Systemic Lupus Erythematosis (SLE)

General Measures

Medicine Treatment

Referral

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ICD-10 Code: M32.9

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These patients need to be managed by a specialist.

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GENERAL MEASURES

• Education regarding the disease and complications.
• Avoid cigarette smoking as it is a trigger for lupus.
• Sun protective barrier creams are often indicated.
• Regularly monitor urine for blood and protein.
• Provide advice regarding family planning as pregnancy may cause a lupus flare.

MEDICINE TREATMENT

Mild disease

For pain:

• Paracetamol, oral, 1 g 4–6 hourly when required.
  • Maximum dose: 15 mg/kg/dose.
  • Maximum daily dose: 4 g in 24 hours.

AND/OR

• NSAIDs, e.g.:
  • Ibuprofen, oral, 400 mg 8 hourly with meals.

LoE:I³⁰

In high-risk patients: i.e. patients >65 years of age, or with a history of peptic ulcer disease, or on concomitant warfarin, aspirin or corticosteroids:

ADD

• PPI, e.g.:
  • Lansoprazole, oral, 30 mg daily 

LoE:II³¹

To suppress disease activity

• Chloroquine sulphate, oral, 150 mg (as base) daily for 5 days of each week.
  • Do ophthalmic examination at baseline within the first year of treatment and annually, to monitor for ocular damage.

LoE:I³²

Corticosteroids
Initiate therapy in patients with life threatening manifestations and organ involvement.

• Corticosteroids (intermediate-acting) e.g.:
  • Prednisone, oral, 2 mg/kg daily, initial dose.
    • Taper to the lowest maintenance dose after a response has been obtained. Refer to Prescription Writing for an example of a dose reduction regimen.
    • Usual maintenance dose: 10 mg daily.

Patients requiring corticosteroids for > 3 months (long-term) should be managed for secondary prevention of osteoporotic fractures. See Osteoporosis.

Additional immunosuppressive therapy
Is often required for life-threatening disease, particularly kidney and CNS involvement. These medicines should be initiated by a specialist and regular FBC monitoring should be done.

• Azathioprine, oral, 1 mg/kg daily, titrated to a maximum of 3 mg/kg daily.

LoE:III

OR

• Cyclophosphamide, oral, 100 mg daily, titrated to a maximum of 200 mg daily (or 1–3 mg/kg daily).

LoE:III

Raynaud’s phenomenon I73.0

• Amlodipine, oral, 5 mg daily.

LoE:II³³

Antiphospholipid antibody syndrome

• Aspirin, oral, 150 mg daily.

Patients with previous thrombo-embolic episodes should receive lifelong warfarin (target INR 3 to 4).

LoE:III

Hormonal therapy in women

• The use of oral contraceptives is controversial.
• Until there is clarity it is advisable to use either progesterone-only, or low dose oestrogens, or non-hormonal methods.

REFERRAL

• All patients to a specialist for initial assessment.
• Lupus flare.
• Nephritis for renal biopsy.
• Persistent haematological derangements i.e. thrombocytopaenia.
• Neurological manifestations of lupus.

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Standard Treatment Guidelines and Essential Medicines List for South Africa, Hospital Level, Adults 2024 Edition