Lupus, SLE Flashcards
Class V lupus nephritis treatment
treat with mycophenolate mofetil
side effects of mycophenolate mofetil?
is this safe for pregnant women?
teratogenic so must be stopped 3 months prior to planned pregnancy
Treatment of lupus nephritis
immunosuppressives: mycophenolate mofetil, cyclophosphamide, azothioprine, rituximab.
When to use cyclophosphamide?
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
Meds to NOT use for lupus nephritis
no adalimumab or methotrexate (toxic with kidney disease)
acute cutaneous lupus presentation
malar (butterfly) rash people with acute cutaneous lupus will develop systemic lupus.
manifestations of SLE pneuropsychiatric features
headache, mild cognitive dysfunction mood disorder severe presentation: seizures psychosis (rare)
what is low in SLE flare up
C3 and C4 complement levels are low.
When to start to see steroid induced psychosis?
greater than 1mg/kg/d and rarely at 20mg daily.
Parvo B19 presentation
arthralgias and nonspecific symptoms. Can resolve within 6 weeks. See positive IgG but IgM is more specific for an acute infection.
how many of SLE pts will develop renal dx in their lifetime?
50%
if someone starts to have proteinuria>500mg/day and elevated cr or active urine sediment they need to get
renal biopsy. Even if they have prior confirmed diagnosis of SLE to help see the subtype of dx of SLE.
Subtypes of SLE nephritis chart
when someone is diagnosed with SLE what antibiodies are checked?
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.
Antiphospholipid antibody syndrome is associated with
associated with recurrent arterial and venous thrombosis and pregnancy loss.
what antibodies are checked with suspected antiphospholipid antibody syndrome?
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).
pregnant women who have APL are treated with:
aspirin and or low molecular weight heparin depending on prior prengnancy complications (fetal loss or pre eclampsia)
what should also be checked in pregnant women who have SLE ?
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.
is hydroxychloroquine safe to use in pregnancy?
yes. if pregnant SLE pts are on it, continue this medication as stopping it can result in SLE flare.
Can we use methotrexate in a pregnant woman to treat her SLE?
no. its teratogenic and actively contraindicated.
what are the clinical differences between drug induced SLE and idiopathic SLE?
What are the differences in labs?
what are clinical features of drug induced SLE?
What drugs commonly cause drug induced SLE?
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)
what is seen with idiopathic SLE on clinical presentation?
What are some of the lab abnormalities associated with SLE?
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
what is a side effect of procainamide drug induced SLE?
can see pleuritis.
what antibodies are associated with drug induced SLE?
anti nuclear antibody and anti histone autoantibodies.
How to treat drug induced SLE?
stop offending drug and symptoms improve.
Clinical manifestations of systemic SLE
why is this rash unique?
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.
How to treat SLE dermatitis
Mild dx 1st line
Moderate dx 2nd line
Severe dx and 3rd line drugs
Cutaneous manifestations of SLE can
mild cases of acute cutaneous SLE can be treated with
sun protection and topical steroids
SLE dermatitis who have moderate dx OR failed initial management (sun protection and topical steroids) can get treated with
antimalarial drugs like hydroxychloroquine (ok in pregnancy)
SLE pts who have severe or systemic dx OR failed prior treatments can get
methotrexate or systemic steroids.
can use azathioprine
Rarely used methotrexate and azathioprine for SKIN lesions unless they are severe or bullous lesions
this is apparently:
discoid lupus. Can be treated with lenalidomide
Common side effects of drugs:
Meant for RA but has enough overlap drugs put in chart under SLE
indications for kidney biopsy to assess and provide prognostic and therapeutic implications for SLE are:
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.
how to treat refractory SLE ?
belimumab
FDA approved to use in pts with systemic SLE with persistent mild to moderate active dx.
stops B lymphocytes stimulator (BLyS) protein.
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?
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.
