DR. CORA LIM-MEDICAL INSIDER
Systemic Lupus Erythematosus
PART 7
This is now Part 7 of our discussion of Systemic Lupus Erythematosus.
Corticosteroids
Studies show that Corticosteroids are used as the mainstay of treatment in acute flares of disease and are useful in this context.
Often on presentation to acute physicians, especially in the acute setting, patients are started on high-dose steroid therapy that is continued for protracted periods of time.
However, the same studies show that their use is associated with significant side effects and in order to limit these, steroids should be used at the lowest effective dose for the shortest duration of time possible.
The often quoted ‘recommended dose’ of 1 mg/kg/day is arbitrary, non-evidence based and should be avoided in most circumstances.
Reduction of steroids is a major goal in the treatment of chronic SLE as evidence is emerging that major damage accumulation results more from steroid therapy than lupus disease activity.
The initial dose of prednisolone in the first month of therapy after diagnosis of SLE is predictive of prednisolone doses over the following 11 months.
Organ complications secondary to chronic corticosteroid use occur in a dose-dependent manner.
The most common complications are musculoskeletal damage, such as osteoporotic fracture, and ocular damage, such as cataracts, and these are also among the first complications to occur. An increase in the average prednisolone dose by 1 mg/day is estimated to increase the risk of cataracts by 3.8% and osteoporotic fractures by 4.2%.
Conventional immunosuppression
Conventional immunosuppressive therapies, studies show, are based around combinations of corticosteroids with azathioprine, mycophenolate mofetil or cyclophosphamide.
Although there is a substantial evidence base for their use from multiple clinical trials, especially in lupus nephritis, their use may be limited by adverse effects, bone marrow, gastrointestinal and hepatotoxicity and their failure to sufficiently suppress active disease in certain patients.
First-line therapy for all patients and the mainstay of treatment for many patients with SLE are antimalarials such as hydroxychloroquine.
These agents have beneficial effects in reducing the frequency and severity of disease flares and thrombotic events, and also influence cardiovascular disease risk.
Methotrexate is often used to treat skin and joint disease. Skin disease may also benefit from topical treatments, such as topical steroids, and topical immunosuppressive agents, such as tacrolimus or pimecrolimus.
According to the study, patients with SLE should also be encouraged to avoid sun exposure and wear high factor sun block (SPF 50+) as this helps to reduce photosensitivity and cutaneous flares.