Systemic Lupus Erythematosus Flashcards
SLE - Environmental Risk Factors
UV light
stress
smoking
drugs
viruses
SLE - Hormonal Risk Factors
estrogen
prolactin
SLE - Pre-Clinical Phase Pathophysiology
B-cell & T-cell overactivation
elevated CD4:CD8 ratio
dysregulation of cellular apoptosis
SLE - Clinical Phase Pathophysiology
autoantibody production -> immune complexes form and deposit in vasculature and tissues -> Type III hypersensitivity reaction -> inflammation -> organ involvement
SLE - Diagnostic Criteria
4/11 needed to diagnose
serositis
oral ulcers
arthritis
photosensitivity
blood disorders
renal involvement
antinuclear antibodies
immunology
neurologic disorder
malar rash
discoid rash
SLE - Signs & Symptoms
fatigue
fever
weight loss
myalgia
Raynaud’s syndrome
dyspepsia, abdominal pain
alopecia
dry eyes
SLE - Antibodies Involved
antinuclear
anti-dsDNA
anti-Sm
antiphospholipid
Antiphospholipid Syndrome
aPL (+) and thrombotic event
Lupus Nephritis
kidney inflammation due to deposition of immune complexes in either glomeruli or glomerular basement membrane
Lupus Nephritis - Diagnostic Criteria
persistent proteinuria or cellular casts
renal biopsy to confirm
Lupus Nephritis - Clinical Presentation
foamy urine
peripheral edema
concomitant hypertension
SLE - Maintenance Drug of Choice
hydroxychloroquine 200-400 mg QD
Hydroxychloroquine - Adverse Reactions
flu-like symptoms
ocular toxicity
allergic skin eruptions
hematological changes
GI upset
cardiomyopathy
SLE - Glucocorticoids’ Role in Therapy
adjunctive treatment for moderate-to-severe initial presentation / organ- or life-threatening SLE / inadequate response to hydroxychloroquine / poor QOL
SLE - Belimumab’s Role in Therapy
adjunctive treatment - to be used in combination with standard
B-lymphocyte stimulator antagonist
preferred in: non-active-CNS, LN III / IV / V
Belimumab - Adverse Reactions
NVD
infusion reactions
depression / CNS effects
PML
infections
SLE - Anifrolumab’s Role in Therapy
adjunctive treatment - to use in combination with standard
interferon antagonist
NOT in active LN or CNS disease
SLE - Immunosuppressants’ Role in Therapy
refractory disease
organ-threatening SLE (mainly LN)
SLE - Immunosuppressants
azathioprine
cyclophosphamide
cyclosporine
methotrexate
mycophenolate
rituximab
tacrolimus
SLE - Methotrexate Indications
concomitant RA or primary presentation of arthritis
SLE - Azathioprine Indications
second line after steroids for a moderate disease course
safest in class in pregnancy
SLE - Mycophenolate Indications
mainly proliferative LN
second line in membranous LN
SLE - Cyclosporine Indication
membranous LN
SLE - Rituximab Indications
off-label severe renal / psychiatric / hematologic disease
last line
SLE - Tacrolimus Indications
proliferative LN
may be used with MMF
SLE - Voclosporin Indications
adjunctive to other immunosuppressants in active LN (except cyclosporine)
Voclosporin - BBWs
infections
malignancies
Voclosporin - eGFR Cut-Off
45 mL/min
SLE Skin Disease - First-Line Agents
topical steroids
topical CNIs
hydroxychloroquine
Mild SLE - First-Line Agents
hydroxychloroquine
PO glucocorticoids
Mild SLE - Refractory Agents
first-line plus methotrexate / azathioprine
Moderate SLE - First-Line Agents
hydroxychloroquine
PO glucocorticoids
methotrexate / azathioprine
CNIs
MMF
Severe SLE - First-Line Agents
hydroxychloroquine
PO glucocorticoids
MMF
cyclosporine
Severe SLE - Last Line
rituximab
SLE - Glucocorticoid Dosing
prednisone 20-60 mg per day with 10% taper every 5-7 days
Lupus Nephritis III-IV - Treatment
induction: MMF or cyclosporine PLUS steroid
remission: taper steroid, switch immunosuppressant as needed
Lupus Nephritis III-IV - No Response to Treatment
add tacrolimus or rituximab
Lupus Nephritis III-IV - Treatment-Responsive
continue MMF or switch to azathioprine after 3-12 months
Lupus Nephritis V - Treatment
RAAS blockade
steroid
MMF
SLE - RAAS Blockade Indications
glomerular disease and
persistent proteinuria or hypertension
SLE - Statin Indication
LDL > 100 mg/dL
SLE - Pregnancy Treatment Options
hydroxychloroquine
acetaminophen instead of NSAIDs
low-potency, non-fluorinated topical steroids
Lupus Nephritis - Pregnancy Treatment Options
mild: hydroxychloroquine / azathioprine
clinically active: non-fluorinated PO steroid
highly active: pre-term delivery (28 wks)
SLE - Pregnancy Options with aPL(+)
low-dose aspirin +/- LMWH
SLE - aPL(+), No Event, Not Pregnant
low-dose aspirin
SLE - Antiphospholipid Syndrome, Not Pregnant
warfarin
arterial: INR 3-4
venous: INR 2-3
