Treatment of SLE

Dr.B.P.Putra Suryana, SpPD-KRRheumatology, Internal Medicine

Brawijaya University-Dr.Saiful Anwar General HospitalMalang

Indonesian Rheumatism Association

Workshop SLEPeralmuni Cabang Malang

29 Oktober 2011

Problem in treatment• Very wide clinical spectrum and disease activities of SLE.

• Individual response to treatment.

• Delayed initiation of disease-modifying treatment.

• Inadequate patient education.

10-Year survival rate of SLE in Asia

Source Country Period Survival Rates

(10 years) %PH Feng Singapor

e1970-80 60

F Wang Malaysia 1974-90 71DM Chang Taiwan 1983-96 75A N Changdra-sekaran

South India

1994 82

SL Chen China 1980-98 84H Hashimoto

Japan 1970-79 86Shun-le Chen. International Congress on SLE. Shanghai 2007.

Clinical Manifestation

N=32Percentage

Kejang 3 9.3Vasculitis 7 22.5Arthritis 20 64.5Proteinuria 5 16.1Skin rash 23 71.8Alopecia 13 41.9Mucosal Ulcer 14 43.7Pleuritis 4 12.5Trombositopeni 2 6.2Leukopenia 2 6.2Raynaud’s 2 6.2Anemia 23 71.8Hemolytic anemia 5 16.1

Clinical manifestation of SLE in Malang

Fatoni A, Kusworini Handono, Suryana BPP. Brawijaya University, Malang. 2007

Non-pharmacologic• Education : disease manifestation, treatment, prognosis, complication.

• Skin protection from UV-light• Rehabilitation• Nutrition

Treatment and Disease Severity

• Mild to moderate lupus :– Paracetamol, NSAIDs– Corticosteroids– DMARDs : chloroquine, MTX• Severe lupus :

- NSAIDs- Corticosteroids (high dose – mega dose)- DMARDs and immunosuppresive : azatioprine, cyclophosphamide, MMF, cyclosporine

- Biologic agent : rituximab

Malar rash

Malar rash in SLE with positive ANASlide from Rheumatology Clinic Dr.Saiful Anwar Hospital, Malang, Indonesia

MTX 7.5 mg / weekFolic acid 1x1 tabPrednison 5 mg (1-0-0)Calcium 500 mg / dayMeloxicam 15 mg prn

Monitoring :CBC (Hb, WBC)LFT (SGOT, SGPT)

Discoid rash in cutaneous lupus

Arthritis and other musculoskeletal

Vasculitis

Erythematous and raised skin lesions represent vasculitis in

42 year-old with SLE Slide from Rheumatology Clinic Dr.Saiful Anwar Hospital, Malang, Indonesia

Azatioprine 50 mg 2x1Methyl-prednisolone 3x8 mg (tap off)Calcium 500 mg / day

Livedo reticularis

Raynaud’s phenomenon

SLE with Polymyositis Dermatomyositis

Male 18-year-old with generalized muscle weakness and typical skin rash (heliotrope) and papules on hands

Slide from Rheumatology Clinic Dr.Saiful Anwar Hospital, Malang, Indonesia

SLE PM-DM : Gottron’s papules

Slide from Rheumatology Clinic Dr.Saiful Anwar Hospital, Malang, Indonesia

Cyclophosphamide pulse 750 mg / monthMethyl-prednisolone 3x16 mgCalcium 1000 mg/day

Monitoring :CBC (Hb, WBC)LFT (SGOT, SGPT)UrinalysisRenal function

Digital vasculitis and necrosis

Digital vasculitis and necrosis in 32 year-old female with SLE

Slide from Rheumatology Clinic Dr.Saiful Anwar Hospital, Malang, Indonesia

Azatioprine 50 mg 2x1Methyl-prednisolone 3x16 mg (tap off)Aspirin 80 mg/dayCalcium 1000 mg / day

Monitoring :CBC (Hb, WBC)LFT (SGOT, SGPT)UrinalysisRenal function

Thrombosis

Slide from Rheumatology Clinic Dr.Saiful Anwar Hospital, Malang, Indonesia

Thrombosis in SLE associate with anti-phospholipid antibodies

SLE with panniculitis, lipo-atrophy

Slide from Rheumatology Clinic Dr.Saiful Anwar Hospital, Malang, Indonesia

MTX 7.5 mg/week, Folic acid 1x1 tab

Pericardial Effusion in SLE

Slide from Rheumatology Clinic Dr.Saiful Anwar Hospital, Malang, Indonesia

Referred to CardiologistCyclophosphamide pulse 750 mg / monthMethylprednisolone 3x16 mg (Tap offf)

Osteoporosis and Fracture

Slide from Rheumatology Clinic Dr.Saiful Anwar Hospital, Malang, Indonesia

MTX 7.5 mg / weekChloroquine 250 mg / dayMethyl-prednisolone 8 mg/dayFolic acid 1x1 tabBisphosphonate infusCalcium 1000 mg/day

Is reducing Anti-dsDNA levels would reduce disease activity?

• Immunosuppresive and steroid reduced mean anti-dsDNA level and fewer flares of disease (Bootsma et al, Lancet 1995).

• Anti-CD20 in refractory SLE showed impressive clinical responses associated with falls in levels of anti-dsDNA

(Cambridge et al, Arthritis Rheum 2006).Isenberg et al. Rheumatology 2007

Future : Immunotherapy in SLE

Karim et al. Rheumatology 2009;48.

Referring and Consultation

• Diagnosis confirmation• Initiation of DMARDs or immunosuppresant

• Poor response to treatment• Severe or life-threatening condition

• Co-morbidity : osteoporosis, cardiovascular disease, drug side effects etc

SUMMARY• SLE is a systemic auto-immune disease with wide clinical spectrum, variable course and prognosis.

• Patient education, exercise, rehabilitation, and nutrition should be advised for all patients.

• Pharmacotherapy include paracetamol, NSAIDs, corticosteroids, DMARDs, and immunosupressant. Also treat concomitant diseases.

Terima kasih, semoga bermanfaat.