The Best Treatment For Active Lupus

Stephen Paget, MD

Disclosures

December 30, 2010

Question:

What is the most effective treatment for active lupus?

Response from Stephen Paget, MD
Professor of Medicine, Weill Cornell Medical College, New York, NY; Physician-in-Chief, Center for Rheumatology, Hospital for Special Surgery, New York, NY

It depends on the manifestation and severity of active lupus. Just as there is a spectrum of severity from mild to severe, non-life or non-organ-threatening to life- or organ-threatening, there is a spectrum of medications that are individualized for that given patient and their problem. The medications chosen vary from less strong with fewer side effects (nonsteroidal anti-inflammatory drugs [NSAIDs], antimalarials, topical steroids) to powerful drugs with many potential side effects (steroids, immunosuppressive drugs like methotrexate and azathioprine, rituximab). Below are treatment algorithms for common lupus manifestations.

Rheumatoid arthritis-like polyarthritis: Hydroxychloroquine (Plaquenil) should be used as long-term treatment in all systemic lupus erythematosus (SLE) patients. Also consider NSAIDs and short courses or increased doses of oral prednisone, methotrexate, or azathioprine.

Serositis: Same as above.

Rash: Topical steroids, hydroxychloroquine or quinicrine (Atabrine), and oral steroids can be tried. Thalidomide can occasionally be used for bullous disease. Rarely immunosuppressives like azathioprine, methotrexate, or mycophenolate should be considered.

Glomerulonephritis: Oral prednisone or pulse methylprednisolone are appropriate; also consider mycophenolate, azathioprine, or cyclophosphamide.

Other visceral manifestations, such as central nervous system disease or peripheral nervous system disease (ie, stroke, transverse myelitis, neuropathy, mononeuritis multiplex), lung inflammation, heart inflammation (myocarditis, severe pericarditis), bowel inflammation/vasculitis, and cytopenias (thrombocytopenia, hemolytic anemia) usually demand high-dose oral or IV steroids, mycophenolate, azathioprine, cyclophosphamide, or rituximab.

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