Lupus, SLE

Question 1

Class V lupus nephritis treatment

Answer 1

treat with mycophenolate mofetil

Question 2

side effects of mycophenolate mofetil?

is this safe for pregnant women?

Answer 2

teratogenic so must be stopped 3 months prior to planned pregnancy

Question 3

Treatment of lupus nephritis

Answer 3

immunosuppressives: mycophenolate mofetil, cyclophosphamide, azothioprine, rituximab.

Question 4

When to use cyclophosphamide?

Answer 4

not a first choice due to side effects when compared to mycophenolate mofetil. Reserved for severe active nephritis to induce remission then start mycophenolate mofetil or azathioprine as maintenance

Question 5

Meds to NOT use for lupus nephritis

Answer 5

no adalimumab or methotrexate (toxic with kidney disease)

Question 6

acute cutaneous lupus presentation

Answer 6

malar (butterfly) rash people with acute cutaneous lupus will develop systemic lupus.

Question 7

manifestations of SLE pneuropsychiatric features

Answer 7

headache, mild cognitive dysfunction mood disorder severe presentation: seizures psychosis (rare)

Question 8

what is low in SLE flare up

Answer 8

C3 and C4 complement levels are low.

Question 9

When to start to see steroid induced psychosis?

Answer 9

greater than 1mg/kg/d and rarely at 20mg daily.

Question 10

Parvo B19 presentation

Answer 10

arthralgias and nonspecific symptoms. Can resolve within 6 weeks. See positive IgG but IgM is more specific for an acute infection.

Question 11

how many of SLE pts will develop renal dx in their lifetime?

Answer 11

50%

Question 12

if someone starts to have proteinuria>500mg/day and elevated cr or active urine sediment they need to get

Answer 12

renal biopsy. Even if they have prior confirmed diagnosis of SLE to help see the subtype of dx of SLE.

Question 13

Subtypes of SLE nephritis chart

Answer 13

Question 14

when someone is diagnosed with SLE what antibiodies are checked?

Answer 14

always check APL or antiphospholipid antibodies (regardless of pregnancy or miscarriage history)

Pregnant pts with active SLE and APL are at increased risk for maternal and fetal complications.

Question 15

Antiphospholipid antibody syndrome is associated with

Answer 15

associated with recurrent arterial and venous thrombosis and pregnancy loss.

Question 16

what antibodies are checked with suspected antiphospholipid antibody syndrome?

Answer 16

anticardiolipin antibodies, lupus anticoagulant, and anti-beta 2-glycoprotein 1 antibodies.

all three tests should be done as only one must be positive to diagnose APL syndrome with pts who have appropriate clinical history (thrombotic events and pregnancy l;oss).

Question 17

pregnant women who have APL are treated with:

Answer 17

aspirin and or low molecular weight heparin depending on prior prengnancy complications (fetal loss or pre eclampsia)

Question 18

what should also be checked in pregnant women who have SLE ?

Answer 18

Check Anti-SSA/Ro and anti- SSB/La antibodies because pts with this can have neonatal lupus and congenital heart block (baby)

Also check anticardiolipin antibodies, lupus anticoagulant, and anti-beta 2-glycoprotein 1 antibodies.

Question 19

is hydroxychloroquine safe to use in pregnancy?

Answer 19

yes. if pregnant SLE pts are on it, continue this medication as stopping it can result in SLE flare.

Question 20

Can we use methotrexate in a pregnant woman to treat her SLE?

Answer 20

no. its teratogenic and actively contraindicated.

Question 21

what are the clinical differences between drug induced SLE and idiopathic SLE?

What are the differences in labs?

Answer 21

Question 22

what are clinical features of drug induced SLE?

What drugs commonly cause drug induced SLE?

Answer 22

clinical features: more abrupt onset, see subacute cutaneous lupus erythematous rash (no malar or discoid lupus rashes). and see no CNS disease.

Can see fever, malaise, myalgias and arthralgias.

Drugs that cause this: procainamide, hydralazine, isoniazid, TNF alpha inhibitors and monocycline (for acne tx)

Question 23

what is seen with idiopathic SLE on clinical presentation?

What are some of the lab abnormalities associated with SLE?

Answer 23

clinical features: gradual onset, see malar or discoid rash

CNS disease is possible

Labs :renal disease, anemia, leukopenia, thrombocytopenia. Can have positive dsDNA, anti Sm and low complement and increased immune complexes

Question 24

what is a side effect of procainamide drug induced SLE?

Answer 24

can see pleuritis.

Question 25

what antibodies are associated with drug induced SLE?

Answer 25

anti nuclear antibody and anti histone autoantibodies.

Question 26

How to treat drug induced SLE?

Answer 26

stop offending drug and symptoms improve.

Question 27

Clinical manifestations of systemic SLE

Answer 27

Question 28

why is this rash unique?

Answer 28

Because this is the SLE malar rash or “butterfly” rash. It spares the nasolabial fold but gets the sun exposed areas of the face and the nasal bridge.

Can be mistaken for rosacea or drug photosensitivity and may need biopsy for diagnosis.

Question 29

How to treat SLE dermatitis

Mild dx 1st line

Moderate dx 2nd line

Severe dx and 3rd line drugs

Answer 29

Question 30

Cutaneous manifestations of SLE can

Question 31

mild cases of acute cutaneous SLE can be treated with

Answer 31

sun protection and topical steroids

Question 32

SLE dermatitis who have moderate dx OR failed initial management (sun protection and topical steroids) can get treated with

Answer 32

antimalarial drugs like hydroxychloroquine (ok in pregnancy)

Question 33

SLE pts who have severe or systemic dx OR failed prior treatments can get

Answer 33

methotrexate or systemic steroids.

can use azathioprine

Rarely used methotrexate and azathioprine for SKIN lesions unless they are severe or bullous lesions

Question 34

this is apparently:

Answer 34

discoid lupus. Can be treated with lenalidomide

Question 35

Common side effects of drugs:

Answer 35

Meant for RA but has enough overlap drugs put in chart under SLE

Question 36

indications for kidney biopsy to assess and provide prognostic and therapeutic implications for SLE are:

Answer 36

increasing serum creatinine without explanation

proteinuria >1000 mg/24 h, proteinuria>500 mg/24 h with hematuria, and proteinuria>500 mg/24 h with cellular casts.

Question 37

how to treat refractory SLE ?

Answer 37

belimumab

FDA approved to use in pts with systemic SLE with persistent mild to moderate active dx.

stops B lymphocytes stimulator (BLyS) protein.

Question 38

if pt with SLE has signs of an acute flare and has signs of significant kidney involvement (low complements, high protein in urine, urine with blood and protein) what to do?

Answer 38

get kidney biopsy

don’t go straight to steroids and mycophenolate mofetil or cyclophosphamide.

Need the kidney biopsy to make decisions about treatment. Biopsy could show a milder mesangial proliferative lupus nephritis (class 2) which wouldnt’ need immunosuppression.