2013 LUPUS for INTERNIST. พญ.ขว ญฤท ย ศร พวาทก ล หน วย ร มาต สซ ม แผนก อาย รกรรม รพ.มหาราช นม.

Transcription

1 2013 LUPUS for INTERNIST. พญ.ขว ญฤท ย ศร พวาทก ล หน วย ร มาต สซ ม แผนก อาย รกรรม รพ.มหาราช นม.

2 Reference organization EULAR ACR NIH APLAR European laegue against rheumatism American college of rheumatology National Institute of Heath ของร ฐบาลอเมร กา ด งน นข อม ลจะไม ถ ก bias โดยบร ษ ทยา Asia- Pacific Laegue against Rheumatism

3 African-American Asia Hispanic

4 What s New??

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7 Development Classification Criteria for SLE

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12 2012 SLICC Classification Criteria :

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14 Diagnosis need : 1) 4 ; at least 1 clinical + 1 immunologic 2) Renal :

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21 acl LAC B2GPI

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31 Figure 2. Necrotizing lesions of the glomerular tuft indicate severe immune aggression in lupus. The necrotizing segments (red arrow) appear fuchsinophilic with the trichrome stains, and they are accompanied by distortion of the tuft and, frequently, by nuclear fragmentation (karyorrhexis) (green arrow). (Masson s trichrome, X400).

32 Lupus nephritis Evaluate 2 components : 1. Proteinuria (NS) 2. Active GN IS IT DPLN??? (diffuse proliferative LN Class 3,4) SEVERE parameters : hr urine Total protein >3g/day 2. Serum alb <3 3. Rbc sediment >50 cell/hpf 4. Mild HT 5. Acute renal failure VERY SEVERE parameters : 1. RPGN 2. Accelerated HT 3. ANASARCA

33 BASIC DATA for decision making UA : Serum : HT - 24 hr.protein - sediment - alb - Cr - mild - accelerate

34 Aims of Treatment in Proliferative Lupus Nephritis 1. Not to delay treatment 2. To induce remission 3. To prevent renal flares 4. To minimize the iatrogenic morbidity

35 Treatment of Proliferative Lupus Nephritis Induction phase - acute phase, renal remission at presentation and during follow up Maintenance phase - prevent relapse and minimizing the side effects of therapy

36 Probability of stable renal course Cyclophosphamide 1970s 1980: Mayo Clinic, NIH prospective RCT Regimens of Cyclophosphamide+prednisolone were more effective than prednisolone alone Prednisolone + cyclophosphamide Prednisolone months Donadio JV,et al. N Engl J Med 299,1978

37 Probability of no renal failure Probability of Maintaining Life-Supporting Renal Function in 107 patients with Active Lupus nephritis IVCY AZCY POCY AZA Prednisolone vs. IVCY p=0.027 PRED Follow up (months) Austin HA,et al. N Engl J Med 314, 1986

38 NIH study Therapy Pts 10 yrs Renal survival Prednisolone 30 40% Azathioprine 20 72% Cyclophosphamide 18 80% AZA+CYC 23 88% IV CYC 20 91% Austin H, et al. NEJM 1984; 314: 6

39 PROBABILITY OF NO EXACERBATION Boumpas DT, Austin HA, et al. Lancet 340, 1992 CYCLOPHOSPHAMIDE-Long course CYCLOPHOSPHAMIDE-Short course FOLLOW UP (Months) Short-course Cy had a higher probability of exacerbations than long-course Cy

40 Combine Pulse Methylprednisolone and pulse IV Cyclophosphamide : Probability That Serum Creatinine Level Will Not Dobule Combination At Median Follow-up 5 years Probability of Remission IVCY IVMP Combination IVCY IVMP FOLLOW UP (Months) FOLLOW UP (Months) Gourley MF,et al. Ann Intern Med 125,1996

41 Probability That Therapy Would Not Fall Controlled Trial in Lupus Nephritis: IVCY vs. IVMP vs. Combination An extended follow-up 11 years Combination IVCY IVMP Months from Study Entry Illei GG, et al. Ann Intern Med 2001; 135:

42 Controlled Trial in Lupus Nephritis: IVCY vs IVMP vs Combination Cyclophosphamide therapy Combination therapy Methylprednisolone therapy Avascular necrosis 36% 31% 30% Osteoporosis 23% 21% 13% Premature amenorrhea 60% 52% 33% Infection 26% 32% 8% Herpes zoster infection 26% 32% 7% Death 5/27 5/28 1/27 Adding pulse methylprednisolone during the initial phase may be advantage for pt with severe proliferative LN Illei GG, et al. Ann Intern Med 2001; 135:

43 Treatment DPLN: with background STEROID Induction phase ( for remission ) maintainace phase ( for prevent relapse ) 1. NIH regimen Monthly IVCY mg*bsa *6 cycle (maybe extended if not remission) ivcy every three months => total course 2 yrs 2. EURO LUPUS trial IVCY Every 2 wks 500 mg*bsa *6 cycle AZATHIOPRINE (immuran) => Total course 2 yrs 3. ALTERNATIVE MMF 2-3 g/day : MMF,AZA

44 SEVERE parameters : 1.24 hr urine Total protein >3g/day 2.Serum alb <3 3.Rbc sediment >50 cell/hpf 4.Mild HT 5.Acute renal failure severity No severe parameter Severe parameter -OPD case Severe parameter - IPD case VERY severe parameter DOSE pred 0.5 MKD (moderate dose) 1.0 MKD (high dose) : no renal failure DEXA 4 mg iv q 6hr/ ivmp ± IVCY : has renal failure Double pulse : Pulse methyl prednisolone + Pulse IVCY : EARLY F/U = 2 weeks If clinical run down => step up treatment

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46 Treatment of Lupus class V Nephrotic range proteinuria : First line treatment high dose alternate day prednisolone (1-2 mg/kg) for 2 months taper to 0.25 mg/kg alternative days within 3-4 mo Optional adjuncts to prednisolone therapy Cyclosporine A 5 MKD Pulse cyclophosphamide 1 g/m 2 every 2 mo Oral cyclophosphamide 2 MKD Oral MMF 2-3 g/day Methylprednisolone/chlorambucil Azathioprine 1-2 mg/kg/day Mixed membranous and proliferative nephropathy: treat as proliferative lupus nephritis

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49 TREATMENT: Depend on SEVERITY MILD - MODERATE - SEVERE

50 Skin / arthritis Pleural effusion MILD MODERATE SEVERE peritonism NEURO symptoms Pericardial effusion Pulmonary hemorrhage Mild LN Mod LN LN with renal failure -Leukopenia -AIHA without anemic symptom -AIHA with anemic symptom -plt 50, ,000 -plt 20,000-50,000 -plt < 20,000 -CQ -NSAIDs Treatment : Steroid at least 0.5 MKD High dose steroid endoxan

51 HEMATOLOGIC ABNORMALITIES WHEN TO TX?? duration response 1.LOW WBC : NO TX 2.PLT: 20-50K oral pred <20K => HIGH DOSE pred 3.AIHA : decrease from baseline within3-5day within 1-2 wk

52 dexamethasone 25 prednisolone 5 methylprednisolone 4 hydrocortisone 1 Order dose Prednisolone 0.5 MKD Prednisolone 1MKD High dose Equivalent with pred 30 mg =6 tab DEXA 5 MG IV Q 6hr 20 mg/day 100 mg Moderately high dose DEXA 10 MG IV Q 6hr 40 mg/day 200 mg 60 mg = 12 tab Pulse methylprednisolone 1g Very high dose 1,000 mg

53 HOW TO TAPERING STEROID 12 TAB 4*3 % change Q 2 wk. 10 5* * * *1 33 Q 1 mo. 4 4* * *1 33 Q 3 mo 1 1* *eod 50

54 CQ / HCQ : immunomodurators Anti inflammation Anti platelet, Antithrombotic Anti apoptosis Anti lipid Longer life span Taper off q 3 mo, because long half-life 1 OD hs -> 1 EOD(4TAB/WK) -> 1tab อ,พฤ (2TAB/WK) -> 1tab/wk (4tab/mo) -> 1 tab d1,16 (2 tab/mo)

55 Glucocoritcoid induce osteoporosis(giop) PROPHYLAXIS WHEN NEED? : IF planning PREDNISOLONE >5mg/d More than 3 MO Treat by? : ca, vit d

56 Calcium carbonate normal requirement about 1g /d ยา 1 g absorp ได 400 mg SO dose :1 tab bid Vitamin D Normal requirement about 800IU /d (normal liver and renal ให MTV if insufficiency ให 1α vit D ) MTV 1tab ม vit D 400IU, SO dose :1 tab bid

57 SLE and PREGNANCY * SHOULD NOT PREGNANCY IN CASE OF ACTIVE DISEASE CARDIO-PULMO-RENAL INSUFF HT * SAFE FOR PREG : DZ. REMISSION ABOUT 6 MO. W/WO ANTIMALARIAL (CAN CONTINUE ALONG PREGNANCY)

58 Lab for pregnancy planning 1.Neonatal lupus : anti RO (LESS anti LA) -> early FETAL ECHO at GA WK. 2.ANTIPHOSPHOLIPID syndrome ( increase risk fetal loss & post partum DVT ) LUPUS ANTICOAGULANT Anti CARDIOLIPIN IgG,IgM >40 Anti B2 GP 1

59 LAB ช ด SLE F/U CBC, ESR UA BUN, Cr CHOL, ALB, AST, ALT

60 Any Questions???