Monitoring

The objective of monitoring is assessment of response to treatment and adverse effects of drugs. Its natural consequence is a readjustment of the treatment that has been given in the preceding visit. Clinical tools for monitoring include customized history-taking, examination and some objective instruments, e.g., SLEDAI (SLE Disease Activity Index). During follow up, routine urinalysis and CBC are done at every visit. Selection of other test depends upon organ systems involved or suspected to get newly involved and upon relative value of the test in assessing outcome and guiding therapy. For example, repeated estimation of 24-hour urinary protein and creatinine clearance is important while treating patients for lupus nephritis. Bacterial culture and antibiotic sensitivity testing of appropriate specimens is very important for prompt identification of infections as well as for distinguishing for affection of the organ by SLE itself. Serum C3 and C4 levels fall during active disease. Their estimation is sometimes important for detection of flare and also for distinguishing from infective involvement. Laboratory tests are sometimes required for monitoring of drug toxicities. For example, estimation of serum transaminases in patients treated with methotrexate and annual blood glucose and BMD (Bone Mineral Density) in patient maintained with long-term steroid therapy.

EMERGING THERAPIES

New Cytotoxic Agents

New drugs in this class are mycophenolate mofetil, fludarabine and cladribine that have fewer side effects than conventional cytotoxic agents.

Stem Cell Restoration

The immune system is generated from cells in the bone marrow known as stem cells. Many researchers believe that dysfunctional stem cells may be the cause of SLE. If they are right, then destroying these disease-producing stem cells and replacing them with healthy stem cells might be a way to stop or eliminate SLE. With stem cell therapy, doctors target bone marrow with radiation or various drugs and then transplant healthy stem cells. While few of these procedures have been tested in clinical trials, the early results appear promising.

Intravenous immunoglobulin (IV Ig) is a substance that has the ability to regulate SLE. IV Ig has also been reported to be an effective treatment for arthritis, thrombocytopenia and the neuropsychiatric manifestations of SLE. Other new experimental therapies target various stages of the immunoinflammatory response. Therapies include inhibition of costimulatory pathways, manipulation of the complement system and manipulation of cytokines.

PROGNOSIS

The prognosis for SLE varies widely depending on the organs involved and the intensity of the inflammatory reactions. The course of SLE is commonly chronic and relapsing, often with long periods of remission. Most patients with SLE have a normal lifespan with periodic doctor visits and treatments with various drugs. Many of the more serious problems do not affect most patients. Death is usually caused by renal failure or infection. The good news is that with appropriate treatment and by taking care of its adverse effects, most SLE patients can hold jobs, have children and lead a near-normal life. At present,
5-year & 10-year survival rates are estimated to be 97% and 90%, respectively.

CONCLUSION

SLE is a challenge to everyone concerned. The health professional has a key role in its management. Accurate documentation, supportive care, emotional support, patient education and access to community resources will provide the patient and her or his family with the tools they need to cope effectively.

Reference

1.The History of Lupus erythematosus; Article by Dr. Wolfe Blotzer, Assistant Professor of Medicine, University of Maryland School of Medicine and Dr. B. Rose, Rheumatologist, Waikato Hospital, New Zealand. 2.Complement and systemic lupus erythematosus, Mark J Walport Division of Medicine, Imperial College of Science, Technology and Medicine, London, UK. 3.American Autoimmune Related Diseases Association, Inc. Wegener's Granulomatosis Association, The NIH Word on Health, April 2001 4.Medicine - Complement Deficiencies Article by R Krishna Chaganti, MD. 5.Lupus: A Patient Care Guide for Nurses and Other Health Professionals. National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) National Institutes of Health (NIH), Bethesda, Maryland 20892-2350 6.Hormones and Lupus. Lupus Foundation of Minnesota. The Atrium Suite135 2626East 82nd Street Bloomington, MN 55425 7.Lupus Clinical Overview; Article by H. Michael Belmont, M.D. Medical Director, Hospital for Joint Diseases, New York University Medical Center 8.MDchoice.com, May15, 2005. 9.Health & Wellness Article by J. Gordon Lambert, MD, G. Eric Morgan, Evanston Northwestern Healthcare 10.Stanford Peng, M.D., Ph.D., Division of Rheumatology, Washington University School of Medicine, St. Louis, MO. 11.Current Medical Diagnosis & Treatment 2003, 42nd Edition. 12.Oxford. 2nd Edition. 13.CECIL, Textbook of Medicine, Vol 2, 19th Edition.