Lupus Nephritis and Hypertension Management

1) IF a cSLE patient without known lupus nephritis has developed daily proteinuria of >500 mg or clinically relevant worsening of GFR/urinary sediment, THEN a kidney biopsy should be performed.

2) IF a patient has known lupus nephritis, THEN a clinical assessment for cSLE should occur at least every 3 months regardless of disease activity.

3) IF a cSLE patient has lupus nephritis plus evidence of ongoing proteinuria >500mg/day, THEN an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blockers (ARB) should be prescribed, unless there are contraindications.

4) IF a patient has LN and/or hypertension, THEN disease co-management with a nephrologist should be considered.

Medication Management

5) IF a patient has cSLE, THEN antimalarial therapy should be prescribed, unless there are contraindications.

6) IF a cSLE patient is receiving a dose of steroids not acceptable for chronic use, then an attempt should be made to taper steroids.

7) IF a patient with cSLE is unable to decrease the dose of steroids acceptable for chronic use, THEN the addition of a steroid-sparing agent, or an increased dose of an existing steroid-sparing agent should be considered.

8) IF a cSLE patient is treated with medications, THEN laboratory surveillance for medication safety should be done at regular intervals. (Table 2)

Vaccinations

9) IF a patient has cSLE, THEN vaccination against influenza and encapsulated organisms should be prescribed, unless there are contraindications.

Bone Health with cSLE

10) IF a patient has received chronic systemic steroids, THEN the patient should have bone mineral density testing documented in the medical record.

11) IF baseline bone mineral density testing is outside of normal limits (Z-score ≤-2.0), THEN bone mineral density should be re-measured after one year.

12) IF a patient is on any steroid therapy, THEN calcium and vitamin supplementation should be recommended after 3 months.

Ophthalmological Surveillance

13) IF a cSLE patient is treated with corticosteroids, THEN an eye screening does not need to occur prior to treatment.

14) IF a cSLE patient is treated with corticosteroids, THEN eye screening should be done at least annually.

15) IF a cSLE patient is treated with antimalarial therapy, THEN eye screening should be done at least annually.

Transfer of Care with cSLE

16) IF an adolescent has cSLE, THEN a transition plan should be carefully designed to facilitate transfer of care to the appropriate adult health-care providers.

Education on Cardiovascular Risk Factors

17) IF a patient has cSLE, THEN education about cardiovascular risk factors should occur in regular intervals with the parent and the patient age 13 years or older.

IF a cSLE patient is treated with medications, THEN laboratory surveillance for medication safety should be done regularly as is documented below:

Interval

AZA

NSAIDS

HCQ

1-monthly

IV CTX

MMF/MPA

3-monthly CTX

Cyclo-A

Prednisone

Rituximab

TNF-antagonists

Baseline

CBC

Liver

CBC

Liver

CBC

CBC

Every month

CBC

Liver

Renal

Every 3 months

CBC Liver

CBC

Liver

Renal

CBC

CBC

Every 6 months

Renal

Liver

Renal

Liver

Every 9 months

UA

Every 12 months

CBC

CBC

Renal

Liver

Liver

Renal

AZA=azathioprine; HCQ= hydroxchloroquine; CTX=cyclophosphamide; MMF/MPA=mycophenolate mofetil/mycophenolic acid; Cyclo-A=cyclosporine-A; CBC=complete blood count and differential; Liver=liver function tests; Renal=renal function tests; UA=urinary protein excretion