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Management of Systemic Lupus Erythematosus

*The major risk factors for toxic retinopathy include long-term use and/
or use of high dose HCQ, concomitant hepatic and renal disease,
concomitant tamoxifen, history of retinal and macular disease and
advanced age. 65; 67

HCQ use during pregnancy and breast-feeding is considered safe. 46
Refer to Subchapter 9.2 for HCQ Effectiveness and Safety in Pregnant
Patients with SLE.

c. Immunosuppressants
Immunosuppressants are used in the treatment of lupus when there
is involvement of major organ or life-threatening manifestations. They
are also used to control active disease with inadequate response to
corticosteroids alone, to prevent lupus flare and as steroid-sparing
agents. The selection of immunosuppressants is guided by the organ
involvement, disease severity, pregnancy and lactation compatibility,
co-morbidities, safety concerns and cost.
i) Azathioprine
Azathioprine (AZA) causes immunosuppression by inhibiting the
synthesis of purines that are needed in the DNA and RNA sequencing
for the production of WBCs. It is used as a steroid-sparing agent in
non-renal SLE and maintenance treatment in renal SLE (refer to
Subchapter 7.1).

An RCT in a systematic review on patients with non-renal SLE showed
both AZA and ciclosporin significantly reduced the mean dose of
corticosteroids by >50% at 12 months compared with baseline. There
was no significant difference between the two drugs at end point.
The reported AEs included leukopenia, respiratory tract infection and
rash. 68, level I
European Alliance of Associations for Rheumatology (EULAR) 2019 and
British Society for Rheumatology (BSR) 2018 guidelines recommend
that AZA should be considered as add on therapy in non-renal lupus
e.g. arthritis and cutaneous disease if HCQ is unable to control disease
activity or when corticosteroids doses cannot be tapered. 21; 50
ii) Methotrexate
Methotrexate (MTX) is an antimetabolite which is commonly used in
the treatment of autoimmune diseases. It can be administered in oral
or subcutaneous form. MTX is often used to treat musculoskeletal
and cutaneous manifestations inadequately controlled with HCQ and
corticosteroids. Folate supplementation is used to ameliorate MTX-
associated AEs and toxicity (minimum dose of 5 mg/week).

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