Lupus Flashcards
Epidemiology
At least 1.5 million Americans and
* 5 million people worldwide have a form of lupus
Gender:
* 9 in 10 people with lupus are women
* More common in ___ of
childbearing age
Age:
* Peak incidence between ages of 15-45
years old
Ethnicity:
* More prevalent in Asian, African, Arab,
Hispanic/Latins and American Indians
background
women
Exact etiology of SLE is unknown but many pre-disposing factors
Drug-induced Lupus Erythematosus (DILE)
- Overreaction to certain medications
- Symptoms occur __ - __ months of
drug initiation - Resolution occurs within ___ of drug discontinuation
- Around 10% of SLE cases are drug-
induced - There are at least 46 medications that
can cause DILE
- 3-6
- weeks
MPMMPHATIQ
- Methimazole
- Propylthiouracil
- Methyldopa
- Minocycline
- Procainamide
- Hydralazine (alone, and in BiDil)
- Anti-TNF agents (ex. Infliximab and
etanercept) - Terbinafine
- Isoniazid
- Quinidine
D) minocycline
Signs/Symptoms
- Fatigue
- Depression
- Photosensitivity
- Joint Pain
- Nausea/Vomiting
- Fever
- Weight Loss
- Malar “_______” rash
butterfly
- butterfly rash, discoid rash, raynaud phenomenon
- lupus retinopathy
- lupus nephritis
a) butterfly
c) sun exposure
Key labs
all labs positive in lupus
- ANA - not ___
- anti-dsDNA - ___ specificity, correlates with disease activity, important marker of lupus ___
- anti-SM - ___ specificity
- Antiphospholipid Antibody - Increase clotting factors
- specific
- high, nephritis
- high
- rash
- mouth ulcers
- ANA +
- anti-dsDNA +
Pharmacologic Treatments
- HCQ
- NSAIDs
- glucocorticoids
- immunosuppressants
- biologics
HCQ
MOA: Antimalarial —> Inhibit overactive immune cells
* Place in therapy: Recommended for ALL patients with SLE
* Benefits: Reduce flares and help manage pain
* Dosing: 200-400 mg PO daily
* Max: 400 mg daily
HCQ SE
Side effects:
- Ophthalmologic: Retinal Toxicity ( ____ )
- CNS: Neuropsychiatric Effects (anxiety,
depression, insomnia, suicidal ideation,
etc)
- CV: QT prolongation, cardiomyopathy
- Neuromuscular: Myopathy
- Dermatologic: Hypersensitivity reaction
- Other: Hypoglycemia, Hemolytic anemia
( ____ )
- bullseye mucopathy
- G6PD
G6PD Deficiency
- ___ disorder that causes RBCs to prematurely break down
X-linked
HCQ - monitoring
Baseline:
* CBC
* LFTs
* SCr
* EKG
Periodic:
* ___ exam
* 3 months after starting therapy,
then annually
- eye
NSAIDs
Place in therapy: Considered first line for mild symptoms
Dosing:
* Ibuprofen: 400-600 mg PO Q6-8H
* Naproxen: 500 mg PO BID
Side effects
- GI: Bleeding, gastritis, perforation
- CV: Increased BP, worsening HF, cardiovascular events
- Renal: Increased SCr, renal toxicity
- Hepatic: Hepatoxicity
Monitoring Parameters:
* Baseline:
* CBC
* LFTs
* SCr
* BP
S/sx of ___and bleeding
- fluid retention
Glucocorticoids
MOA: Inhibit B and T cell responses
Benefits: Anti-inflammatory and helpful
during flares
- Variable dosage forms - PO, topical, IV
- Place in therapy: ___ treatment, if not responsive to NSAIDs/ antimalarial
- adjunctive
GC
PO/IV Side Effects
* Ophthalmologic: Glaucoma
* CV: ___ BP
* Bone: Increased risk of ___
* GI: GI bleed, gastritis
* CNS: Psychosis/sleep disturbances
* Other: Weight gain, increased ___ ,
increased risk of infection risk &
___ syndrome
Topical SE
- skin atrophy
- rosacea
- telangiectasis
- increased
- osteoporosis
- BG
- Cushing
Glucocorticoids (GC)
Monitoring parameters:
Baseline:
* BP
* BMP
* FLP
* Bone mineral density
Routine:
* ___ - Every 6 months
* ___- Every 6 months
* ___ - Annually
- BMP
- FLP
- Bone mineral density
Immunosuppressants (IS)
MOA: Suppression of immune function
from attacking healthy cells
Place in therapy:
- Adjunct to ___ therapy to lower
the dose
- Insufficient response to ___
Medications:
* Methotrexate (MTX)
* Azathioprine (AZA)
* Cyclophosphamide (CYC)
* Mycophenolate mofetil (MMF)
- steroid
- HCQ
Dosages and Side Effects
- weekly
- BID
Dosages and Side Effects
cyclophosphamide (CYC)
IV: ___ mg/m2 BSA q month x 6 months
- 0.5
AZA: monitor ___
TPMT
Biologics
MOA: Monoclonal antibodies that block __ -cell mediated immunity
Place in therapy:
* Inadequate response to ___
and ___
* Severe disease
Medications:
* ___ (Benlysta®)
* ___ (Tiruxan ®)
* ___ (Saphnelo®)
- B-cell
- HCQ, immunosuppressants
- belimumab
- rituximab
- anifrolumab
biologics
Pearls:
- No live vaccines ___ days before starting therapy OR ___
therapy
- Do not use more than 1 biologic at the same time
- 30
- during
biologic
BEL
SE
- ___
- infusion reactions
anifrolumab
- ___
rituximab
SE
- Infusion reactions
- ___ reactivation
- premedication ~ 30 min prior
Additional therapies
___ Inhibitors (CNI)
Calcineurin
Cutaneous Lupus
- 10% of lupus cases and rarely life-threatening
- Presents on the skin with rash and lesions
First Line:
Topical agents:
- GC: Clobetasol, betamethasone, triamcinolone, hydrocortisone
- CNI: Tacrolimus, pimecrolimus
not topical
- ___
- Systemic GC
Refractory:
* High-dose GC
* ___ or ___
- HCQ
- MTX, MMF
Lupus Nephritis
LN is a serious complication of SLE which can affect 60% of patients within
10 years of diagnosis
Therapy:
Mild/moderate nephritis (Class 1 or 2 LN):
- GC+/- another immunosuppressant ( ___ , ___ , or ___ )
Severe nephritis (Class 3 or 4 LN):
- ___ (preferred) or CYC +/- GC
Triple therapy:
* ___ + ___ or CYC +/- ___
* ___ + ___ +/- GC (triple therapy)
- AZA, MMF, or CNI
- MF
- MF
- belimumab, MMF, GC
- CNI, MMF
LN flow chart
MSC
- diuretics
- NSAIDs (unless nephritis)
Pregnancy & SLE
Higher maternal and fetal risk compared with healthy women
* Miscarriage
* Fetal growth retardation
* Maternal mortality
* Preeclampsia
The best prognosis is when the patient
achieves remission for ≥ ___ months
before pregnancy
* Pregnancy can cause flares
Contraception
* Avoid ___ -containing
contraception
* Screen for ___ syndrome
- 6
- estrogen
- antiphospholipid
Antiphospholipid antibody
An autoimmune disorder characterized by ___ that can cause blood clots and miscarriages
- antiphospholipid syndrome
summary
- SLE primarily occurs in women of childbearing age
- SLE is a multi-system autoimmune disease that can involve any
organ and present in many ways - Many drugs can induce lupus-like symptoms
- Backbone of lupus therapy: ___ +/- ___ +/- ___ for pain and
inflammation - Monitor for drug side effects/toxicities
- HCQ, GC, NSAIDs
