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Monitoring
Lifelong
monitoring is required for systemic lupus erythematosus patients. The frequency
of visits depends on the disease activity, severity and extent, response to
treatment, type of treatment, and monitoring of toxicity.
The most important tool in the management of systemic lupus
erythematosus is a careful, frequent clinical and laboratory evaluation to
detect disease flares, drug side effects, and appearance of infections, and to
tailor management based on the patient response. It is therefore essential to do
active surveillance of opportunistic infections and adjust current therapy (eg
corticosteroids and immunosuppressants) according to the severity of organ involvement
during systemic lupus erythematosus flares. Patients with severe systemic lupus
erythematosus, complications, comorbidities, and drug toxicity will require
more frequent follow-ups.
Monitoring during clinic
visits should include history-taking, physical examination, and laboratory
tests (eg CBC, platelet count, creatinine measurement,
urinalysis, renal and liver function tests, ESR, CRP, immunology or serology,
electrocardiography, and imaging). For active systemic lupus erythematosus disease,
monitoring can be done every 1-3 months after diagnosis or flare while for low
or no disease activity or with stable treatment course, monitoring can be done every
6-12 months.
After achieving a low disease activity or remission, 20-25% of patients
with SLE will flare within 1-2 years and 40-66% within 5-10 years. The risk
factors for SLE flare include age of SLE onset ≤25
years old, male gender, persistent clinical disease activity, major organ
involvement (eg cytopenias, nephritis, neuropsychiatric, vasculitis); lab
findings of low serum C3/C4, high anti-dsDNA antibodies; and treatment concerns
(eg poor compliance, discontinuation or has never been on Hydroxychloroquine,
rapid tapering or withdrawal of maintenance immunosuppressive treatment).
The results of laboratory tests that
may precede a disease flare include a decrease in serum complement levels, an increase
in anti-dsDN, an increase in ESR, a decrease in hemoglobin level, leukocyte, or
platelet counts, an increase in creatine phosphokinase (CPK) levels, and the appearance
of microscopic hematuria or proteinuria.
Physicians
may be aided by at least 1 of the following several global or body
system-specific indices developed for long-term observation of SLE: SLEDAI,
BILAG, PGA, and ECLAM.
Lupus
Nephritis
Monitoring of lupus
nephritis includes a blood pressure check and laboratory tests such as
urinalysis, protein/creatinine ratio, serum creatinine, C3/C4, and anti-dsDNA
levels.
Please see Lupus Nephritis disease
management chart for further information.
Complications
Toxicity
Patients on
long-term glucocorticoids should be monitored for electrolyte, glucose, and
lipid levels to identify metabolic conditions. Bone densitometry may be
requested to identify osteoporosis and monitor response to treatment.
Patients on Hydroxychloroquine should have ophthalmological screening (eg
visual fields examination and/or spectral domain-optical coherence tomography)
performed at baseline, after 5 years, and then annually in those with no risk
factors for retinal toxicity.
For
those with known toxic retinopathy risk factors (eg long-term and/or high-dose
use of Hydroxychloroquine, advanced age, history of retinal and macular
disease, concomitant Tamoxifen), ophthalmologic screening should be performed
at baseline and then annually.
Patients on
immunosuppressants should be monitored for hematologic, liver and renal
toxicity, and the occurrence of infection.