2007-07-04 00:00 来源:丁香园 作者:西门吹血
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  Systemic Lupus Erythematosus (SLE)

  With the incidence of systemic lupus erythematosus (SLE) increasing, anesthesiologists are more likely to be exposed to patients with the disease. Next weeks we'll be discussing various aspects of SLE, and This week, we'll be discussing the treatment of SLE.

  1.  What is the basic treatment regimen for SLE?
  2.  Given the effectiveness of corticosteroids in the treatment of SLE inflammation, why should they not be used continuously?
  3.  Can thalidomide play a role in the treatment of SLE?








  有症状的冠心病(RR 1.7,95% CI 1.1,2.5),及
  白内障(RR 1.9,95% CI 1.4,2.5)

  此外,每两月接受大剂量强的松治疗的患者,其发生无血管性坏死(95% CI 1.1,1.4)和中风(95% CI 1.0,1.5)的几率增加1.2倍。需要更进一步的研究以判断SLE疾患的相对影响,以及皮质激素器官特定损害的作用机制。新的控制性(节制)激素疗法用于治疗活动性SLE,从而最大程度的降低强的松的累积性和大剂量性损害。



  What is the basic treatment regimen for SLE?

  Regular medical evaluations to monitor SLE are vital for a good prognosis, as this allows for the tailoring of drug regimens. For mild joint inflammation, nonsteroidal anti-inflammatory medications are appropriate, and with progression towards generalized systemic inflammation, judicious use of corticosteroids are often the mainstay of therapy (1). Anti-malarials such as hydroxychloroquine reduce SLE activity and are helpful for moderate skin and joints symptoms. With severe SLE symptoms, stronger immunosuppressive drugs such as azathioprine and cyclophosphamide can be utilized. Even with severe disease, SLE is known for its periodic remissions, so tapering and/or discontinuing of medications can occasionally be considered (1).

  Given the effectiveness of corticosteroids in the treatment of SLE inflammation, why should they not be used continuously?

  Despite their dramatic reduction of symptoms and occasional ability to achieve clinical remission, corticosteroids should be avoided on a continuous basis due to the potential for permanent organ damage. Zonana-Nacach et al. (2), evaluated the occurrence of organ damage using the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index. The authors noted that the risk of organ damage for a cumulative prednisone reference dose of 36.5 gm (e.g., 10 mg of prednisone daily for 10 years) was significantly associated with the development of:

  •  osteoporotic fractures (relative risk [RR] 2.5, 95% confidence interval [95% CI] 1.7, 3.7),
  •  symptomatic coronary artery disease (RR 1.7, 95% CI 1.1, 2.5), and
  •  cataracts (RR 1.9, 95% CI 1.4, 2.5).

  Moreover, each 2-month exposure to high-dose prednisone was associated with a 1.2-fold increase in the risk of both avascular necrosis (95% CI 1.1, 1.4) and stroke (95% CI 1.0, 1.5). Additional research is required to determine the relative contributions of SLE disease activity and corticosteroids to the pathogenesis of specific types of organ damage. New steroid-sparing therapies are being developed (to be discussed in tomorrow's Answerpage) to treat disease activity and minimize cumulative and high-dose prednisone exposure.

  Can thalidomide play a role in the treatment of SLE?

  The teratogenicity and significant neuropathy associated with thalidomide has limited its use. However, thalidomide appears to be an effective treatment for the cutaneous forms of lupus erythematosus refractory to other therapies. Although recurrence after discontinuation of treatment frequently occurs, moderate doses are effective in slowing and sometimes reversing the progress of the disease. Currently, the mechanism by which thalidomide exercises its effects remains unclear. As the potential for severe thalidomide side effects is known, identification of suitable patients and the use of reliable contraceptive measures are strictly observed. Close clinical and neurophysiological supervision using nerve conduction studies has been recommended.


  1.  http://www.rheumatology.org/patients/factsheet/sle.html
  2.  Zonana-Nacach A, Barr SG, Magder LS, Petri M. Damage in systemic lupus erythematosus and its association with corticosteroids. Arthritis Rheum. 2000 Aug;43(8):1801-8.
  3.  Karim MY, Ruiz-Irastorza G, Khamashta MA, Hughes GR. Update on therapy--thalidomide in the treatment of lupus. Lupus 2001;10(3):188-92


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