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Key Clinical Updates in Systemic Lupus Erythematosus

Belimumab is FDA-approved for the treatment of active lupus nephritis.

Anifrolumab, a type 1 interferon receptor antagonist, is FDA-approved to treat non-renal lupus that has not responded to standard therapies.

Voclosporin, a novel calcineurin inhibitor, is FDA-approved to treat active lupus nephritis when used in combination with mycophenolate mofetil.

Evidence increasingly suggests that renal response can be enhanced with combination immunosuppressive therapy.

Morand EF et al; TULIP-2 Trial Investigators. N Engl J Med. [PMID: 31851795]

Rovin BH et al. Lancet. [PMID: 33971155]

ESSENTIALS OF DIAGNOSIS

  • Occurs mainly in young women.

  • Rash over areas exposed to sunlight.

  • Joint symptoms in 90% of patients.

  • Anemia, leukopenia, thrombocytopenia.

  • Glomerulonephritis, CNS disease, and complications of antiphospholipid antibodies are major sources of disease morbidity.

  • Serologic findings: antinuclear antibodies (100%), anti–double-stranded DNA antibodies (approximately two-thirds), and low serum complement levels (particularly during disease flares).

GENERAL CONSIDERATIONS

SLE is an inflammatory autoimmune disorder characterized by autoantibodies to nuclear antigens. It can affect multiple organ systems. Many of its clinical manifestations are secondary to the trapping of antigen-antibody complexes in capillaries of visceral structures or to autoantibody-mediated destruction of host cells (eg, thrombocytopenia). The clinical course is marked by spontaneous remission and relapses. The severity may vary from a mild episodic disorder to a rapidly fulminant, life-threatening illness.

The incidence of SLE is influenced by many factors, including sex, environmental exposures, and genetic inheritance. About 85% of patients are women and most cases develop after menarche and before menopause. Among older individuals, the sex distribution is more equal. Race is also a factor, as SLE occurs in 1:250 Black women but in 1:1000 White women. Familial occurrence of SLE has been repeatedly documented, and the disorder is concordant in 25–70% of identical twins. If a mother has SLE, her daughters’ risks of developing the disease are 1:40 and her sons’ risks are 1:250. Serologic abnormalities (positive antinuclear antibody) are seen in asymptomatic family members, and the prevalence of other rheumatic diseases is increased among close relatives of patients. The importance of specific genes in SLE is emphasized by the high frequency of certain HLA haplotypes, especially DR2 and DR3, and null complement alleles (see eTable 20–1).

eTable 20–1.Association between the presence of various HLA markers and selected autoimmune diseases.

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