Future management of systemic lupus erythematosus

The management of systemic lupus erythematosus (SLE) will take on a completely new look in the next 10 years, some of which has little to do with lupus medications. By the year 2017, we will know which gene or set of genes causes lupus and under what set of circumstances these susceptibility genes are activated. Since women with SLE have a 10% risk of their daughter and a 2% risk of their son developing the disease, as well as a 50% probability of their offspring being antinuclear-antibody positive (in addition to having an increased prevalence of other autoantibodies), we should be able to identify individuals at risk [1]. It might be possible to vaccinate or give peptide toleragens to at-risk populations, with the goal being disease prevention. Additionally, environmental factors, including certain occupational exposures and immunogenic chemicals that promote autoimmune reactions will be better elucidated, which could lead to the implementation of protective measures. The future of lupus management also hinges on an improved, statistically validated definition for the various forms of lupus and its variants: SLE, chronic cutaneous lupus, undifferentiated connective tissue disease, overlap syndromes, mixed connective-tissue disease and drug-induced lupus. A national data bank complemented with an electronic medical record accrual system, which in selected centers will include updated, validated clinical indices, will permit lupologists to better understand the epidemiologic, demographic, clinical and laboratory characteristics of the disorder. Outcomes will be easier to predict and the implementation of measures to circumvent an undesirable prognosis will be more focused. An integrated health system allowing access to rheumatologic expertise will be in place. Hopefully, rheumatologists will be able to work with primary care physicians to improve the outcome and quality-of-life of the lupus patient. Some of the interventions outside of prescribing lupus medications, which in controlled studies have been shown to improve morbidity, mortality and quality-of-life, include [2]: • Screening for osteoporosis and treating those at risk; • Identifying patients at risk for antiphospholipid mediated thromboembolic events and utilizing prophylactic initiatives (e.g., low-dose aspirin); • Recommending physical measures and exercise regimens that diminish the risks of muscle atrophy and bone demineralization while utilizing optimal ergonomic workplace dynamics; • Smoking cessation measures; • Screening for and interdicting accelerated atherogenesis, hyperlipidemia, hyperglycemia (especially in those on corticosteroids) and hypertension. This can be accomplished with periodic electrocardiograms, chest x-rays, laboratory testing, cardiac imaging, carotid duplex scanning, assessments of baseline pulmonary pressures and promotion of a cardioprotective diet [3]; • Patient education about the disease; • Use of biofeedback, relaxation measures and cognitive behavioral regimens to treat the dysautonomia of lupus (e.g., Raynaud’s, lupus headache and cognitive dysfunction). Existing lupus medications will be complemented with newer agents, along with a more intelligent use of combinations of corticosteroids, immune suppressives and biologics.