunctive measures as plasmapheresis. or IVIG No definitive evidence exists about how to treat unresponsive patients although a relative good experience has been obtained with rituximab.
Finally, a summary of the main recommendations for prevention of cardiovascular complications is presented including the different therapeutic goals for blood pressure or serum lipid levels and the main therapeutic interventions.
Disclosure of Interest J. Calvo Alén Consultant for: GSK, Lilly and MSD
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