Systemic lupus erythematosus is a chronic, multisystem, inflammatory, autoimmune disorder characterized by formation of autoantibodies directed against self-antigens and immune-complex formation.
It can be suspected when ≥2 organ systems are involved.
It is predominantly diagnosed in females of childbearing age, rarely diagnosed before 8 years old.
Clinical presentation varies in different patients and the disease activity varies over time in a single patient. Majority of patients have arthralgia of the hand.

Principles of Therapy

  • Patients require individualized therapy depending on disease manifestations, activity & severity
  • Control disease manifestations
  • Allow the patient to have a good quality of life w/o major exacerbations
  • Prevent serious organ damage that adversely affect function or life span
  • Prevent adverse effects of the drugs used


Oral corticosteroids
  • Patients w/ mild systemic lupus erythematosus (SLE) do not normally require use of systemic corticosteroids but there are patients who has low quality of life if not given low-dose corticosteroids
  • Actions: Decreases inflammation by suppression of the immune system
    • Decreases lymphocyte volume & activity, PMN migration, capillary permeability
    • High doses over periods of >2-3 weeks, suppress adrenal function
  • Used as initial therapy for severe discoid lupus erythematosus or lupus vasculitis
  • Low-dose corticosteroids may be added to Hydroxychloroquine for fatigue & fever
  • High-dose corticosteroids are necessary for refractory manifestations of SLE & for severe organ involvement especially CNS, renal & hematologic manifestations
    • Patients w/ milder forms of renal manifestations (eg mesangial glomerulonephritis & focal proliferative glomerulonephritis) may respond to corticosteroids monotherapy
    • Show improved survival in patients w/ severe forms of SLE nephritis
    • May also be useful in severe, life-threatening thrombocytopenia & hemolytic anemia
    • May also be useful in pleuritis or pericarditis
  • Corticosteroid use should be tapered as soon as desired response is observed (control of inflammatory manifestations) to avoid toxicity
Topical corticosteroids
  • Helpful for discoid lesions especially on the scalp
  • Use a less potent steroid on the face because it is more prone to atrophy
Parenteral Corticosteroids
  • Pulse therapy w/ IV corticosteroids in combination w/ immunosuppressive therapy is recommended for Class III/IV SLE patients w/ confirmed glomerulonephritis
  • Inhibits chemotaxis of eosinophils & locomotion of neutrophils & impairs complement-dependent antigen-Ab reactions
  • Used for skin & joint manifestations
    • Useful for patients w/ skin disease that are unresponsive to topical corticosteroids & in patients w/ arthritis that does not respond to NSAID
  • Recommended as background treatment for Class III/IV SLE patients w/ nephritis
    • Patients w/ continuing treatment w/ Hydroxychloroquine showed less renal damage as compared to those on placebo
  • Also used for preventing flares, reducing CV risk & recurrent infection, & other constitutional symptoms
Choice of immunosuppressant will depend on nature & severity of disease manifestation
  • These agents act as immunosuppressive, cytotoxic & anti-inflammatory agents
    • In the treatment of severe CNS & severe glomerulonephritis, thrombocytopenia & hemolytic anemia, high-dose glucocorticoids & immunosuppressants are used
    • Concomitant use w/ corticosteroids allows lower doses of immunosuppressants
  • Antagonizes purine metabolism & inhibits synthesis of DNA, RNA & proteins
  • May be used as the initial immunosuppressant for SLE nephritis
  • A steroid-sparing agent in SLE-related organ involvements (ie renal, neurological, hematological)
  • May decrease proliferation of immune cells, resulting in lower autoimmune activity
  • The first US FDA-approved biologic therapy for the treatment of SLE
  • A human monoclonal antibody that binds to soluble B-lymphocyte stimulator (BLyS/BAFF) to reduce disease activity
  • Used for active, autoantibody-positive SLE patients currently on standard therapy
  • Not recommended for patients w/ severe active lupus nephritis or severe active CNS disease
  • Studies have shown that patients on Belimumab therapy experienced reduced risk of severe flares, improved health-related quality of life & reduced steroid use as compared to those on placebo
  • As an alkylating agent, may involve cross-linking of DNA, which may interfere w/ growth of normal & neoplastic cells
  • Used as the initial immunosuppressant for SLE nephritis
    • Concomitant use w/ Prednisone is the standard treatment for lupus nephritis as it helps preserve renal function
  • Useful for severe SLE w/ involvement of different organ systems (eg severe CNS involvement, vasculitis or lupus nephritis)
Mycophenolic acid
  • A reversible inhibitor of inosine monophosphate dehydrogenase which is the rate-limiting step in de novo purine synthesis
  • An alternative treatment, both in initial and maintenance therapy of lupus nephritis
  • Recommended as induction & maintenance therapy for patients w/ lupus nephritis & has shown better results (less adverse effects & infections) as compared to intravenous Cyclophosphamide
Intravenous Immune Globulin (IV Ig)
  • Neutralizes circulating myelin antibodies through anti-idiotypic Abs
    • Down-regulates proinflammatory cytokines, including interferon-gamma
    • Blocks receptors on macrophages, suppresses inducer T & B cells, & augments suppressor T cells
    • Blocks complement cascade, promotes remyelination & may increase colony stimulating factor lgG
  • Used as immunosuppressant in serious SLE flares
  • Blocks purine synthesis, increases anti-inflammatory adenosine concentration at sites of inflammation
  • May be used as the initial immunosuppressant for severe arthritis
  • A chimeric anti-human CD20 antibody w/c regulates B-cells
  • Used as rescue therapy for SLE patients unresponsive to standard therapy
  • Further studies are needed to determine the efficacy of Rituximab & other anti-CD20 antibodies (ie Ocrelizumab) in patients w/ SLE
Nonsteroidal anti-inflammatory drugs (NSAIDs)
  • Inhibit inflammatory reactions & pain by decreasing prostaglandin synthesis
  • These drugs provide symptomatic relief of fever, arthritis & mild serositis
  • SLE patients have a high incidence of NSAID-induced hepatotoxicity
  • Patients w/ SLE should apply sunscreen w/ at least an SPF of 30 to prevent dermal or systemic disease flares upon exposure to ultraviolet light

Non-Pharmacological Therapy


  • Patients w/ systemic lupus erythematosus (SLE)  should apply sunscreen w/ at least an sun protection factor (SPF) of 30 to prevent dermal or systemic disease flares upon exposure to ultraviolet light
Digital Edition
Asia's trusted medical magazine for healthcare professionals. Get your MIMS Rheumatology digital copy today!
Sign In To Download
Editor's Recommendations
Most Read Articles
15 Sep 2018
Prenatal and postpartum vitamin D supplementation does not appear to improve foetal or infant growth, a study reports.
13 Sep 2018
Excessive daytime sleepiness appears to increase the long-term risk of amyloid β (Aβ) deposition, a recent study has shown.
Tristan Manalac, 2 days ago
The causes, presentations and management of anaphylaxis vary considerably with age, according to a recent Singapore study, which reported that children are more likely to present with food anaphylaxis, while drug anaphylaxis is more common in adults.
13 Sep 2018
Substituting diets high in carbohydrates with those high in monounsaturated fatty acids in the context of low saturated fatty acids do not appear to yield favourable effects on blood pressure, according to a meta-analysis.