S LEaving my brain at home Flashcards
SLE triggers
- UV light triggers
- stress
- smoking
- virus/virus ike elements
SLE dx
4 out of the following 11 SOAP, BRAIN, MD
1. serotosis
2. oral ulcers
3. arthritis
4. photosensitivity
5. blood disorders
- hemolytic anema w/ reticulocytosis
- leukopenia on 2+ occassions
- lymphopenia on 2+ occasions
- thrombocytopenia in absence of offending drugs
6. renal involvement: persistent proteinuria, cellular casts
7. antinuclear Ab
8. immunology/serologic testing
9. neurologic disorder (with unclear cause)
10. malar rash
11. discoid
SLE serologoic testing
- ANA: if negative, pretty positive it’s NOT SLE, but if positive, eh
- Good for excluding, not confirming SLE
- Anti-dsDNA Ab: perform after ANA titer to confirm
- Anti-Sm Ab: smith proteins
Antiphospholipid syndrome (APS)
- secondary APS: aPL(+) AND thrombotic event
- associated with DVTs, stroke, and neurologic manifestations
lupus nephritis (LN)
- kidney inflammation d/t either
- intravascular deposition of immune complexes in glomeruli
- formation of immune complexes on self-antigens on glomerular basement membrane
presnetation of SLE
LN dx
- persistent proteinuria and/or cellular casts
- renal biopsy and histology to confirm
LN presentation
- foamy urine
- peripheral edema
- concomitant HTN
topical steroids in SLE
- lower potency for face
- using it around the clock makes it lose its efficacy
- can use a topical CNI if topical steroid CI
adequte HCQ trial in SLE
6 months
HCQ in SLE
- give to everyone
- reduces flares and reduces risk of major organ involvemnt
gluocortivoid use in SLE
- Adjunctive treatment for
- Moderate-severe flare
- Rapid symptom relief: prednisone 20-60mg/day or IV pulse followed by PO taper
- Taper down by 10-20% Q 5-7 D
- Rapid symptom relief: prednisone 20-60mg/day or IV pulse followed by PO taper
- organ or life threating
- inadequater response to hydroxychloroquine or NSAIDs
- Moderate-severe flare
- Poor QOL without
GLutocorticoid lonog term use AE
- OP
- HLD
- Fat redistribution
- Moon facies
- Growth faillure
- Amenorrhea
- Immunsuppresion
- HPA suppression
- Cataracts
- Obesity
- Seziures
- Echymosis
- Muscle weakness
- Acne
Belimumab use in SLE
- b lymphocyte stimulat antag
- adjunctive treatment for
- non-active-CNS, Ab (+) SLE
- musculoskeletal cutaneous disease unresponsive to HCQ, NSAID, steroid
- lupus nephritis III, IV, or V
belimumab AE
- nausea
- diarrhea
- allergic reaction
- ifusion reaction
- depression/suicidality
- PML
anifrolumab use in SLE
- interferon antag → reuce imune cell recruitment, improves symptoms, stabilizes organ disease
- Adjunct med to be used in combo with standard SLE treatment
- IV inf Q4W
- NOT indicated in active LN or CNS disease
When to use immunosuppressants in SLE and list them
- for poor symptom control refractory to HCQ/NSAID/steroid
- indicated for organ threatening LE (lupus nephritis
- immunosuppressants
- MTX
- AZA
- MMF
- CYC (cyclophsophamide)
- Cyclosporine
- rituximab
- CNIs (tacrolimus)
- Voclosporin
MTX use inSLE
If pt also has RA or primary presentaiton of arhtritis
AZA use in SLE
- Second line after steroids for a more moderate disease coures
- Safe in preggers
AZA AE
- Bone marrow suppresion
- N/V
MMF use in SLE
- For proliferative (II-IV) LN and is second line for membranous (V) LN
- Better than cyclophosphamide
Also used in non-renal disease (non LN)
Not really effective in neuropsychiatric disease
MMF AE
- Diarrhea
- Abdoimal pain
- Anorexia
- Nausea
- Hematologic
- CV
- Teratogenicty → no preggers
CYC use in SLE
Used for organ-threatening cardiopulmonary, renal or neuropsych disease
CYC AE
TOXIC
- Hematologic tox
- Cardio tox
- neurologic to
- Permanent infertility
Cyclosporine use in SLE
- Used for membranous (V) LN
- Approximately same effectivness as CYC but less tox
Cyclosporine AE
- HTN
- Hematologic tox
- Nephrotox
- Neurologic tox
Rituximab use in SLE
- really last resort
- Off label use in pts with severe renal, hematologic or neurpsych SLE refractory to other agents
- Failure of MMF/CYC in LN or relapsing disease
PO tacrolimus use in SLE
For plroferative (V) L alone or in combo with MMF
Voclosporin use in SLE
- PO CNI → decreases cytokine production and lymphocyte proliferation
- In adjunct to one of the
immunosuppresants in active lupus nephritis - Do NOT use with CYC
- CYP 3A4 interactions
Voclosporin AE
- BBW: infections adn malignances
- Nephrotoxic if eGFR <45
SLE treat to target principles
- Shared decisions between pt and MD
- Prolong survival
- Minimize organ damage
- Improve QOL
- SLE may require multidisciplinary
- Monitor, f/u and adjust
SLE treat to target recommendations
- Remissio or reduced disease
- Flare prevention is a realisitic goal
- do NOT have to escalate treatment in asymptomatic pts with stable or increaseing serological activity
- Prevent dmaage accrual
- Pay attention to QOL
- Recognize and treat LN early
- Optimize LN outcomew with 3 yrs of immunosuppressive therapy after induction
- Lowest posible dose of steroid
- Pay attention to APS
- Consider antimalarials
- Supportive treatments for toehr disease states PRN
SLE nonpharm
- Sunscreen
- Avoid photosensitizing agents, stress, smoking
- Immunizations, vaccines
SLE skn disease first line agents
- Topicals: steroids, topical CNIs
- HCQ
SLE skn disease refractory agents
- systemi steroids: preferred agent if first line isn’t enough
- methotrexate
- MMF
- belimumab
- anifrolumab
- retinoids
- dapsone
Rfractory/severe SLE agents
- Steroid -sparing immunosuppresnats
- methotrexate
- MMF
- azathioprine: for preggers
- cyclophosphamide in organ-threatening idsease
- Other
- belimumab
- anifrlumab
Non-SLE/LN speific tratment that neds to be considered in these pts
- IF pt has glomerular disease (persistant proteinuria and/or HTN): ACE or ARB
- IF pt has LDL >100: statin
Class III-IV (proliferative LN) treatment
- Initial optiosn
- glucocorticoid + MMF OR
- glucocorticoid + low dose IV CY OR
- glucocorticoid + MMF + TAC
- If pt responds with 3-12 months, de-escalate to MMF or AZA
- IF pt does NOT respond: switch to alternative induction therapy or add TC to MMF or rituximab
Class V (membranous LN) treatment
- Initial options
- UPr <3: RAAS blockade (consider GC + MMF)
- UPr > 3: RAAS blockde AND GC + MMF
- If pt responds with 3-12 months, de-escalate to MMF or AZA
- IF pt does NOT respond: IV CY or CNI
- If still no response:
- CNI monotherapy or add on to MMF OR
- high dose IV CY OR
- rituximab
- If still no response:
If preggers and active LN
- Continue HCQ if already on
- non-fluorinated PO GC
- AZA (MDD 2mg/kg) if necessary
- consider pre-term delivery if LN real bad@28wks
APL (+) with no event treatment
- baby asa QD
- if preggers: can consider adding LMWH
APS treatment
antiphospholipid syndrome
- warfarin
- if arterial, goal INR: 3-4
- if venous, goal INR: 2-3
