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Management of Systemic Lupus Erythematosus

           6.  PRINCIPLES OF TREATMENT

           Due to its multisystem involvement, SLE may present with a myriad of
           possible clinical manifestations, making it a challenge to diagnose and
           treat.

           •  Principles of SLE treatment are to achieve:
               disease remission
               disease flare prevention
               organ damage prevention
               quality of life improvement
               minimisation of drug side effects
           •  If  complete  remission  cannot  be  achieved,  the  lowest  possible
             disease activity in all organs involved should be targeted.

           6.1  Disease Assessment

           Patients with SLE may have a fluctuating disease course or persistently
           active disease despite being on medications. Both persistent disease
           activity and disease flares can contribute to irreversible damage and
           impact health-related quality of life. The principal goal of SLE treatment
           according to the ‘treat-to-target’ approach emphasises minimisation of
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           disease activity.  Achieving remission in SLE is desirable but not always
           attainable, hence low disease activity state is an acceptable alternative.
           SLE  flare  is  generally  defined  as  any  increase  in  disease  activity
           leading  to  intensification  of  therapy.  It  refers  to  a  measurable
           increase  in  disease  activity  in  one  or  more  organ  systems  involving
           new  or  worsening  clinical  signs  and  symptoms  and/or  laboratory
           measurements.  It  must  also  be  considered  clinically  significant  to
           warrant adjustment of treatment. 38, level III
           Disease activity in SLE can be measured as clinical activity (inflammation
           of  organs)  or  serological  activity  (elevated  anti-dsDNA  antibodies  or
           low complements levels). In clinical practice, disease activity in SLE
           can be evaluated by assessment of symptoms, signs and laboratory
           tests including serology. There are many disease activity assessment
           tools in SLE, however these were created mainly for clinical trials. The
           commonly used and validated tools are (Table 3):
             •  Systemic Lupus Erythematosus Disease Activity Index (SLEDAI)
               in  its  original  version  or  improved  versions  which  are  Safety
               of  Estrogens  in  Lupus  Erythematosus  National  Assessment
               (SELENA)-SLEDAI or SLEDAI 2000 (SLEDAI-2K)
             •  British Isles Lupus Activity Group index (BILAG)-2004

           All three SLEDAIs have the same items (24 clinical presentations within
           a period of 10 days) and weightage (1 to 8 [range 0 - 105]) with some

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