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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.

22