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Management of Systemic Lupus Erythematosus

           v)  Leflunomide
           Leflunomide is a pyrimidine synthesis inhibitor with anti-inflammatory
           properties.
           In a  systematic  review  on  mild  to moderate  active  SLE, leflunomide
           was  more  effective  than  placebo  in  reducing  SLEDAI  at  24  weeks
           (11.0±6.1 vs 4.5±2.4; p=0.02) but there were no significant differences
           in proteinuria, complement, anti-dsDNA antibodies and corticosteroids
           dose.  There  were  also  no  difference  in  AEs  between  the  two
           groups. 68, level I
           Leflunomide may be considered in moderate lupus refractory/intolerant/
           not suitable for other immunosuppressants. It may also be considered
           when CYC and biological agents are not suitable or not available. 21

           vi)  Mycophenolate mofetil
           Mycophenolate mofetil (MMF) is an immunosuppressant used for SLE
           patients with both renal and non-renal involvement.
           The  use  of  MMF  in  renal  involvement  of  SLE  is  well  established.
           A  systematic  review  included  a  report  on  the  secondary  non-renal
           outcomes of the Aspreva Lupus Management Study (ALMS), a large
           RCT on induction treatment for LN. The RCT showed MMF (0.5 g/12 h
           and increased to 1.5 g/12 h) had comparable effectiveness with CYC
           0.5  -  1  g/m2/month  in  improving  BILAG  scores,  inducing  remission
           in  the  mucocutaneous,  musculoskeletal  and  cardiovascular  (CV)/
           respiratory systems as well as reducing SELENA-SLEDAI flares at six
           months. 68, level I

           Recommendation 7
           •  Immunosuppressants  should  be  considered  as  add-on  therapy  to
             patients  with  systemic  lupus  erythematosus  (SLE)  not  responding
             to  hydroxychloroquine  (HCQ)  alone  or  in  combination  with
             corticosteroids, or when corticosteroids doses cannot be tapered.
           •  Immunosuppressants may be considered in active SLE patients with
             HCQ intolerance.
           •  Cyclophosphamide  or  mycophenolate  mofetil  may  be  used  as
             induction therapy in certain major organ involvement in SLE.


           d.  Biologics
           Biologics are used as adjunct therapy in active SLE despite optimal
           treatment with corticosteroids and immunosuppressants. They may also
           be considered in refractory diseases and/or when there is intolerance
           or contraindication to standard treatment.





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