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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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