Internal Medicine

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

Systemic Lupus Erythematosus 1401

General Measures

■prophylaxis regarding sun exposure

■birth control or estrogen replacement

■treat hypertension aggressively

■control hyperlipidemia

specific therapy

■Conservative Management

➣arthritis/arthralga and myalgia: acetaminophen, NSAIDs, hydro-

xychloroquine, low-dose corticosteroids if quality of life impaired

■cutaneous lupus:

➣sunscreens, topical corticosteroids, hydroxychloroquine,

➣dapsone, etretinate for resistant rashes

■fatigue:

➣often due to comorbid fibromyalgia

➣may requires oral corticosteroids

■serositis:

➣NSAIDs or low-moderate dose corticosteroids

➣alternative to low-dose corticosteroids: methotrexate

■Aggressive Management

➣initial therapy of severe organ system involvement:

prednisone for 6–8 wks with gradual tapering

for diffuse proliferative GN, or for other life-threatening dis-

ease, e.g. severe pneumonitis, vasculitis, and CNS lupus:

■IV cyclophosphamide repeated monthly for 6 months and then every

3 months for 18–24 months, with escalation unless WBC is <1500;

optional initial pulse methylprednisolone

■monitor WBC at 10 and 14 d post cyclophosphamide treatment,

adjusting dose to keep nadir WBC >1500

■alternative 1: mycophenolate mofetil (500 mg BID escalating to max.

3 gm/d) for minimum of two years, then taper; optional initial pulse

methylprednisolone

■alternative 2: azathioprine (1–3 mg/kg/d); optional initial pulse

methylprednisolone

■alternative 3: IV pulse methylprednisolone (7 mg/kg) daily×3 d, then

repeated monthly for 6 months

Special Situations

■Arterial or venous thrombosis (manifestation of antiphospholipid

syndrome): warfarin to keep INR 3–3.5, low-dose aspirin, avoid estro-

gens