The Management of Systemic Lupus Erythematosus

7/25/2019 The Management of Systemic Lupus Erythematosus

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THE MANAGEMENT OF SYSTEMIC

LUPUS ERYTHEMATOSUS

Mulia

September 2011


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Itr!"u#ti!

$ SLE i% a #&r!i# i'ammat!r(aut!immue "i%ea%e !) u*!+eti!l!,(- +it& .ariable #lii#almai)e%tati!- #!ur%e a" pr!,!%i%/

$ It i% #&ara#terie" b( peri!"% !)remi%%i!% a" peri!"% !)ea#erbati!%- +&i#& ma( i.!l.ea( !r,a !r %(%tem i .ari!u%

#!mbiati!%/ri#a C!lle,e !) R&eumat!l!,( A" H!# C!mmittee ! SLE ,ui"elie%/ Art&riti% R&eum 1342567189


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$ I t&e USA- t&e pre.ale#e !) SLE i%1 7 1-000

$ At RSCM- 1/4=!) t!tal !utpatiet%i t&e Clii# !) R&eumat!l!,( i 2002+a% SLE/

$ Female 7 male > ;14 7 1

$ T&e ,reat ma?!rit( !) t&e%e patiet%are +!me i t&eir #&il"beari,(ear%/

eri#a C!lle,e !) R&eumat!l!,( A" H!# C!mmittee ! SLE ,ui"elie%/ Art&riti% R&eum 134256718a Reumat!l!,i I"!e%ia/ Pa"ua "ia,!%i% "a pe,el!laa SLE- September 2004/


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$ Sur.i.al rate% are @90= at 10 (ear%a)ter "ia,!%i% a" @


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Clinical Features


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$ #riteria 5ANA;p!%iti.e6 alm!%t %urel( SLE/

$ #riteria 5ANA;e,ati.e6 .er( l!+pr!babilit(/

$ Ol( ANA;p!%iti.e uli*el( SLE/

Specifcity Sensitivity

4D11 #riteria @:= 9:=


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Conditions that may beconfused with SLE

$ U"ieretiate" #!e#te" ti%%ue"i%ea%e

$ S?!,re% %("r!me$ Atip&!%p&!lipi" atib!"( %("r!me

$ Fibr!m(al,ia +it& ANA 56

$ I"i!pat&i# t&r!mb!#(t!peia purpura$ ru,;i"u#e% lupu%

$ Earl( r&eumat!i" art&riti%

$ a%#uliti%


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Characteristics of Mild SLE

S Lif th t i


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Severe or Life-threateningSLE

S Lif th t i


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Severe or Life-threateningSLE


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Assessment ofDisease Activity and Severity

$ I% imp!rtat )!r t&e e%tabli%&met !)

a appr!priate treatmet pr!,ram/

$ I% ee"e" t! #l!%el( )!ll!+;up t&e

a#ti.it( !) "i%ea%e/


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Disease Activity Indees

$ SLEAI5SLE i%ea%e A#ti.it( I"e 6

$ MEJ;SLEAI5T&e Mei#a SLE i%ea%e

A#ti.it( I"e6$ SLAM 5SLE A#ti.it( Mea%ure6

$ BILAG I"e 5T&e Briti%& I%le% Lupu%

A%%e%%met Gr!up6$ LAM; 96

$ Real impairmet 5%#!re > 46

$ Hem!li%i% D tr!mb!%it!peia 5%#!re > 6

$ Mi!%iti% 5%#!re > 6

$ Art&riti% 5%#!re > 26$ Mu#!#utae!u% impairmet 5%#!re > 26

$ Ser!%iti% 5%#!re > 26

$ Fe.er K 9C D )atiue 5%#!re > 16

$ Leu#!p&eia D L(m)!p&eia 5%#!re > 16

S#!re7 K12 > %e.ere "i%ea%e a#ti.it(

12 > mil" t! m!"erate "i%ea%e a#ti.it(

> .er( mil" !r ! "i%ea%e a#ti.it(


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"he Aims of Management

Geeral

Spe#i#


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"he #illar of "reatment


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"he "reatment of Mild SLE


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"he "reatment of Mild SLE


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"reatment of Serious$ Life-threatening$

or %rgan-threatening SLE

$ T&e pillar !) treatmet i% %imilar t!mil" SLE- e#ept t&e p&arma#!l!,i#altreatmet/


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Corticosteroids

$ Pre"i%!e : ; 0 m, "ail( are ee#ti.ei treatmet !) mil";t!;m!"erate SLE-i#lu"i, #utae!u% "i%ea%e- art&riti%-a" %er!%iti%/

$ M!re %e.ere !r,a i.!l.emet 5ep&riti%-peum!iti%- &emat!l!,i# ab!rmalitie%- CNS "i%ea%e-

a" %(%temi# .a%#uliti%6reuire &i,& "!%a,e%!) pre"i%!e 1 ; 2 m,D*,D"a(/


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Corticosteroids

$ Li)e;t&reatei, SLE I pul%e MP51 ,6 )!r "a(%/

$ Ster!i" #a a#t a% bri",i, t&erap()!r t&e %l!+er;a#ti,

immu!m!"ulat!r( a,et%/


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$ T&e "!%e #a t&e be tapere"+&et&e immu!m!"ulat!r be,i% t! ta*e

ee#t/

$ O#e t&e "i%ea%e a#ti.it( i% u"er#!tr!l- tapere" t! !e !r miimal"ail( 5pre"i%!e : m,D"a(6 !ralterate;"a( "!%i, )!r maitea#et&erap(/

Corticosteroids


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A&athio'rine

$ A purie aal!,/

$ Aat&i!prie 522/: m,D*,D"a(6 i% a%a alterati.e maitea#e t&erap(t! CY i patiet% +it& lupu% ep&riti%

a" !t&er !r,a;t&reatei,mai)e%tati!%/


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C + CY C

C!rti#!%ter!i" itermittet CY

5i. b!lu% re,ime% !) 0/:1,Dm2 BSA6

Ha" %i,i#atl(better real %ur.i.al

C!rti#!%ter!i" al!e

/

Cyclo'hos'hamide

Au%ti H- et al/ N E,l Me" 19


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$ T&e tra"iti!al CY re,ime7

< t! 8 m!t&l( pul%e !) CY al!e !r +it&

pul%e MP i t&e i"u#ti!- a" t&e uarterl(pul%e CY )!r 2 (ear%/

$ I i)u%i! !) me%a ri,!r!u%&("rati! t! pre.et &em!rr&a,i#

#(%titi% a" bla""er #a#er )r!ma#r!lei- a t!i# metab!lite !) CY/

$ Si"e ee#t%7 i)ertilit("ue t!


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$ RCT MMF appeare" t! be a% ee#ti.e a%i. CY i i"u#i, %&!rt;term remi%%i! !)lupu% ep&riti% +it& a better %a)et( pr!le/

$ T&e r!le !) MMF i impr!.i, l!,term!ut#!me% !) lupu% ep&riti% remai%

u*!+/

$ T&e "!%i, ra,e )r!m :00m, t! 1:00m, t+i#e "ail(/

Giler E- et al/ N E,l Me" 200:3:7221;2229/

Myco'henolate Mofetil


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%ther Drugs and Modalities

$ Le'u!mi"e

$ e&("r!epia"r!%ter!e 5HEA6

$ T&ali"!mi"e$ Itra.e!u% immu!,l!buli 5IIG6

$ Pla%ma e#&a,e !r pla%map&ere%i%

$ Aut!l!,!u% Stem CellTra%platati!


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SLE and #regnancy

$ Sterilit( a" )ertilit( )ate% )!r +!me+it& SLE are #!mparable t! #!tr!l,r!up% +it&!ut "i%ea%e/

$ T&e i#i"e#e !) 'are "uri,pre,a#( !r a)ter "eli.er( i#rea%eab!ut


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1/ Pre,a#( !ut#!me i% !ptimal +&e"i%ea%e i% i #!mplete #lii#al remi%%i!)!r < ; 12 m!t&%/

2/ C!rti#!%ter!i" %&!ul" be ,i.e a% l!+"!%e a% p!%%ible !) le%% t&a 20 m, "ail(/

/ Aat&i!prie#a be u%e" "uri,pre,a#(/

&ar P- S!*!l R/ Cli Me" a" Re%ear#& 200


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SLE and A#S


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1/ Elimiate t&e Atip&!%p&!lipi" atib!"ie%b( u%i, Immu!%uppre%i.e "ru,%/

2/ Impr!.e t&e ri%* )a#t!r% %u#& a% #ea%e !)#i,arette/

/ P&arma#!l!,(7 L!+ "!%e 590 m,6 "ail( !) A%piri/

Ati#!a,ulat5UFH- LMQH- !r Qar)ari6


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Lu'us (e'hritis

$ Hi%t!pat&!l!,( )eature i% ee"e" t! #!rmt&e iitial treatmet #!rti#!%ter!i" al!eversus immu!%uppre%i.eD#(t!t!i# "ru,%/

$ Salt re%tri#ti! i) &(perte%i! D e"ema/

Pr!tei re%tri#ti! +&e real )u#ti!impairmet !) 40=/

L!,;term Cal#ium %upplemet )!r t&!%e+&! ! #!rti#!%ter!i" K8/:m, "ail(/


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Lu'us (e'hritis

$ U%e "iureti# a% ee"e"/

$ A.!i" NSAI%/

$ M!it!ri, real )u#ti!7 urial(%i%-#reatiie- albumi- C- ati;"%NA- 24&!ur uriar( pr!tei- CrCl 1;2 +ee*l(/

$ A,,re%%i.e treatmet !) &(perte%i!/


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Lu'us Cerebral

$ Hi,& m!rbi"it( a" m!rtalit( rate/

$ T&e Ameri#a C!lle,e !)

R&eumat!l!,(7 Mil" %(mpt!m%7 &ea"a#&e 5i#lu"i,

mi,raie6- rea#ti.e p%(#&iatr( "i%!r"er-

#!,iti.e "(%)u#ti!- aiet( "i%!r"er/ Se.ere %(mpt!m%7 a%epti# mei,iti%-

)!#al "e#it eur!l!,( 5"ue t! C !r"em(eliati! %("r!me6- #&!rea-

m(el!pat&(- %eiure- a#ute #!)u%i!al


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$ T&e "ia,!%i% i% "i#ult- a% t&ere are

! %pe#i# lab!rat!r( te%t%/

$ I %e.ere )!rm 5i#lu"i, .a%#uliti%67 i.

pul%e %ter!i" MP 1 , "ail( )!r "a(%/

$ I) ! re%p!%e I CY 0/8:

1/00,Dm2 ;< +ee*l(/

$ Clii#al %table pre"i%!e 1m,D*,D"a( i "i.i"e" "!%e/


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M!it!ri, SLE

$ Li)el!, m!it!ri, t! "ete#t'are% earl( a" i%titute pr!mpt-appr!priate t&erap(/

$ It i% imp!rtat t! re"u#e m!"iableC ri%* )a#t!r% i#lu"i, t!ba##!

u%e- !be%it(- %e"etar( li)e%t(le-"(%lipi"emia- a" &(perte%i!/


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C!mplemet C- C4Titer !) ati;"%NA


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C!mplemet C- C4Titer !) ati;"%NA

T&e )reue#( !) t&e%e e.aluati!+ill "epe" !7/ T&e a#ti.it(- %e.erit(- a" etett&e SLE/

/ T&e re%p!%e t! treatmet// T&e t(pe !) treatmet


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$ A "e#rea%e i %erum C-C4

$ A i#rea%e i ati;"%NA

$ A ri%e i ESR

$ A "e#rea%e iHaem!,l!bi !r Leu*!#(te!r Platelet #!ut%

$ A ri%e i CP le.el$ T&e appeara#e !)mi#r!%#!pi# &aematuria !rpr!teiuria

Ma( pre#e"e a#lii#al "i%ea%e

'are/

M!"i#ati! !)treatmet

Si,i#atl(re"u#e t&e

#&a#e !) 'are

C&a,e% i t&e#ertai lab!rat!r(

re%ult%/


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THE

TEA

M

APP

RO

ACH


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Summary

$ SLE i% a #!mple "i%!r"er +it& .ariablepre%etati!%- #!ur%e- a" pr!,!%i%/

$ T&e pillar maa,emet !) SLE #!%i%t% !)e"u#ati!D#!u%eli,- eer#i%eDre&abilitati!pr!,ram- a" p&arma#!l!,i#al treatmet/

$ Li)el!, m!it!ri, i% reuire" )!r m!%tpatiet%/


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Summary

$ It %&!ul" be maa,e" b( a teamappr!a#&/


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THAN YOU


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S l i Ab liti i


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Serologic Abnormalities inSLE

lippel H- ieppe PA- e"it!r/ R&eumat!l!,(/ L!"!7 M!%b(319/


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"he #illar of "reatment

E"u#ati! D #!u%eli,-

Eer#i%e D Re&abilitati! pr!,ram-

P&arma#!l!,i#al treatmet7 NSAI%-

Atimalarial "ru,%-

Glu#!#!rti#!i"%- Immu!%uppre%i.eD#(t!t!i# "ru,%/


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Myco'henolate Mofetil

MMF i% a ia#ti.e pr!"ru, !)m(#!p&e!li# a#i" 5MPA6- +&i#&i&ibit% i!%ie

m!!p&!%p&ate "e&("r!,ea%e-l(mp&!#(te pr!li)erati!-

a" b!t& T; a" B;#ell )u#ti!/


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F * D * b i


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Fa*t!r pe#etu%De*%a%erba%i

SLESLE

Obat :Obat :

KeguguranKeguguran

KehamilanKehamilanTindakanpembedahan

Tindakanpembedahan

n!eksin!eksi

Sinar "#$%&'()'' nm*

Sinar "#$%&'()'' nm*

r,cainami

d-idrala.in/etild,paC01 2-

r,cainami

d-idrala.in/etild,paC01 2-

#atients with )nown renal


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#atients with )nown renaldisease

$ A urial(%i%-

$ 24;&!ur urie pr!tei-

$ Creatiie %erum- Cr#l

$ C!mplete bl!!"#!ut-

$ Lipi" pr!le-

$ Cal#ium- P&!%p&ate-$ S!"ium a" P!ta%ium/

1D12at t&e !%et

!) ep&riti%


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#atients with )nown renal


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#atients with )nown renaldisease

$ A urial(%i%-

$ 24;&!ur urie pr!tei-

$ Creatiie %erum-

$ C!mplete bl!!"#!ut-

$ Lipi" pr!le-

$ Cal#ium- P&!%p&ate-$ S!"ium a"

P!ta%ium/

1D12at t&e !%et

!) ep&riti%

M!re !)te

I) t&e #!"iti!i% u%table

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The Management of Systemic Lupus Erythematosus