eMedicine Specialties > Rheumatology > Systemic Rheumatic Disease

Systemic Lupus Erythematosus: Follow-up

Author: Christie M Bartels, MD, Instructor of Rheumatology, Department of Medicine, University of Wisconsin School of Medicine and Public Health
Coauthor(s): Daniel Muller, MD, PhD, Department of Internal Medicine, Section of Rheumatology, Associate Professor, University of Wisconsin at Madison
Contributor Information and Disclosures

Updated: Jan 22, 2009

Follow-up

Further Inpatient Care

Fever in patients with systemic lupus erythematosus (SLE) is grounds for inpatient admission because of the difficulty of distinguishing a disease flare from infection in these immunocompromised hosts. Patients with SLE are often complement deficient and at particular risk for infections with encapsulated organisms. For example, meningococcemia in young females with lupus may be catastrophic. Additionally, stress-dose steroid protocols should be used in patients who are receiving maintenance corticosteroids when they are admitted with infectious or perioperative stress.

Further Outpatient Care

Periodic follow-up and laboratory testing, including CBC counts, creatinine, and urinalyses, are imperative for detecting signs and symptoms of new organ-system involvement and for monitoring response and adverse reactions to therapies. Periodic complement levels and dsDNA titers may be used as adjuncts to clinical evaluation for detecting lupus flares. The EULAR recently released key recommendations for the management of SLE.

Preventative care should include prophylactic immunization against encapsulated organisms: meningococcal vaccination, Pneumovax, and routine Haemophilus influenzae childhood vaccination. Annual influenza vaccine is also encouraged.

Transfer

CNS lupus with depressed consciousness may prompt ICU transfer and consideration of protective intubation. TTP and catastrophic antiphospholipid antibody syndrome should prompt transfer to a center capable of offering plasma exchange therapy.

Deterrence/Prevention

  • Avoid ultraviolet light and sun exposure to minimize worsening symptoms due to photosensitivity.
  • Estrogen therapies have typically been avoided to prevent disease flares; progesterone contraception has been encouraged. However, recent studies have suggested that oral contraceptives may not be associated with disease flares or thrombosis risk in patients with mild lupus without antiphospholipid antibodies.14,28
  • High rates of sulfa allergy and anecdotal reports of disease flares have also led to avoidance of sulfa-based medications in patients with SLE.
  • Aggressive blood pressure and lipid goals may help to prevent CAD or renal disease progression.25
  • Antimalarial therapy (hydroxychloroquine) has been shown to prevent relapses and to improve mortality.27
  • Angiotensin-converting enzyme (ACE) inhibitors and/or angiotensin receptor blockers may be useful in patients with renal disease.
  • Calcium, vitamin D, and prophylactic bisphosphonates may reduce the risk of glucocorticoid-induced osteoporosis.

Complications

Opportunistic infections can develop, most often in patients receiving chronic immunosuppressive therapy. Another less-common complication is osteonecrosis, especially of the hips and knees after prolonged high-dose corticosteroid usage. More commonly, premature atherosclerotic disease and myocardial infarction are indolent complications of chronic inflammation.

Prognosis

SLE carries a highly variable prognosis, largely predicted by individual patient manifestations and disease course. Renal and CNS involvement tend to be associated with a worse prognosis.10

Patient Education

  • Photosensitivity: Instruct patients with SLE to avoid exposure to sunlight and ultraviolet light.
  • Medication toxicity: Monitor the use of NSAIDs and salicylates because of increased renal and hepatic toxicity. Additionally, monitoring should include surveillance for cytopenias or toxicities specific to individual immunosuppressive agents.
  • Opportunistic infections: Instruct patients with SLE to seek medical care for evaluation of new symptoms, including fever.
  • CAD: Educate patients with SLE regarding aggressive lipid and blood pressure goals to minimize the risk of CAD. In addition, teach patients to recognize the signs and symptoms of myocardial infarction.
  • For excellent patient education resources, visit eMedicine's Blood and Lymphatic System Center, Arthritis Center, and Muscle Disorders Center. Also, see eMedicine's patient education articles Lupus (Systemic Lupus Erythematosus), Chronic Fatigue Syndrome, and Chronic Pain.

Miscellaneous

Medicolegal Pitfalls

  • Failure to monitor for systemic lupus erythematosus (SLE) or failure to recognize progression or complications of disease: New organ-system involvement and infectious or thromboembolic complications, especially those that may lead to irreversible CNS disease, renal disease, or death, must be recognized.
  • Failure to counsel patients on medication risks: Medication toxicity, risks of discontinuing therapy, and noncompliance should all be included in the discussion.
  • Discussion of contraception and potential pregnancy planning: Disclosing potential teratogenicity and planning contraception, as well as carefully planning and monitoring pregnancy, may be key in female patients of reproductive age.

Special Concerns

  • Pregnancy
    • Fertility rates in women with SLE are similar to those in the general population. However, the incidences of spontaneous abortion, premature labor, and intrauterine death are somewhat higher in women with SLE, especially in those with SSA(Ro)/SSB(La) antibodies, antiphospholipid antibodies, or lupus nephritis.
    • Ideally, SLE should be well controlled for at least 4 months prior to conception to minimize complications.
    • SLE can also flare during or after pregnancy. Additionally, neonatal lupus can develop in the babies of mothers with antibodies to SSA/Ro, causing skin rashes and congenital heart block.
    • Obstetricians who handle high-risk pregnancies should monitor all pregnancies in patients with SLE.
    • Suggestions for treatment of SLE during pregnancy are also included in the recent EULAR recommendations.
    • For additional information, see the article Systemic Lupus Erythematosus and Pregnancy in eMedicine’s Rheumatology volume.
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous coauthor Julie Hildebrand, MD, to the development and writing of this article.



More on Systemic Lupus Erythematosus

Overview: Systemic Lupus Erythematosus
Differential Diagnoses & Workup: Systemic Lupus Erythematosus
Treatment & Medication: Systemic Lupus Erythematosus
Follow-up: Systemic Lupus Erythematosus
Multimedia: Systemic Lupus Erythematosus
References
Further Reading
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References

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Further Reading

Additional resources on system lupus erythematosus (SLE) are available at Medscape's Lupus Resource Center.

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Keywords

systemic lupus erythematosus, SLE, lupus, systemic lupus, multisystem inflammatory disease, autoimmune disorder, chronic autoimmune disease, multisystem microvascular inflammation, nephritis, severe systemic vasculitis, malar rash, discoid rash, photosensitivity, Jaccoud arthropathy, butterfly rash, discoid lupus, lupus profundus, vasculitic purpura, microangiopathic lupus cerebritis, renal lupus, CNS lupus, lupus pneumonitis, chronic lupus interstitial lung disease, lupus disease, lupus peritonitis, drug-induced lupus erythematosus, neonatal lupus, lupus nephritis, lupus skin rash, lupus arthritis, lupus flare

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Contributor Information and Disclosures

Author

Christie M Bartels, MD, Instructor of Rheumatology, Department of Medicine, University of Wisconsin School of Medicine and Public Health
Christie M Bartels, MD is a member of the following medical societies: American College of Physicians-American Society of Internal Medicine and American College of Rheumatology
Disclosure: Nothing to disclose.

Coauthor(s)

Daniel Muller, MD, PhD, Department of Internal Medicine, Section of Rheumatology, Associate Professor, University of Wisconsin at Madison
Daniel Muller, MD, PhD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, American College of Rheumatology, and American Holistic Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Carlos J Lozada, MD, Director of Rheumatology Fellowship Program, Associate Professor, Department of Medicine, Division of Rheumatology and Immunology, Jackson Memorial Medical Center, University of Miami School of Medicine
Carlos J Lozada, MD is a member of the following medical societies: American College of Physicians and American College of Rheumatology
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Elliot Goldberg, MD, Dean of the Western Pennsylvania Clinical Campus, Professor, Department of Medicine, Temple University School of Medicine
Elliot Goldberg, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, and American College of Rheumatology
Disclosure: Nothing to disclose.

CME Editor

Alex J Mechaber, MD, FACP, Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine
Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Chief Editor

Herbert S Diamond, MD, Professor of Medicine, Temple University School of Medicine; Chairman Emeritus, Department of Internal Medicine, Western Pennsylvania Hospital
Herbert S Diamond, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American College of Rheumatology, American Medical Association, and Phi Beta Kappa
Disclosure: medifocus Honoraria Review panel membership; health dialogs Honoraria Consulting; West Penn Allegheny Health System None Board membership

 
 
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