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Management of Systemic Lupus Erythematosus

In a landmark study on non-renal SLE (The Exploratory Phase II/III
SLE Evaluation of Rituximab [EXPLORER] trial), rituximab showed no
significant difference with placebo in major or partial clinical response
via the BILAG at week 52. 75, level I However a systematic review of mainly
moderate quality observational studies showed that rituximab had a
steroid-sparing effect, in addition to improvement in disease activity and
immunologic parameters. 76, level I

Two guidelines support the use of rituximab in organ threatening,
refractory moderate and severe lupus, intolerance/contraindications
to standard immunosuppressive agents and as steroid sparing
therapy. 21; 50
Rituximab also had good safety profile where most frequent AEs were
infusion reactions and infections. 76, level I

Recommendation 8
• Biologics may be used as an adjunct therapy in active systemic lupus
erythematosus (SLE) despite standard therapy with corticosteroids
and immunosuppressants.
• Biologics may be considered in refractory disease of SLE, intolerance
or contraindication to standard treatment.

e. Nonsteroidal anti-inflammatory drugs
Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used to
relieve pain and reduce inflammation due to their analgesic and anti-
inflammatory effects. There is no retrievable latest evidence on its
effectiveness as its use has been established and well-tolerated for
short-term symptomatic relief. NSAIDs may be used cautiously in non-
renal mild SLE (e.g. inflammatory arthralgia or myalgia) when there is
intolerance or poor response to paracetamol. There is also potential
increased risk of renal, hepatic and CV toxicity when NSAIDs are used
in SLE patients. 21; 61, level II-2

f. Others
i) Plasma exchange/Plasmapheresis
Plasma exchange (PE) or plasmapheresis is a therapeutic intervention
that involves extracorporeal removal of high molecular weight
substances (e.g. circulating immune complexes, autoantibodies and
other immune reactants) involved in the pathogenesis of SLE with
subsequent return or exchange of blood plasma or components. It has
been utilised as an alternative therapeutic modality in selected patients
with acute life-threatening manifestations, rare complications and
severe treatment-refractory disease, in particular LN.

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