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New therapeutic strategies in systemic lupus erythematosus management

Abstract

The current treatment approach for systemic lupus erythematosus (SLE), as outlined in the recommendations by international medical associations including EULAR and the ACR, is mostly eminence-based rather than evidence-based. However, knowledge on SLE is growing quickly, and such new advances need to be translated into clinical practice. Questions remain regarding the choice and timing of drug administration and tapering until withdrawal, which both can affect the balance between the control of disease activity and damage to organs triggered by long-standing and/or disproportionate immunosuppression. Currently, the treating physicians of patients with SLE are required to weigh the present with the future situation of their patients in an optimized balance between therapeutic harm and benefit. In this Review, the available therapeutic strategies and main challenges in the approach to SLE treatment are discussed. Remission and low disease activity are desirable therapeutic goals. Although the drug armamentarium for SLE has not expanded much in the past few decades, there are nonetheless opportunities to make better choices and explore combination therapies; such opportunities offer the potential of a personalized medicine strategy.

Key points

  • Early diagnosis and early treatment are required for a better outcome in systemic lupus erythematosus (SLE).

  • Preventive strategies should be applied at any stage of the disease course to minimize disease evolution or worsening; potential comorbidities should be prevented from the start of SLE treatment.

  • The achievement of clinical remission and subsequent tapering of glucocorticoids until withdrawal are desirable subsequent steps in SLE management.

  • Even when remission cannot be attained, the treatment of patients with SLE should be optimized to achieve the lowest stable level of disease activity.

  • Tapering of treatment should be initiated once there is a stable response and requires careful monitoring.

  • Patient-tailored therapeutic strategies should consider the immunological background, clinical features, realistic potential for recovery and the expectations of each patient.

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Fig. 1: Levels of prevention in SLE.
Fig. 2: Proposed treat-to-target algorithm in SLE.
Fig. 3: Proposed algorithm for the management of patients with SLE in remission.

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Gatto, M., Zen, M., Iaccarino, L. et al. New therapeutic strategies in systemic lupus erythematosus management. Nat Rev Rheumatol 15, 30–48 (2019). https://doi.org/10.1038/s41584-018-0133-2

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