Skip to Main Content

We have a new app!

Take the Access library with you wherever you go—easy access to books, videos, images, podcasts, personalized features, and more.

Download the Access App here: iOS and Android. Learn more here!

Chapter 22. Treatment of Systemic Lupus Erythematosus

Maria Dall'Era, MD; David Wofsy, MD

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).
View Table||Download (.pdf)
Table 22–1. Commonly Used Medications in Systemic Lupus Erythematosus (SLE).
AgentTypical DosePotential ToxicitiesFollow-upComments
Glucocorticoids
  • Mild SLE: ≤10 mg/d
  • Moderate to severe SLE: ≥10 mg/d
Hypertension, dyslipidemia, atherosclerosis, hyperglycemia, osteoporosis, avascular necrosis, infection, weight gain, adrenal insufficiencyLipid profile yearly, urinalysis for glucose, bone densitometry, blood pressureRegimen for organ- or life-threatening disease: prednisone, 1 mg/kg/d, or pulse intravenous methylprednisone, 1 g/d for 3 days
Hydroxychloroquine
  • ≤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, nauseaOphthalmologic examination with fundoscopy and visual field testing yearly
  • Reduce dose in renal insufficiency
  • Ophthalmologic examination every 3 months when using chloroquine
Methotrexate7.5–15 mg/dMyelosuppression, lymphoproliferative disorders, cirrhosis, pulmonary inflammation and fibrosisCBC, 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
  • Target dose of 2 mg/kg/d
Myelosuppression, hepatotoxicity, malignancy, nausea and vomiting, infectionCBC and platelets every 2 weeks with dosage change, and every 8 weeks thereafterConsider testing for the thiopurine methyltransferase gene prior to drug initiation; reduce dose in renal insufficiency
Mycophenolate mofetilTarget dose of 2–3 g/dMyelosuppression, nausea, diarrheaCBC and platelets every 2 weeks with dosage change, and every 8 weeks thereafterReduce dose in renal insufficiency
Cyclophosphamide
  • 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

CBC, complete ...

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.

This site uses cookies to provide, maintain and improve your experience. MH Privacy Center Close