Systemic%20lupus%20erythematosus Management

• The most important tool in the management of SLE is a careful, frequent clinical and laboratory evaluation to detect disease flares and drug side effects, appearance of infections and to tailor management based on patient response
  
  • Do active surveillance of opportunistic infections
  • Adjust current therapy (eg corticosteroids and immunosuppressants) according to the severity of organ involvement during SLE flares 
  • Patients with severe SLE, complications, comorbidities and drug toxicity will require more frequent follow-up
• Monitoring during clinic visit should include history-taking, physical exam and lab tests (eg CBC, platelet count, creatinine measurement, urinalysis, renal and liver function tests, immunology, ECG, imaging) 
  • For active SLE disease, monitoring can be done every 1-3 months after diagnosis or flare while for low/no disease activity or with stable treatment course, monitoring can be every 6-12 months
• Physicians may be aided by at least 1 of the following several global or body system-specific indices developed for long-term observation of SLE: SLEDAI, BILAG, PGA and ECLAM 
• Results of laboratory tests that may precede a disease flare:
  • Decrease in serum complement levels
  • Increase in anti-dsDNA
  • Increase in ESR
  • Decrease in hemoglobin level, leukocyte or platelet counts
  • Increase in creatine phosphokinase (CPK) levels
  • Appearance of microscopic hematuria or proteinuria

Toxicity

• Patients on long-term glucocorticoids should be monitored for:
  • Electrolyte, glucose and lipid levels to identify metabolic conditions
  • Bone densitometry to identify osteoporosis and monitor response to treatment
• Patients on Hydroxychloroquine should have ophthalmological screening (eg visual fields examination and/or spectral domain-optical coherence tomography) performed at baseline, after 5 years, and then annually in those with no risk factors for retinal toxicity
• Patients on immunosuppressants should be monitored for hematologic, liver and renal toxicity, and occurrence of infection

• Establish good working relationship amongst the primary care physician, non-lupus specialist (eg general internist or pediatrician), lupus specialist (eg rheumatologist), nurse, pharmacist, other healthcare providers, the patient and his/her family
  
  • Team approach will allow for earlier identification of disease flares and medication toxicity
• Patient will initially present to a primary care physician or non-lupus specialist who is responsible for:
  • Recognizing the signs and symptoms of SLE in their patients
  • Making an initial diagnosis
  • Treating and monitoring patients with mild disease
  • Referring patient to a rheumatologist or other lupus specialist (eg nephrologist) and participating in further SLE diagnosis, management and monitoring of patients with moderate to severe disease
• The lupus specialist is the integral part of the medical team managing an SLE patient
• Referral to a lupus specialist especially the rheumatologist is indicated for:
  • Confirmation of diagnosis
  • Management plan for patient
  • Periodic evaluation of disease activity and severity
  • Management of uncontrolled disease and complications
  • Management of organ involvement or life-threatening disease
  • Prevention and/or management of treatment toxicities
  • Special situations (eg pregnancy, antiphospholipid syndrome, life-threatening disease, concomitant infection and surgery)
• Multidisciplinary care involves referral of SLE patients to a psychologist, psychiatrist, physical and/or occupational therapist, ophthalmologist, dermatologist, cardiologist, orthopedic surgeon and other specialists when necessary