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Treatment of SLE H. Michael Belmont Hospital for Joint Diseases NYU School of Medicine. SLE SUBSETS. Discoid lupus erythematosus (DLE) Systemic lupus erythematosus (SLE) Drug-induced SLE (DANA vs DILE) ANA negative lupus/Ro lupus/SCLE Antiphospholipid antibody syndrome Neonatal lupus.

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sle subsets
SLE SUBSETS
  • Discoid lupus erythematosus (DLE)
  • Systemic lupus erythematosus (SLE)
  • Drug-induced SLE (DANA vs DILE)
  • ANA negative lupus/Ro lupus/SCLE
  • Antiphospholipid antibody syndrome
  • Neonatal lupus
slide3

SLE:Demographics

  • Affects .5 million (.2%) vs 1.5 million (.6%) of US population (epidemiologic vs LFA random digit dialing telephone survey)
  • Female:Male ratio of 10:1
  • 70% of SLE: females between ages 15-45
  • African American to Caucasian ratio 3:1
  • Highest prevalence in Afro-Caribbean females 1:250
  • Genetic factors HLA-A1, B8, Dr3 - C4A null genes - Fc receptor polymorphisms -gene linked to chromosome 1
slide4

SLE:Demographics

  • Environmental factors - Concordance for monozygotic twins is 30% (70% of genetically identical twins will not share the disease)
  • Child of SLE mother risk of SLE 1:15 (7%)
  • ANA positive in 5-20% of population. 10 times more likely to have false positive ANA than disease
slide5

SLE:ETIOLOGY

  • AUTOANTIBODY PRODUCTION
  • GENERATION OF CIRCULATING IMMUNE COMPLEXES
  • EPISODIC COMPLEMENT ACTIVATION
slide6

SLE:Pathobiology

  • Autoantibodies (AIHA, AITP, Anti-neuronal antibody, APS)
  • Immune complex disease (microangiitis and vasculitis)
  • Neutrophil and endothelial cell adhesive interaction with leukoaggregation
  • Thrombophilia (Antibody mediated thrombosis in secondary antiphospholipid antibody syndrome with micro and macrovascular noninflammatory occlusion
serology
SEROLOGY
  • ANA (Titer and pattern: diffuse, speckled, rim, nucleolar, centromere)
  • double stranded-DNA
  • Sm
  • RNP
  • Ro (SS-A)/La (SS-B)
  • C3
  • C4
positive ana
POSITIVE ANA
  • SLE
  • Non SLE CTD (RA, SS, PSS, CREST, DM/PM)
  • DRUG-INDUCED
  • NORMALS (FALSE POSTIVE)
  • LYMPHOPROLIFERATIVE DISORDER
  • CHRONIC INFECTION (HIV, Leprosy)
pitfalls
PITFALLS
  • ANA POSITIVE FIBROMYALGIA
  • STEROIDS FOR MUSCULOSKELETAL SYMPTOMS
  • EXCESSIVE DURATION OF STEROIDS
  • INADEQUATE MONITORING (C3, C4, dsDNA)
  • DIAGNOSTIC OR THERAPEUTIC DELAYS (RENAL BIOPSY, CYTOTOXICS)
slide10

SLE:Health Status

  • Disease activity (SLEDAI, SLAM. BILAG)
  • Damage Index (SLICC DI) (disease, treatment or co-morbidity)
  • Treatment/iatrogenic induced illness (e.g. avascular necrosis of bone, accelerated atherosclerosis, cataracts, striae, immunosupression, etc.)
  • Infection
treatment
TREATMENT
  • SUNSCREEN
  • TOPICAL STERIODS
  • NSAIDs
  • ANTIMALARIALS
  • STEROIDS
  • CYTOTOXICS
  • CALCIUM, VITAMIN D, FOLATE SUPPLEMENTATION
  • INFLUENZA VACCINE (annual)
  • PNEUMOCCOCAL VACCINE (decade)
clinical features
CLINICAL FEATURES
  • CONSITUTIONAL
  • CUTANEOUS
  • JOINTS
  • SEROSAL
  • CYTOPENIAS
  • RENAL
  • NEUROLOGIC
  • ANTIPHOSPHOLIPID ANTIBODY SYNDROME
steroid therapy
STEROID THERAPY
  • ACUTE LUPUS CRISIS
  • ACTIVE NEPHRITIS
  • ACUTE ACTIVE CNS
  • ACUTE CYTOPENIAS (AIHA,AITP)
  • REFRACTORY SEROSITIS
  • VASCULITIS
  • SEVERE CONSTITUTIONAL (fever, fatigue, wgt loss, synovitis, anemia)
cytotoxic therapy
CYTOTOXIC THERAPY
  • Azathioprine, Methotrexate, Leflunomide
  • Steroid sparing (constitutional, serositis, immune cytopenias)
  • Articular
  • Mycophenolate mofetil, Cyclophosphamide
  • Nephritis, CNS, immune cytopenias, vasculitis
antiphospholipid antibody syndrome aps
ANTIPHOSPHOLIPID ANTIBODY SYNDROME (APS)
  • ASYMPTOMATIC
  • No Treatment
  • Antiplatelet (ASA 81 mg, Ticlid, Plavix)
  • THROMBOTIC EVENT (DVT, PE, CVA)
  • Coumadin INR > 3
  • PREGNANCY
  • ASA 81 mg, Prednisone 40-20 mg, sc Heparin, sc LMWH (IVIG)
  • CAPS (Catastrophic APS)
  • Heparin, steroids, pheresis, IVIG, cytoxan
novel therapy
NOVEL THERAPY
  • Immunoablative chemotherapy with or without autologous stem cell transplant
  • B-cell toleragen (Single signal anergy)
  • Complement inhibitors (anti-C5, soluble CR1)
  • Adhesion molecule inhibitors (anti-ICAM 1 antiCD11b/CD18)
  • Co-stimulatory pathway inhibitors (anti-CTLA-4, anti-CD40ligand)