The lupus case scenario: a treatment approach

Kristi V. Maiselle, MD, MPH, FACR: We see the patient, she has ANA 1 to 640, a homogeneous pattern. She has a high double-stranded DNA, a low C3, and she has synovitis on examination of her small joints in her hands and feet. He has what looks like a rash, too. We say, well, it looks like we’re getting to what might be called lupus. Well, let’s make sure we’ve left out other things that could be there at the same time, or could be interfering somehow. We make sure we check rheumatic blood studies, and possibly check x-rays. We make sure we are comfortable with our diagnosis. Then, well, we have a lupus diagnosis, we’re pretty relieved. With their manifestations, if she had mild synovitis on the exam, I would then suggest an antimalarial, which would be a perfect fit, as well as UV protection with a regular sunscreen with a high SPF. I usually recommend at least 50 to 70 for patients with lupus as a way to try to prevent UV rays that cause or develop lupus attacks or increase disease activity. Then I sent her on her way to see how she handles the antimalarials.

Ann E. Winkler, MD, PhD, MACP: If she is not feeling well, now she has seborrheic nephritis. How are you going to deal with that knowing that she’s on antimalarials and leflunomide?

Kristi V. Maiselle, MD, MPH, FACR: the correct. She comes with some tiredness, some swelling in the legs, a slight rise in blood pressure, which is different for her, right? If it’s been working fine for a year and a half, or two years, and then you come up with this stuff that says then, we have to think, is there something else going on? And that just gives us an opportunity to go back and say, every time we see patients, we should evaluate any signs or symptoms, or lab findings, that would hint at lupus activity. We check for signs, symptoms, and lab findings, which may be indicative of increased lupus activity, even if the patient is unwell. We have to keep raising the antenna, like I said. And I said earlier in the discussion, check our urine protein for creatinine ratios to make sure patients are fine, and that doesn’t increase proteinuria, also check UA to make sure there is no microscopic hematuria. We do these things, she’s back and now she has a urine protein to creatinine ratio of 4, which is not good. That’s the scope of renal proteinuria and we’re concerned that she has bad lupus nephritis, we’re looking at renal proteinuria, we’re looking at class 5, with potential for some overlap, likely with other classes of lupus nephritis. But normally, we’d be worried about category 4 mostly, and that’s the bad lupus nephritis that would be very worrying, as people would lose kidney function. Bad lupus nephritis which we are concerned about because it can certainly develop rapidly and can progress towards loss of kidney function very quickly and lead to patients becoming dependent on dialysis.

Text edited for clarity