eMedicine Specialties > Emergency Medicine > Rheumatology

Systemic Lupus Erythematosus: Follow-up

Author: Mark J Leber, MD, MPH, FACEP, Attending Physician and Faculty, Department of Emergency Medicine and Residency Program, Lincoln Medical and Mental Health Center
Coauthor(s): Viraj S Lakdawala, MD, Resident Physician, Department of Emergency Medicine, Lincoln Medical and Mental Health Center, Bronx, NY
Contributor Information and Disclosures

Updated: Oct 27, 2009

Follow-up

Further Inpatient Care

  • Patients with systemic lupus erythematosus (SLE) may require admission for treatment of severe complications, such as lupus nephritis (for pulse steroids, cytotoxic agents) or other entities responsive to high-dose steroids.
  • Admit patients with neuropsychiatric presentation or stroke syndromes.
  • Admit patients to appropriate service (rheumatology if available) with subspecialty consultations as needed.

Further Outpatient Care

  • Conservative management is indicated for the symptomatic relief of arthralgia, arthritis, or myalgia with nonacetylated salicylates, nonsteroidal anti-inflammatory drugs (NSAIDs), or low-dose glucocorticoids.

Inpatient & Outpatient Medications

  • Nonacetylated salicylates or NSAIDs may be indicated.

Deterrence/Prevention

  • Patients with systemic lupus erythematosus (SLE) should be encouraged to take steps to prevent sunburn by limiting sun exposure, wearing protective clothing, and using sunscreen that protects against both UV-A and UV-B. Exposure to UV light causes SLE to flare in approximately 70% of patients. Sunscreen should have an SPF of at least 15 and should be applied frequently (every 2-3 h) and in the quantity recommended by the manufacturer.
Photosensitive systemic lupus erythematosus (SLE)...

Photosensitive systemic lupus erythematosus (SLE) rashes typically occur on the face or extremities, which are sun-exposed regions. Photo courtesy of Dr. Erik Stratman, Marshfield Clinic.

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Photosensitive systemic lupus erythematosus (SLE)...

Photosensitive systemic lupus erythematosus (SLE) rashes typically occur on the face or extremities, which are sun-exposed regions. Photo courtesy of Dr. Erik Stratman, Marshfield Clinic.

  • Patients should have yearly vaccinations for influenza. Pneumococcus vaccine should be updated every 3-6 years.20
    • Hepatitis B vaccines are recommended.
    • Patients on high-dose immunotherapy should NOT receive live vaccines. 
  • Although organ involvement requires specific drug therapy, a number of general issues are applicable to every patient with SLE.
  • Patients should avoid exposure to direct or reflected sunlight and other sources of UV light. Use sunscreens that block both UV-A and UV-B with sun protection factor (SPF) of 30.
  • A conservative approach is to recommend a balanced diet consisting of carbohydrates, proteins, and fats. However, the diet should be modified based on disease activity and response to therapy. Patients with active inflammatory disease and fever may require an increase in caloric intake.
  • Glucocorticoids enhance appetite, resulting in potentially significant weight gain. Hunger can be somewhat lessened by the ingestion of water, antacids, proton pump inhibitors, and/or histamine H2 blockers. A low calorie diet should be instituted if significant weight gain occurs.
  • Most patients with SLE have low serum levels of 25-hydroxyvitamin D (calcidiol), probably due at least in part to avoidance of sun exposure. Patients with low vitamin D levels should be treated with supplemental vitamin D.
  • Patients on long-term glucocorticoids and postmenopausal women should ingest 800 units of vitamin D plus 1500 mg of calcium per day and/or a bisphosphonate to minimize the degree of bone loss. 
  • Cigarette smoking may increase the risk of developing SLE, and smokers in general have more active disease. Patients should be counseled not to smoke or to quit smoking and be provided with help to do so. 
  • Inactivity produced by acute illness causes a rapid loss of muscle mass and stamina resulting in a sense of fatigue. This can usually be treated with graded exercise. In selected refractory cases, relief can be obtained with antimalarial drugs.

Complications

Prognosis

  • Mortality of those with systemic lupus erythematosus (SLE) has decreased over the past 20 years.23
  • Five-year survival rate in Western countries ranges between 93-95%.23
  • Mortality typically in the first few years of illness is active disease (eg, CNS, renal, or cardiovascular disease) or infection due to immunosuppression, whereas late deaths are due to atherosclerosis.23,9

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Failure to evaluate for ordinary or opportunistic infections
  • Failure to involve a rheumatologist or a primary care provider in the management and disposition of a patient

Special Concerns

  • Whether flares of systemic lupus erythematosus (SLE) are more frequent during pregnancy is controversial. The flares do not seem to be exceedingly more serious compared with those in nonpregnant patients. Pregnancy outcomes are generally more likely to be complicated.
    • Increased rates of hypertension during pregnancy, premature delivery, unplanned cesarean delivery, postpartum hemorrhage, and maternal venous thromboembolism are all more frequent in women with SLE than in others.
    • Fetal growth restriction and neonatal deaths are also frequently seen in association with SLE.
    • Predictors for fetal loss include active nephritis at conception and the presence of antiphospholipid (aPL) antibodies.
  • High-dose aspirin and NSAIDs should be avoided in the last few weeks of pregnancy.
  • Hydroxychloroquine has not been shown to induce congenital malformations. Furthermore, unnecessary discontinuation of hydroxychloroquine during pregnancy may result in lupus flares.
  • If indicated, prednisone, prednisolone, and methylprednisolone are the corticosteroids of choice during pregnancy because of their minimal placental transfer.
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Anuritha Tirumani, MD, to the development and writing of this article.



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References
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Further Reading

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Contributor Information and Disclosures

Author

Mark J Leber, MD, MPH, FACEP, Attending Physician and Faculty, Department of Emergency Medicine and Residency Program, Lincoln Medical and Mental Health Center
Mark J Leber, MD, MPH, FACEP is a member of the following medical societies: American College of Emergency Physicians and American College of Physicians
Disclosure: Nothing to disclose.

Coauthor(s)

Viraj S Lakdawala, MD, Resident Physician, Department of Emergency Medicine, Lincoln Medical and Mental Health Center, Bronx, NY
Viraj S Lakdawala, MD is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians
Disclosure: Nothing to disclose.

Medical Editor

Richard S Krause, MD, Senior Faculty, Department of Emergency Medicine, State University of New York at Buffalo School of Medicine
Richard S Krause, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

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

Managing Editor

Gino A Farina, MD, Program Director, Associate Professor of Clinical Emergency Medicine, Department of Emergency Medicine, Long Island Jewish Medical Center, Albert Einstein College of Medicine
Gino A Farina, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

 
 
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