Systemic lupus erythematosus medical therapy: Difference between revisions
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Topical corticosteroids: first-line therapies for patients with DLE or SCLE / twice daily application of a super high potency or high potency topical corticosteroid / clobetasol propionate : first-line therapy for acute flares of DLE / inimal disease activity on the face,: hydrocortisone 1% or 2.5% / triamcinolone acetonide 0.1% cream or fluocinonide 0.05% cream: trunk, extremity, or scalp disease/ lowest-potency agent that maintains disease control should be utilized. When all signs of disease activity (eg, scale or erythema) are absent, treatment can be discontinued / a topical calcineurin inhibitor or intralesional corticosteroid therapy: If an acute flare of DLE or SCLE doesn't respond to corticosteroid therapy for two to four week / Cutaneous atrophy is a potential side effect of the long-term use of topical corticosteroids | Topical corticosteroids: first-line therapies for patients with DLE or SCLE / twice daily application of a super high potency or high potency topical corticosteroid / clobetasol propionate : first-line therapy for acute flares of DLE / inimal disease activity on the face,: hydrocortisone 1% or 2.5% / triamcinolone acetonide 0.1% cream or fluocinonide 0.05% cream: trunk, extremity, or scalp disease/ lowest-potency agent that maintains disease control should be utilized. When all signs of disease activity (eg, scale or erythema) are absent, treatment can be discontinued / a topical calcineurin inhibitor or intralesional corticosteroid therapy: If an acute flare of DLE or SCLE doesn't respond to corticosteroid therapy for two to four week / Cutaneous atrophy is a potential side effect of the long-term use of topical corticosteroids | ||
Topical calcineurin inhibitors: pimecrolimus 1% cream and as tacrolimus 0.03% or 0.1% ointment / more expensive than topical corticosteroids, and may be slower-acting | Topical calcineurin inhibitors | ||
18797893: pimecrolimus 1% cream and as tacrolimus 0.03% or 0.1% ointment / more expensive than topical corticosteroids, and may be slower-acting | |||
Patients with focal lesions that do not respond to topical corticosteroids or topical calcineurin inhibitors can be treated with intralesional corticosteroid injections | Patients with focal lesions that do not respond to topical corticosteroids or topical calcineurin inhibitors can be treated with intralesional corticosteroid injections | ||
16966017 | |||
SYSTEMIC THERAPY | SYSTEMIC THERAPY | ||
Antimalarials are the first-line systemic therapy for the treatment of DLE and SCLE/ | Antimalarials are the first-line systemic therapy for the treatment of DLE and SCLE/ Antimalarials — Hydroxychloroquine, chloroquine, and quinacrine / hydroxychloroquine (200 to 400 mg/day) for at least six weeks / after improvement, decreased the dosage to 200 mg/day for maintenance therapy / | ||
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359493 | |||
|For patients with DLE or SCLE, we suggest the use of topical agents as first-line therapy (algorithm 1) (Grade 2B). We suggest treatment with topical corticosteroids over topical calcineurin inhibitors as initial therapy (Grade 2C). The relatively rapid onset of topical corticosteroids is beneficial. | |||
●If topical corticosteroid therapy is not effective, we suggest treatment with a topical calcineurin inhibitor such as tacrolimus 0.1% ointment or pimecrolimus 1% cream (Grade 2C). Topical calcineurin inhibitors also may be useful for long-term therapy for lesions in areas of the skin where the risk of corticosteroid-induced atrophy is a concern. (See 'Topical corticosteroids' above and 'Topical calcineurin inhibitors' above.) | |||
●For patients with focal lesions of DLE or SCLE that fail to respond to topical therapy, we suggest treatment with intralesional corticosteroid injections (Grade 2C). (See 'Intralesional corticosteroids' above.) | |||
●Patients who fail local therapy or who have extensive disease that makes topical or intralesional therapy impractical may benefit from systemic medications. We suggest treating these patients with hydroxychloroquine (Grade 2B). If therapy with hydroxychloroquine is unsuccessful, we suggest adding quinacrine 100 mg/day (Grade 2C). Switching from hydroxychloroquine to chloroquine is an additional therapeutic option. (See 'Antimalarials' above.) | |||
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Raviteja Guddeti, M.B.B.S. [2]
Overview
As lupus erythematosus is a chronic disease with no known cure, treatment is restricted to dealing with the symptoms; essentially this involves preventing flares and reducing their severity and duration when they occur. There are several means of preventing and dealing with flares, including drugs, alternative medicine and lifestyle changes.
Medical Therapy
Due to the variety of symptoms and organ system involvement with Lupus patients, the severity of the SLE in a particular patient must be assessed in order to successfully treat SLE. Mild or remittent disease can sometimes be safely left untreated. If required, non-steroidal anti-inflammatory drug and anti-malarials may be used.[1]
Disease-modifying antirheumatic drugs (DMARDs) are used preventively to reduce incidence of flares, the process of the disease, and lower the need for steroid use; when flares occur, they are treated with corticosteroids. DMARDs commonly in use are anti-malarials and immunosupressants (e.g. methotrexate and azathioprine). Hydroxychloroquine (trade name Plaquenil) is an FDA approved anti-malarial used for constitutional, cutaneous, and articular manifestations, while Cyclophosphamide (trade names Cytoxan and Neosar) is used for severe glomerulonephritis or other organ-damaging complications, and in 2005, CellCept became accepted for treatment of lupus nephritis.
In more severe cases, medications that modulate the immune system (primarily corticosteroids and immunosuppressants) are used to control the disease and prevent re-occurrence of symptoms (known as flares). Patients who require steroids frequently may develop obesity, diabetes and osteoporosis. Depending on the dosage, corticosteroids can cause other side effects such as a puffy face, an unusually large appetite and difficulty sleeping. Those side effects can subside if and when the large initial dosage is reduced, but long term use of even low doses can cause elevated blood pressure and cataracts. Due to these side effects, steroids are avoided if possible.
Since a large percentage of Lupus patients suffer from varying amounts of chronic pain, stronger prescription analgesics may be used if over-the-counter drugs, mainly non-steroidal anti-inflammatory drug do not provide effective relief. Moderate pain in Lupus patients if typically treated with mild prescription opiates such as Dextropropoxyphene (trade name Darvocet), and Co-codamol (trade name Tylenol #3). Moderate to severe chronic pain is treated with stronger opioids such as Hydrocodone (trade names Lorcet, Lortab, Norco, Vicodin, Vicoprofen) or longer-acting continuous release opioids such as Oxycodone (trade names OxyContin), MS Contin, or Methadone. The Fentanyl Duragesic Transdermal patch is also a widely-used treatment option for chronic pain due to Lupus complications because of its long-acting timed release and easy usage. When opioids are used for prolonged periods drug tolerance, chemical dependency and (rarely) addiction may occur. Opiate addiction is not typically a concern for Lupus patients, since the condition is not likely to ever completely disappear. Thus, lifelong treatment with opioids is fairly common in Lupus patients that exhibit chronic pain symptoms; accompanied by periodic increased titration that is typical of any long-term opioid regimen.
Contraindicated medications
all patients with SLE with any degree and type of disease activity should be treated with hydroxychloroquine or chloroquine, unless these agents are contraindicated=
| Cutaneous lupus erythematosus | Photoprotection: broad spectrum sunscreens and sun protective clothing
Avoidance of exacerbating drugs Smoking cessation |
LOCAL THERAPY :
Topical corticosteroids: first-line therapies for patients with DLE or SCLE / twice daily application of a super high potency or high potency topical corticosteroid / clobetasol propionate : first-line therapy for acute flares of DLE / inimal disease activity on the face,: hydrocortisone 1% or 2.5% / triamcinolone acetonide 0.1% cream or fluocinonide 0.05% cream: trunk, extremity, or scalp disease/ lowest-potency agent that maintains disease control should be utilized. When all signs of disease activity (eg, scale or erythema) are absent, treatment can be discontinued / a topical calcineurin inhibitor or intralesional corticosteroid therapy: If an acute flare of DLE or SCLE doesn't respond to corticosteroid therapy for two to four week / Cutaneous atrophy is a potential side effect of the long-term use of topical corticosteroids Topical calcineurin inhibitors 18797893: pimecrolimus 1% cream and as tacrolimus 0.03% or 0.1% ointment / more expensive than topical corticosteroids, and may be slower-acting Patients with focal lesions that do not respond to topical corticosteroids or topical calcineurin inhibitors can be treated with intralesional corticosteroid injections 16966017 SYSTEMIC THERAPY Antimalarials are the first-line systemic therapy for the treatment of DLE and SCLE/ Antimalarials — Hydroxychloroquine, chloroquine, and quinacrine / hydroxychloroquine (200 to 400 mg/day) for at least six weeks / after improvement, decreased the dosage to 200 mg/day for maintenance therapy / 359493 |
For patients with DLE or SCLE, we suggest the use of topical agents as first-line therapy (algorithm 1) (Grade 2B). We suggest treatment with topical corticosteroids over topical calcineurin inhibitors as initial therapy (Grade 2C). The relatively rapid onset of topical corticosteroids is beneficial.
●If topical corticosteroid therapy is not effective, we suggest treatment with a topical calcineurin inhibitor such as tacrolimus 0.1% ointment or pimecrolimus 1% cream (Grade 2C). Topical calcineurin inhibitors also may be useful for long-term therapy for lesions in areas of the skin where the risk of corticosteroid-induced atrophy is a concern. (See 'Topical corticosteroids' above and 'Topical calcineurin inhibitors' above.) ●For patients with focal lesions of DLE or SCLE that fail to respond to topical therapy, we suggest treatment with intralesional corticosteroid injections (Grade 2C). (See 'Intralesional corticosteroids' above.) ●Patients who fail local therapy or who have extensive disease that makes topical or intralesional therapy impractical may benefit from systemic medications. We suggest treating these patients with hydroxychloroquine (Grade 2B). If therapy with hydroxychloroquine is unsuccessful, we suggest adding quinacrine 100 mg/day (Grade 2C). Switching from hydroxychloroquine to chloroquine is an additional therapeutic option. (See 'Antimalarials' above.) |
SLE complication treatment
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