Management overview for systemic lupus erythematosus (SLE) in adults

All patients diagnosed with systemic lupus erythematosus (SLE) should be initially managed by a specialist. Ideally, management should comprise a multidisciplinary approach with specialist input. Pharmacological management for SLE depends on the organ(s) involved and the severity of inflammation.

Management considerations specific to children and adolescents with SLE are discussed separately in Management for SLE in children and adolescents.

Urgently refer patients with severe organ- or life-threatening disease to a specialist centre because immunomodulatory drugs are usually required. Treatment choice and dosing are complex and must be individualised. Except for systemic corticosteroids, immunomodulatory drugs can take several months to become effective. Combination therapy may be required, most commonly:

• hydroxychloroquine first line
• systemic corticosteroids
• additional immunomodulatory drugs, if necessary.

A common dilemma in the management for SLE is distinguishing between disease flare, and infection (associated with use of immunomodulatory drugs). Inflammatory markers will be elevated in both situations, but serum C-reactive protein (CRP) concentration may be more elevated than erythrocyte sedimentation rate (ESR) in the presence of infection. There is also individual variation in the pattern of elevation of these markers, so knowing each patient’s pattern during previous episodes can be helpful.

Disease flare may be accompanied by a rise in double-stranded DNA (dsDNA) antibodies and reduction in C3 and C4 complement proteins. These may be helpful biomarkers of imminent flare in people with this pattern; however, treatment changes, based solely on rising biomarkers, are not recommended.

For reproductive health considerations in people with SLE, see Reproductive health in people with systemic lupus erythematosus.