Systemic lupus erythematosus (SLE)

M32.9

These patients need to be managed by a specialist.

GENERAL MEASURES

Education regarding the disease and complications.

Avoid cigarette smoking as it is a trigger for lupus.

Sun protective barrier creams are often indicated.

Regularly monitor urine for blood and protein.

Provide advice regarding family planning as pregnancy may cause a lupus flare.

MEDICINE TREATMENT

Mild disease

For pain:

  • Paracetamol, oral, 1 g 4–6 hourly when required.
    • Maximum dose: 15 mg/kg/dose.
    • Maximum daily dose: 4 g in 24 hours.

AND/OR

  • NSAID, e.g.:
  • Ibuprofen, oral, 400 mg 8 hourly with meals.

LoEI [30]

In high-risk patients: i.e. patients > 65 years of age, or with a history of peptic ulcer disease, or on concomitant warfarin, aspirin or corticosteroids:

LoEII [31]

ADD

  • PPI, e.g.:
  • Lansoprazole, oral, 30 mg daily.

To suppress disease activity

  • Chloroquine sulphate, oral, 150 mg (as base) daily for 5 days of each week.
    • Do ophthalmic examination at baseline within the first year of treatment and annually, to monitor for ocular damage.

LoEI [32]

Corticosteroids

Initiate therapy in patients with life threatening manifestations and organ involvement.

  • Corticosteroids (intermediate-acting) e.g.:
  • Prednisone, oral, 2 mg/kg daily, initial dose.
    • Taper to the lowest maintenance dose after a response has been obtained. Refer to Appendix II for an example of a dose reduction regimen.
    • Usual maintenance dose: 10 mg daily.

Patients requiring corticosteroids for >3 months (long-term) should be managed for secondary prevention of osteoporotic fractures. See Osteoporosis.

Additional immunosuppressive therapy

Is often required for life-threatening disease, particularly kidney and CNS involvement. These medicines should be initiated by a specialist and regular FBC monitoring should be done.

  • Azathioprine, oral, 1 mg/kg daily, titrated to a maximum of 3 mg/kg daily.

LoEIII

OR

Cyclophosphamide, oral, 100 mg daily, titrated to a maximum of 200 mg daily (or 1–3 mg/kg daily).

LoEIII

Raynaud’s phenomenon I73.0

  • Amlodipine, oral, 5 mg daily.

LoEII [33]

Antiphospholipid antibody syndrome

  • Aspirin, oral, 150 mg daily.

Patients with previous thrombo-embolic episodes should receive lifelong warfarin (target INR 3 to 4).

LoEIII

Hormonal therapy in women

The use of oral contraceptives is controversial.

Until there is clarity it is advisable to use either progesterone-only, or low dose oestrogens, or non-hormonal methods.

REFERRAL

  • All patients to a specialist for initial assessment.
  • Lupus flare.
  • Nephritis for renal biopsy.
  • Persistent haematological derangements i.e. thrombocytopaenia.
  • Neurological manifestations of lupus.