Lupus nephritis medical therapy: Difference between revisions
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* Moderate cases are defined as more than 2 organ involvement during disease flares with low grade of involvement and complications or one or two organ involvement with more extensive involvements. | * Moderate cases are defined as more than 2 organ involvement during disease flares with low grade of involvement and complications or one or two organ involvement with more extensive involvements. | ||
* Severe cases are defined as presentation of the disease with life threatening complications and multiple (more than 2) organ involvements. | * Severe cases are defined as presentation of the disease with life threatening complications and multiple (more than 2) organ involvements. | ||
===== Lupus nephritis treatment<ref name="pmid25014039">{{cite journal |vauthors=Schwartz N, Goilav B, Putterman C |title=The pathogenesis, diagnosis and treatment of lupus nephritis |journal=Curr Opin Rheumatol |volume=26 |issue=5 |pages=502–9 |year=2014 |pmid=25014039 |pmc=4221732 |doi=10.1097/BOR.0000000000000089 |url=}}</ref><ref name="pmid23328501">{{cite journal |vauthors=Hogan J, Appel GB |title=Update on the treatment of lupus nephritis |journal=Curr. Opin. Nephrol. Hypertens. |volume=22 |issue=2 |pages=224–30 |year=2013 |pmid=23328501 |doi=10.1097/MNH.0b013e32835d921c |url=}}</ref><ref name="pmid25778500">{{cite journal |vauthors=Tunnicliffe DJ, Singh-Grewal D, Kim S, Craig JC, Tong A |title=Diagnosis, Monitoring, and Treatment of Systemic Lupus Erythematosus: A Systematic Review of Clinical Practice Guidelines |journal=Arthritis Care Res (Hoboken) |volume=67 |issue=10 |pages=1440–52 |year=2015 |pmid=25778500 |doi=10.1002/acr.22591 |url=}}</ref> ===== | |||
* Aggressive [[antihypertensive therapy]] with [[blood pressure]] goal of 130/85 | |||
* In patients with [[proteinuria]], antiproteinuric therapy with blockade of the [[renin-angiotensin system]] include [[ACEIs]] and [[ARBs]]: | |||
** [[ACE inhibitor|ACE inhibitors]]; [[captopril]] PO 25 mg 3 times daily | |||
*** Antiproteinuric effect | |||
** [[ARBs]]; [[losartan]] PO initial: 50 mg once daily; can be increased to 100 mg once daily based on [[blood pressure]] response | |||
*** Slowing progression of [[GFR]] decline; | |||
* [[Lipid]] lowering with [[statin therapy]] with the goal of [[LDL]]< 130 | |||
* Diffuse or focal proliferative LN: | |||
** Preferred regimen: [[Immunosuppressive therapy]] with [[glucocorticoids]] plus either [[Intravenous therapy|intravenous]] or oral [[Mycophenolate sodium|mycophenolate mofetil]]: 0.5 g of [[Mycophenolate sodium|mycophenolate mofetil]] twice daily for the first week, then 1 g twice daily for the second week, and thereafter increase the dose to 1.5 g twice daily | |||
** Alternative regimen: [[Immunosuppressive therapy]] with [[glucocorticoids]] plus IV [[cyclophosphamide]] 500 mg every two weeks for a total of six doses | |||
* Severe active disease: | |||
** Preferred regimen: [[Glucocorticoid|Glucocorticoid therapy]] is initiated with [[Intravenous therapy|intravenous]] pulse [[methylprednisolone]] (250 mg to 1000 mg given over 30 minutes daily for three days) to induce a rapid [[immunosuppressive]] effect, followed by conventional doses | |||
** Alternative regimen: Conventional doses of oral [[glucocorticoids]] (eg, 0.5 to 1 mg/kg per day of prednisone) without a pulse. | |||
*** Oral [[prednisolone]] at a dose of 60 mg/day, tapered every two weeks by 10 mg/day until 40 mg/day is reached, then tapered by 5 mg/day until 10 mg/day is reached | |||
===== Considerations<ref name="pmid25778500" /> ===== | |||
* Appropriate adjunct therapy: | |||
** [[Vitamin D]] and [[calcium supplement|calcium supplements]]<nowiki/> for preventing [[osteoporosis]] in patients using [[corticosteroids]] | |||
** [[Antihypertensive drugs]] and [[statins]] were also recommended in patients using [[corticosteroids]] | |||
* Adverse effects: Cutaneous [[atrophy]] is a potential side effect of the long-term use of [[Topical steroid|topical steroids]] | |||
==References== | ==References== | ||
Revision as of 16:34, 20 July 2018
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:
Overview
There is no treatment for [disease name]; the mainstay of therapy is supportive care.
OR
Supportive therapy for [disease name] includes [therapy 1], [therapy 2], and [therapy 3].
OR
The majority of cases of [disease name] are self-limited and require only supportive care.
OR
[Disease name] is a medical emergency and requires prompt treatment.
OR
The mainstay of treatment for [disease name] is [therapy].
OR The optimal therapy for [malignancy name] depends on the stage at diagnosis.
OR
[Therapy] is recommended among all patients who develop [disease name].
OR
Pharmacologic medical therapy is recommended among patients with [disease subclass 1], [disease subclass 2], and [disease subclass 3].
OR
Pharmacologic medical therapies for [disease name] include (either) [therapy 1], [therapy 2], and/or [therapy 3].
OR
Empiric therapy for [disease name] depends on [disease factor 1] and [disease factor 2].
OR
Patients with [disease subclass 1] are treated with [therapy 1], whereas patients with [disease subclass 2] are treated with [therapy 2].
Medical Therapy
Treatment goals in systemic lupus erythematosus (SLE) include:
- Ensure long-term survival
- Achieve the lowest possible disease activity
- Prevent organ damage
- Minimize drug toxicity
- Improve quality of life
General treatment
- Hydroxychloroquine: 200 to 400 mg daily as a single daily dose or in 2 divided doses.
- Generally, all patients with any type of SLE manifestation should be treated with hydroxychloroquine regardless of the severity of the disease.
The treatment choice for systemic lupus erythematosus (SLE) is varied based on the severity of the disease and symptoms:
- Mild cases are defined as disease pattern with one or two organ involvement.
- Moderate cases are defined as more than 2 organ involvement during disease flares with low grade of involvement and complications or one or two organ involvement with more extensive involvements.
- Severe cases are defined as presentation of the disease with life threatening complications and multiple (more than 2) organ involvements.
Lupus nephritis treatment[1][2][3]
- Aggressive antihypertensive therapy with blood pressure goal of 130/85
- In patients with proteinuria, antiproteinuric therapy with blockade of the renin-angiotensin system include ACEIs and ARBs:
- ACE inhibitors; captopril PO 25 mg 3 times daily
- Antiproteinuric effect
- ARBs; losartan PO initial: 50 mg once daily; can be increased to 100 mg once daily based on blood pressure response
- Slowing progression of GFR decline;
- ACE inhibitors; captopril PO 25 mg 3 times daily
- Lipid lowering with statin therapy with the goal of LDL< 130
- Diffuse or focal proliferative LN:
- Preferred regimen: Immunosuppressive therapy with glucocorticoids plus either intravenous or oral mycophenolate mofetil: 0.5 g of mycophenolate mofetil twice daily for the first week, then 1 g twice daily for the second week, and thereafter increase the dose to 1.5 g twice daily
- Alternative regimen: Immunosuppressive therapy with glucocorticoids plus IV cyclophosphamide 500 mg every two weeks for a total of six doses
- Severe active disease:
- Preferred regimen: Glucocorticoid therapy is initiated with intravenous pulse methylprednisolone (250 mg to 1000 mg given over 30 minutes daily for three days) to induce a rapid immunosuppressive effect, followed by conventional doses
- Alternative regimen: Conventional doses of oral glucocorticoids (eg, 0.5 to 1 mg/kg per day of prednisone) without a pulse.
- Oral prednisolone at a dose of 60 mg/day, tapered every two weeks by 10 mg/day until 40 mg/day is reached, then tapered by 5 mg/day until 10 mg/day is reached
Considerations[3]
- Appropriate adjunct therapy:
- Vitamin D and calcium supplements for preventing osteoporosis in patients using corticosteroids
- Antihypertensive drugs and statins were also recommended in patients using corticosteroids
- Adverse effects: Cutaneous atrophy is a potential side effect of the long-term use of topical steroids
References
- ↑ Schwartz N, Goilav B, Putterman C (2014). "The pathogenesis, diagnosis and treatment of lupus nephritis". Curr Opin Rheumatol. 26 (5): 502–9. doi:10.1097/BOR.0000000000000089. PMC 4221732. PMID 25014039.
- ↑ Hogan J, Appel GB (2013). "Update on the treatment of lupus nephritis". Curr. Opin. Nephrol. Hypertens. 22 (2): 224–30. doi:10.1097/MNH.0b013e32835d921c. PMID 23328501.
- ↑ 3.0 3.1 Tunnicliffe DJ, Singh-Grewal D, Kim S, Craig JC, Tong A (2015). "Diagnosis, Monitoring, and Treatment of Systemic Lupus Erythematosus: A Systematic Review of Clinical Practice Guidelines". Arthritis Care Res (Hoboken). 67 (10): 1440–52. doi:10.1002/acr.22591. PMID 25778500.