Exam 4 - Systemic Lupus Erythematosus Flashcards
What are potential risk factors for the development of SLE? (7)
ultraviolet light, stress, smoking, medications, viruses, hormones, genetics
Explain the pre-clinical phase of SLE?
autoimmune proliferation as overactive B/T-cell activation and impaired tolerance and immune complex clearance (Type III hypersensitivity)
How does SLE most commonly present? (3)
fever, arthralgias, and rash in a woman of childbearing age
What are the ACR diagnostic criteria for SLE? (11)
serositis, oral ulcers, arthritis, photosensitivity, blood disorders, renal involve/impairment, antinuclear Ab, immunology, neurologic disorder, malar rash, discoid rash
What are the serologic tests for SLE? (3)
antinuclear, anti-dsDNA, and anti-Sm (Smith proteins) Abs
What constitutes antiphospholipid syndrome in SLE?
antiphospholipid antibody (aPL) positive and a thrombotic event
What constitutes lupus nephritis? (2)
persistent proteinuria and/or cellular casts and renal biopsy and histology
How does lupus NEPHRITIS commonly present (3)
foamy urine, peripheral edema, concomitant hypertension
What are nDMARDs for SLE? (4)
topical corticosteroids, calcineurin inhibitors, acetaminophen, NSAIDs
What is the DMARD for SLE?
hydroxychloroquine
How long does hydroxychloroquine take to work?
2-4 months
What are glucocorticoids reserved for in adjunctive treatment of SLE? (4)
moderate-severe initial presentation, organ/life-threatening SLE, inadequate response to hydroxychloroquine or NSAIDs, poor QoL without
What is the MOA of belimumab (Benlysta)?
B-lymphocyte stimulator antagonist
What is belimumab (Benlysta) reserved for in adjunctive treatment of SLE? (3)
non-active-CNS Ab+ SLE, unresponsive to hydroxychloroquine/NSAIDs/steroid, lupus nephritis III-V
How long does belimumab (Benlysta) take to work?
2-4 months
What are AEs of belimumab (Benlysta)? (5)
GI, hypersensitivity reactions, infusion reactions, suicidality, PML
What is the MOA of anifrolumab (Saphnelo)?
interferon antagonist
What are contraindications for anifrolumab (Saphnelo)? (2)
active lupus nephritis, CNS disease
When is methotrexate indicated in SLE? (2)
concomitant RA or primary presentation of arthritis
When is azathioprine indicated in SLE?
second-line (after steroids) for more moderate disease
When is mycophenolate mofetil indicated in SLE? (2)
proliferative (II-IV) lupus nephritis, second-line for membranous (V) lupus nephritis
Why is cyclophosphamide use in SLE controversial?
positive long-term evidence but incredibly toxic
When is cyclosporine indicated in SLE?
membranous (V) lupus nephritis
When are calcineurin inhibitors indicated in SLE?
membranous (V) lupus nephritis
What is an off-label last-line treatment for SLE?
rituximab
What are clinical pearls for voclosporin (Lupkynis)? (3)
boxed warning for infections and malignancies, eGFR <45 cutoff, 3A4 interactions
What are first-line treatments for skin disease in SLE? (3)
topical steroids, calcineurin inhibitors, hydroxychloroquine
What are treatments for refractory skin disease SLE? (7)
systemic steroids, methotrexate, mycophenolate, belimumab, anifrolumab, retinoids, dapsone
What is initial treatment for lupus nephritis (III-IV)?
mycophenolate mofetil or cyclosporine plus steroid
What is remission therapy for lupus nephritis?
tapered steroid
What can be added to steroid + mycophenolate mofetil combos in lupus nephritis (III-IV) treatment?
tacrolimus
When should lupus nephritis (III-V) treatment be reassessed?
3-12 months
If lupus nephritis (III-IV) is responsive to treatment? If not?
mycophenolate mofetil or azathioprine with tapered steroid; alternative induction therapy or add tacrolimus or rituximab
What is initial treatment for lupus nephritis (V) with a UPr <3?
RAAS blockade (ACEi/ARB)
What are initial treatments for lupus nephritis (V) with a UPr >3? (2)
RAAS blockade (ACEi/ARB), mycophenolate mofetil plus steroid
If lupus nephritis (V) is responsive to treatment? If not?
continue same treatment with tapered steroid; calcineurin inhibitor (monotherapy or add-on to mycophenolate mofetil) or cyclosporine or rituximab
What are the indications for ACE-i/ARBs in SLE? (2)
persistent proteinuria (>0.5 g/24hr) and/or HTN
What is the indication for statin therapy in SLE?
LDL >100 mg/dL
Explain pregnancy with regards to SLE medications? (4)
hydroxychloroquine = good, NSAIDs = unsafe in 3rd trimester (use APAP), topical steroids must be low-potency and non-fluorinated, azathioprine is the only safe immunosuppresant
What is the treatment for aPL+ and not pregnant? Pregnant?
low-dose aspirin; low-dose aspirin +/- low molecular weight heparin (enoxaparin)
What is the treatment for APS and pregnant?
low-dose aspirin +/- low molecular weight heparin (enoxaparin)
What is the treatment for APS with an arterial manifestation?
warfarin (INR 3-4)
What is the treatment for APS with a venous manifestation?
warfarin (INR 2-3)
What is treatment for lupus nephritis in pregnant patients?
hydroxychloroquine with azathioprine
