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Treatment Decisions in SLEAhmed ElshebinyAhmed Elshebiny
University of MenoufyiaUniversity of Menoufyia
General Principles Treatment should be tailored to every patient Risk benefit evaluation Timing of treatment changes Treatment Precautions Monitoring response and side effects General measures Cardiovascular risk correction Cancer screening
Treatment Plan
General measures
Assessment of disease activity Various global or individual organ scoring
systems( SLEDAI, SLAM, BILAG, ECLAM, LAI..)
SLICC /ACR damage indexPractice points : assess Disease activity Disease damage Co morbidities especially infection Drug side effects Quality of life
Causes of mortality Early in the first years
Infection Flares
Late Atherosclerosis and cardiovascular disease
In 1950, 5 year survival in patients with nephritis was nearly zero, recently it is 85%
Lupus Nephritis 1/3 of patients with lupus develop overt renal
disease , of them nearly 25 % reach ESRD by 10 years.
Histologically almost all patients will have changes
Renal biopsy …..modified (ISN/Renal pathological Society) classification
6 classes of lupus nephritis
Lupus Nephritis (pathophsiology) Immune complexes Glomerular Thrombosis (associated with
antiphospholipid syndrome)
Modified Classification of LNClass Histological Clinical
IMinimal mesangial LNA symptomatic
IIMesangial proliferative LNMild renal disease
IIIFocal LN10-20% of cases
Hematuria and proteinuria
IVDiffuse LNProgression to NS, HTN, and Renal imp.
Most common and most severe
VMembranous10-20% of cases
Good prognosis
VIAdvanced sclerosingProgressive renal failure
(Kumar and Clarks’s , Clinical Medicine 2009)
Lupus nephritis ( CLINICALLY) Indicators of activity Clinically relevant lupus nephritis Anti C1q Biopsy Heavy proteinuria and edema are common with diffuse
proliferative and membranous HTN with diffuse proliferative Systemic manifestations, CNS, serositis are associated with
focal and diffuse proliferative Asymptomatic may or insidious finding with mesangial and
membranous
Renal biopsy Should be considered especially in the first attack of nephritis May be useful in recurrent nephritis Biopsy gives idea about prognosis and outcome of nephritis
and can alter management Clinical situation can predict biopsy findings in 75% of
cases , Always perform biopsy if its findings will alter the ttt Interpret biopsy with the clinical Biopsy may depend on the pathologist
(E- Medicine, Rheumatology, Nephritis, Lupus,2009)
Biopsy spicimens
Biopsy specimens
Activity and Chronicity in Renal biopsy
Activity indexChronicity IndexEndocapillary hypercellularity with or without leucocyte infiltration ; luminal reductionKaryorrhexisFibrinoid necrosisRupture of GBMCellular or Fibrocellular CrescentsSubendothelial deposits on LMIntraluminal Immune aggregates
Glomerular sclerosis, segmental or globalFibrous adhesionFibrous crescents
Treatment of Lupus nephritis When to give steroids? When to add cyclophosphamide? Aggressive
disease, inadequate response, sensitivity to steroids How to treat HTN and proteinuria? Nutrition ( fat and protein) Statins? Active lupus nephritis should avoid pregnancy?
How?
Treatment of Lupus Nephritis base on biopsy Class
ClasasTreatment
INon specific
II20-40 for 1 -3 months
IIIPrednisolone 1mg/kg/d for 1 month then taper depending on the clinical response to 5-10 mg for 2-2.5 years or Pulses for 3 days in
severly ill add imunosupressive when indicated, adjust immunosupressine with cbc
IV
VPrednisone for 1-3 months followed by low dose for 1-2 years
Azathioprin , chlorambucil, cyclophosphamide or MMF may decrease proteinuria
VIPrepare for hemo which is better than peritoneal
Arrange for renal Tx, treat extra-renal lupus
Active Lupus Nephritis :
Induction of remission Goal of therapy? Biopsy Extra-renal lupus AND OTHER GENERAL MEASURES
Prospective controlled trials in active lupus nephritis show that administration of high doses of glucocorticoids (1000 mg of methylprednisolone daily for 3 days) by intravenous routes compared with daily oral routes shortens the time to maximal improvement by a few weeks but does not result in better renal function. It has become standard practice to initiate therapy for active, potentially life-threatening SLE with high-dose IV glucocorticoid pulses, based on studies in lupus nephritis. This approach must be tempered by safety considerations, such as the presence of conditions adversely affected by glucocorticoids (infection, hyperglycemia, hypertension, osteoporosis, etc.). (Harrison online 2008)
Prognosis of Lupus glomerulonephritis Treatment leading to normalization of
proteinuria, HTN and renal dysfunction indicate a good prognosis.
Glomerulosclerosis usually predicts ESRD
(Kumar and Clarks’s , Clinical Medicine 2009)
Lupus cerebritis Is it lupus, the responsible? Stroke? Is it a flare or athersclerosis or
antiphospholipid Siezures? Antiepiliptic Headache Cognitive dysfunction Others
Hematological abnormalities (cytopenias)
Aetiology can be multifactorial Are often mild. Treatment is not always necessary Granulocyte colony stimulating factor? Leucopenia Thrombocytopenia (as ITP) Anemia (hemolytic)
Ciclosporin may be considered in steroid resistant cases with caution of potential nephrotoxcicity
Current , Rheumatology)
Serositis NSAIDs Moderate steroids Hydroxychloroquine Steroid sparing
Cutaneous manifestations of Lupus
Uncommom features Pnemonitis and diffuse alveolar hage Mesentric vasculitis
Pregnancy and Lupus Factors that influence pregnancy outcome in
Women with lupus (activity, nephritis, antiphospholipid)
Lowest doses of cortisone for shortest periods to give responses
If antiphospholipid add heparin and aspirin If anti Ro monitor fetus and deliver as soon as
possible
Lupus+ Antiphospholipid syndrome INR recommendations
Prednisolone Long term use leads to osteoporsis, a vascular
necrosis, HTN, diabetes,…etc cataracts, glucoma, weight gain, myopathy and skin
changes, mood changes…….. Growth retardation in children.. Adrenal insufficiency if stopped abruptly
Metabolism is increased by Liver enzyme inducers B- fetal riskContraindicationsNo absolute , however severe bacterial, viral or fungal,
active peptic ulcer , diabetes should be considered
Methylprednisolone Less mineralocorticoid effect and should be
considered in patients with edema Oral and IV Doses 10-40 mg/kg
Cyclophosphamide
500-1000 mg /month IV for 6 months Then every 2-3 month Adjust doses according to cbc, clinical response, toxcity,
GFR Phenobarb increases its toxcicity Cyclophosphamime increases the effect of succynylcholine
for up to 10 days with IV doses Side effects: Nausea, vomiting hagic cystitis, alopecia,
cytopenias, infection, infertility, teratogenicity, malignancies…
MMF (Celcept) or Mycophenolic acid(Myfortic) Start with 500 bid then increase over 2
months to 1000 bid of MMF Antacids reduce its absorption Avoid live attenuated vaccines with its use
Azathioprine 2-3 mg/kg day single or divided doses Start with 1 mg then increase With allopurinol decrease the dose by 65-75% May cause anemia nd leucopenia in combinartion
with ACE May decrease anti coagulant effect of warfarin Contraindications; documented active infections,
cytopenias, Abnormal liver function test results may occur
Ciclosporin
Rutiximab
Plasmaphresis If there is TTP or HUS
Hydroxychloroquin
References