Systemic lupus erythematosus (SLE) is a heterogeneous, multisystem disease. SLE manifests in a unique way in each patient, and treatment should be tailored to the type and severity of organ system involvement (Table 22–1). Unfortunately, this is more easily said than done, because there are few large studies to guide decision-making. The lack of large scale, randomized controlled trials has resulted in therapeutic strategies that are largely empiric. Despite these limitations, well-accepted community standards exist and are helpful in guiding treatment. In the end, the patient and his or her physician must weigh the potential risks and benefits of a particular therapy and agree upon a course of action.
Table 22–1. Commonly Used Medications in Systemic Lupus Erythematosus (SLE). |Favorite Table|Download (.pdf)
Table 22–1. Commonly Used Medications in Systemic Lupus Erythematosus (SLE).
|Agent||Typical Dose||Potential Toxicities||Follow-up||Comments|
- Mild SLE: ≤10 mg/d
- Moderate to severe SLE: ≥10 mg/d
|Hypertension, dyslipidemia, atherosclerosis, hyperglycemia, osteoporosis, avascular necrosis, infection, weight gain, adrenal insufficiency||Lipid profile yearly, urinalysis for glucose, bone densitometry, blood pressure||Regimen for organ- or life-threatening disease: prednisone, 1 mg/kg/d, or pulse intravenous methylprednisone, 1 g/d for 3 days|
- ≤400 mg/d;
- Not to exceed 6.5 mg/kg/d
|Ocular effects including inability to focus, corneal deposits, and retinopathy; rash, hyperpigmentation, myopathy, headache, nausea||Ophthalmologic examination with fundoscopy and visual field testing yearly|
- Reduce dose in renal insufficiency
- Ophthalmologic examination every 3 months when using chloroquine
|Methotrexate||7.5–15 mg/d||Myelosuppression, lymphoproliferative disorders, cirrhosis, pulmonary inflammation and fibrosis||CBC, platelets, liver function tests, albumin, creatinine every 8 weeks or more frequently during dose changes|
- Do not use in patients with impaired renal function;
- use concomitant folic acid 1 mg/d or folinic acid 2.5 mg/wk
|Azathioprine||Myelosuppression, hepatotoxicity, malignancy, nausea and vomiting, infection||CBC and platelets every 2 weeks with dosage change, and every 8 weeks thereafter||Consider testing for the thiopurine methyltransferase gene prior to drug initiation; reduce dose in renal insufficiency|
|Mycophenolate mofetil||Target dose of 2–3 g/d||Myelosuppression, nausea, diarrhea||CBC and platelets every 2 weeks with dosage change, and every 8 weeks thereafter||Reduce dose in renal insufficiency|
- NIH regimen: 0.5–1.0 g/m2 intravenously monthly for 3–6 months for induction; every 3 months for maintenance
- Euro-lupus regimen: 500 mg every 2 weeks for six doses, then azathioprine for maintenance
- Oral dosing: Target dose of 2 mg/kg/d
|Myelosuppression, malignancy, hemorrhagic cystitis, bladder cancer, gonadal failure, infection|
- Intravenous dosing: CBC with platelets 7–14 days after dose to determine leukocyte nadir, then every 1–3 months thereafter
- Oral dosing: CBC and platelets every 1–2 weeks with dose change, every 1–3 months thereafter
- Intravenous and oral: Urinalysis and urine cytology every month while receiving treatment, every 6–12 months lifelong
|Reduce dose in renal insufficiency, obesity, and advanced age; use PCP prophylaxis; ensure adequate hydration during treatment; use antiemetics and mesna with intravenous dosing; consider use of leuprolide in women receiving intravenous therapy...|
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