Malar rash, arthritis, serositis, cytopenia, nephritis
Screen → confirm: ANA (screen) → anti-dsDNA / anti-Smith (specific)
Treat: Hydroxychloroquine (all patients, ≤5 mg/kg/day) + steroids for flares — GC are bridging only: maintenance ≤5 mg/day and withdrawn when possible (EULAR 2023); consider belimumab or anifrolumab EARLY when HCQ alone insufficient or GC cannot be tapered
Nephritis → renal biopsy → triple immunosuppression (2024 ACR LN): GC + MMF or low-dose IV CYC (Euro-Lupus) + belimumab or voclosporin; IV GC pulses then oral ≤0.5 mg/kg/d, taper to ≤5 mg/d by 6 mo; target proteinuria ≤0.5 g by 6–12 mo
Order set
- ANA → dsDNA/anti-Sm
- Complement (C3/C4)
- FBC, U&E, urinalysis
- Antiphospholipid antibodies
Criteria
AdmitMajor organ flare (nephritis, cerebritis, cytopenia, serositis)
ICULife-threatening flare, alveolar haemorrhage, thrombosis
DischargeFlare controlled, immunosuppression + hydroxychloroquine, follow-up
Key
- Drug-induced (hydralazine, procainamide, INH) → anti-histone.
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
- Nephritis
- Cerebritis
- Cytopenias
- APS thrombosis
Differentials
- Drug-induced lupus
- Vasculitis
- Viral
- Mixed CTD
Common mistakes
- Missing lupus nephritis (check urine)
- Stopping hydroxychloroquine
Disposition & follow-up
Hydroxychloroquine baseline; immunosuppression for organ disease.
Discharge package
MedicationsHydroxychloroquine; immunosuppression for organ disease
Follow-upRheumatology; monitor renal/bloods
VaccinationNon-live vaccines; avoid live on immunosuppression
LifestyleSun protection
Warning symptomsFlare, swelling, fever, chest pain, neuro symptoms
💊 Treatment detail — doses & preparation
Hydroxychloroquine (SLE)DMARD
Dose200–400 mg OD (≤5 mg/kg real body weight/day) — backbone of SLE, flares and pregnancy-safe
Preparation200 mg tablets
MonitorRetinal screen baseline + annually after 5 yr
NaproxenNSAID
Dose500 mg BD with food (SLE arthralgia/serositis — caution in lupus nephritis)
Preparation250/500 mg tablets; add PPI if risk factors
MonitorRenal function, GI bleeding, BP; avoid in CKD/HF
Prednisolonecorticosteroid
DoseSLE flare: 0.5–1 mg/kg OD (LN: IV pulses then oral ≤0.5 mg/kg/d), taper to ≤5 mg/day and withdraw when possible (EULAR 2023)
Preparation5/25 mg tablets; gastro-resistant or plain with food
MonitorGlucose, BP, mood; bone protection if >3 mo (Ca²⁺/D ± bisphosphonate)
Mycophenolate mofetilimmunosuppressant
Dose500 mg BD titrate to 1–1.5 g BD (lupus nephritis)
Preparation250/500 mg tablets/capsules
MonitorFBC weekly ×4 then monthly; teratogenic — contraception essential
Cyclophosphamidealkylating immunosuppressant
DoseLupus nephritis/vasculitis: 500 mg IV q2 wk ×6 (Euro-Lupus) or 15 mg/kg PO/IV regimens
PreparationIV reconstitute + MESNA cover + pre/post hydration
MonitorFBC (nadir day 10–14), haemorrhagic cystitis, infertility counsel
📖 EULAR SLE 2023 / ACR LN 2024Reviewed July 2026