SLE Flashcards by Brooke Thornburg

What is SLE

-autoimmune dx linked to Ab production
-multisystem dx effecting multiple organ systems

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Goal of SLE tx

-prevent flares and eexacerbations
-achieve remission
-limit organ damage
-limit steroid use
-minimize cost
-improve QOL/dec ADRs

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SLE epidemiology

-WOMEN
-15-44
-non-white

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SLE etiology

-genetics (HLA-DR2 and DR3)
-estrogen and progesterone
-maybe X chromo link

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Environmental factors SLE

-linked to exacerbations
-cigs
-UV light
-viral infection (epstein barr)
-air pollution
-heavy metals

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SLE patho

-triggers cause abnormal immune response
=autoAb immune complexes
-inflammtion
-organ damage

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Drug induced lupus

-weeks to months after tx
-triggered by agent that causes autoimmune rxn similar to SLE
-resolution through d/c agent (reversible)

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Drugs that can induce SLE

-Minocycline
-Hydralazine
-Procainamide
-TNF inhibitors
-methimazole
-propylthiouracil
-methyldopa
-terbinafine
-isoniazid
-quinidine

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s/sx of SLE

-fatigue
-depression
-photosensitivity
-joint pain
-N/V
-fever
-weight loss
-Butterfly rash

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Organ system involvement in SLE

-renal: lupus nephritis
-CV: inflammation, peri/myocarditis, HTN
-pulmonary: effusion, SOB
-Musc/ske: arthritis, myalgias
-opthalmologic: lupus retinopathy
-CNS: sz, psychosis
-GI: ab pain, nausea
-thrombosis: ANTIPHOSPHOLIPID syndrome
-muscocutaneous: butterfly rash, discoid rash, Raynauds

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Diagnostic criteria SLE

-SLICC
-EULAR/ACR

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SLICC

-select pt for clinical trials
-NOT diagnostic tool
-used to identify pt at higher risk

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EULAR/ACR

-for early diagnosis
-requires positive ANA test
-classify as lupus if score of 10+

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Lab tests for SLE

-antiphospholipid Ab: inc clotting factors
-anti-smith Ab: higher specificity for SLE
-Anti-dsDNA: higher spec, important for lupus nephrititis!
-ANA: positive in SLE but NOT specific

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Non-rx SLE options

-social support
-aerobic exercise
-wt loss
-light protection
-smoking cessation

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RX tx options for SLE

-HYDROXYCHLOROQUINE
-NSAIDs
-glucocorticoids
-immunosuppressants
-biologics

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Hydroxychloroquine MOA

-antimalaria
-inhibit immune response
-prevent flares
-anti-inflammatory
-immunomodulator
-ANTITHROMBOTIC effect

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Hydroxychloroquine use in SLE

-give ts to everyone
-alone or combo
-200-400mg qd
-MAX: 400mg qd

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Hydroxychloroquine ADRs

-retinal!
-cardiac
-neuromuscular
-GI upset
-rash
-skin hyperpigmentation
-hemolytic anemia!! (do not give to pt w G6PD deficiency)

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Hydroxychloroquine monitoring

-annual eye exam starting 3mo after initiation
-CBC
-SCr
-chem panel
-AST/ALT

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Factors that inc retinal toxicity risk w hydroxychloroquine

->400mg qd
-macular or renal dysfx
-tamoxifen use

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NSAIDs for SLE

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-sx management for mild sx
-effective for myalgias, arthralgias, fever, serositis
-ibuprofen 400mg q6-8h
-naproxen 500mg BID

NSAID ADRs

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-GI bleeding, perforation
-CV events
-inc BP
-worsened HF
-inc SCr (renal)
-hepatotoxicity

NSAID monitoring

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-CBC
-LFTs
-SCr
-BP
-s/sx bleeding
-fluid retention

Glucocorticoid MOA

-inhibit B and T cell immune response

Glucocorticoid use in SLE tx

-adj for flares unresponsive to hydroxychloroquine and NSAIDs -PO -IV -Topical

Glucocorticoid options

-PO -IV methylprednisolone IV then PO prednisone after 3-6 days -TOPICALS: -low (face): fluocinolone and hydrocortisone -mod (trunk and extremeties): triamcinolone, betamethasone -high (scalp+palms): clobetasol

Glucocorticoid ADRs

-fluid retention -N/V -mood -insomnia -inc appetite/wt gain -inc BP -inc BG -topical: -skin atrophy -rosacea -telangiectasis

Glucocorticoid warnings

-ADRENAL SUPPRESSION (HPA) if taking longer than 14 days -GI bleed -glaucoma -osteoporosis -cushings -infection

Glucocorticoid monitoring

-BMP q6mo -lipid panel q6mo -bone mineral density qyear -BP qvisit

Immunosuppressant drugs for SLE

-MTX -mycophenolate -cyclophosphamide* -Azathioprine

Immunosuppressant use in SLE

-adj to steroid tx in cases: -low dose steroid desired -inadequate response to hydroxychloroquine

MTX dosing + warnings

-weekly -immunosuppressant -bone suppression -infection

Mycophenolate dosing + warnings

-BID -immunosuppressant -acute inflammatory syndrome

Cyclophophamide dosing + warnings

-qd -immunosuppressant -bone marrow suppression -malginancy -cardiac hemorrhagic cystitis

Azathioprine dosing + warnings

-50mg qd -immunosuppressant -avoid in TMPT deficiency (=toxic) -bone marrow suppression -malignancy -infection

Biologic drugs for SLE

-Belimumab -rituximab -anifrolumab

Biologic use in SLE

-mAbs that block B-cell immunity -tx REFRACTORY lupus that doesnt respond to immunosuppressants or hydroxychloroquine -SEVERE disease

Biologics considerations

-live vax contraindicated -no more than 1 biologic used at a time

Belimumab ADRs

-psychiatric disturbances

Rituximab ADRs

-infusion rxn -PML -hep B reactivation

Alt tx for SLE after biologics

-Calcineuin inhibitors: -tacrolimus -pimecrolimus -voclosporin for lupus nephritis!

Alt SLE tx

-DHEA -vit D (give w steroid to prevent bone effects) -yoga -acupuncture -not enough data

Cutaneous lupus tx

-not life threatening -all SLE pt should be on hydroxychloroquine!! 1. topical agents: -steroid or calcineuin inhibitors -if fail: -systemic high dose steroid -MTX -mycophenolate

Lupus nephritis tx

-serious complication -mild-mod: -glucocorticoid +/- immunosuppressant -severe: -mycophenolate/cyclophos +/- glucocorticoid -Triple tx: + belimumab OR: calcineurin inhibitor + mycophenolate +/- GC

Additional SLE management

-sz: anticonvulsant -infection: Abx -osteoporosis: bone drugs -HTN: antiHTN -pain/arthritis: NSAIDs -edema: diuretics

Pregnancy concerns in SLE

-high mom+kid risk -≥ 6mo remission before conception -screen for antiphospholipid =AVOID estrogen contraception -give progestin only

SLE preg options

-Hydroxychloroquine -NSAIDs (d/c at 20 weeks) -GCs (lowest dose)

AVOID in preg SLE

-mycophenolate, cyclophosphamide, MTX (d/c 3-4mo before preg -AZA (inc risk of ICP) -biologics: maybe rituximab but can cross placenta

Antiphospholipid syndrome in SLE + Tx options?

-group of Ab associated w clotting/preg -give anticardiolipin -anti-B2 glycoprotein -lupus anticoag

Low dose aspirin in antiphospholipid syndrome

-asx aPL carrier or low/high risk aPL carrier w NO hx of thrombosis or preg complication -nonpreg women w hx of obstetric complications

Warfarin in antiphospholipid syndrome

-pt w APS and first venous thrombosis event -INR goal 2-3

Enoxaparin + aspirin in antiphospholipid syndrome

-preg pt w APS and hx of thrombosis +/- fetal loss

Recurrent thrombosis event in antiphospholipid syndrome while taking warfarin tx options

-inc INR goal -add low dose asprin -switch to enoxaparin

SLE Flashcards

(54 cards)