Internal Medicine

0521779407-19 CUNY1086/Karliner 0 521 77940 7 June 6, 2007 17:50

1402 Systemic Lupus Erythematosus

■Severe thrombocytopenia: high-dose prednisone and/or IV IgG;

danazol, or splenectomy

■CNS lupus: with stroke, treat anti-phospholipid antibody medi-

ated hypercoagulation; for seizures, diffuse cerebritis, cranial neu-

ropathies, use moderate-high-dose corticosteroids plus psychoac-

tive drugs for psychiatric manifestations

■Membranous glomerulonephritis: high-dose corticosteroids for 2–4

months or no treatment

■chronic stable glomerulonephritis: no treatment

■pregnancy:

➣with recurrent fetal loss (manifestation of antiphospholipid

syndrome): low-dose aspirin, moderate-high-dose corticos-

teroids or heparin

➣screen for anti-Ro (SS-A)

■SLE in older persons: generally more benign with more muscu-

loskeletal complaints, less renal disease; consider drug-induced

lupus

Side Effects/Toxicities

■NSAIDs: see section in Osteoarthritis

■Corticosteroids: see section on Polymyositis

■Hydroxychloroquine: retinopathy, indigestion, rash

■Cyclophosphamide:

➣Hemorrhagic cystitis (leads to bladder carcinoma),

➣infection, suppression of gonadal function/infertility

■Azathioprine:

➣nausea, vomiting, diarrhea, bone marrow suppression, hepatitis,

increased risk of lymphoproliferative malignancies

■Mycophenolate mofetil:

➣bone marrow suppression, hepatitis, nausea, vomiting diarrhea,

long-term risk of malignancy

Contraindications

■Corticosteroids: relative: uncontrollable diabetes or hypertension,

severe osteoporosis, steroid psychosis, life-threatening infection

■Hydroxychloroquine: absolute: retinopathy

■Cyclophosphamide:

➣absolute: cytopenia due to marrow suppression, life-threatening

infection, irreversible renal disease, refusal to accept risk of infer-

tility

➣relative: refractory hemorrhagic cystitis, severe nausea and vom-

iting, previous radiation therapy, history of malignancy