gm/24 hours)] - 32세 여자

Arthritis Care Res. 2012;64:797

• The first-line treatment for patients with mild SLE

• Effective in the treatment of mild SLE manifestations, as well as in preventing the occurrence of new mild SLE

manifestations, but it is ineffective in preventing the occurrence of severe SLE manifestations

• Inhibit phagosome function, thereby inhibiting Toll-like

receptor (TLR) activation, leading to a downregulation of IFN-α and decreasing the antigen processing necessary for

autoantigen presentation

• SE: Retinal damage, agranulocytosis, aplastic anemia, ataxia,

cardiomyopathy, dizziness, myopathy, ototoxicity, peripheral

neuropathy, pigmentation of skin, seizures, thrombocytopenia

• The mainstay of treatment in patients with SLE, especially at the beginning of a flare

• Strong antiinflammatory effects on both acquired and innate immune pathways

• 0.5–1 mg/kg per day for severe SLE

• 0.07–0.3 mg/kg per day or qod for milder disease

• SE: Infection, VZV infection, hypertension, hyperglycemia, hypokalemia, acne, allergic reactions, anxiety, aseptic

necrosis of bone, cushingoid changes, CHF, fragile skin, insomnia, menstrual irregularities, mood swings,

osteoporosis, psychosis

• Useful analgesics/anti-inflammatories, particularly for arthritis/arthralgias

• Higher incidence of aseptic meningitis, transaminitis, decreased renal function, vasculitis of skin; entire class, especially COX-2-specific inhibitors, may increase risk for myocardial infarction

• Pulse cyclophosphamide defined the standard of care for lupus nephritis for many years

• 7–25 mg/kg q month x 6; consider mesna administration with dose

• NIH protocol versus low dose(mini-pulse) (500mg fixed q 2wks x 6): no difference in efficacy

• SE: Infection, VZV infection, bone marrow

suppression, leukopenia, anemia, thrombocytopenia, hemorrhagic cystitis (less with IV), carcinoma of the bladder, alopecia, nausea, diarrhea, malaise,

malignancy, ovarian and testicular failure

• The prodrug of mycophenolic acid, an inhibitor of inosine monophosphate

dehydrogenase; enzyme controls the de novo synthesis of guanosine nucleotides, a step essential for DNA synthesis in lymphocytes.

• An inhibitor of purine synthesis and blocks the proliferation of activated T and B lymphocytes

• Results of a large multinational trial examining the efficacyof MMF compared with that of intravenous cyclophosphamideover 6 months as induction therapy and either MMF orazathioprine as maintenance therapy in patients with lupus nephritis for 36 months : comparable in the MMF and cyclophosphamide groups. Moreover, no safety

advantage was shown forMMFduring the induction phase. In contrast, the

maintenance phase demonstrated a clear advantage of MMF over azathioprine.

• As effective as CYC and tended to have a better safety profile as an induction

• therapy for LN than CYC

• Infection, leukopenia, anemia, thrombocytopenia, lymphoma, lymphoproliferative disorders, malignancy, alopecia, cough, diarrhea, fever, GI symptoms, headache, hypertension, hypercholesterolemia, hypokalemia, insomnia, peripheral edema, transaminitis, tremor, rash



6개월 cyclophosphamide (NIH protocol) 치료 후에도 proteinuria 지속되어 MMF로 6개월 치료하였으나 호전되지 않고

creatinine이 상승한다면 다음에 고려해야 할 것은?

March 9, 2011

• Belimumab is the first drug licensed for use in SLE in ≥ 50 years.

• For SLE patients with refractory/life threatening disease

• Biologically agents will be increasingly used in the near future and will have a significant impact on the management of SLE patients

 자연유산 경험이 2회 (15주, 22주) 있었던 30세 여자가 임신 20주에 산부인과에서 의뢰되었다.

 백혈구 3,200/mm³, 헤모글로빈 10.4g/dL, 혈소판 60,000/mm³,

 항핵항체 1:1280 양성, 항이중가닥 DNA 항체 양성,

 프로트롬빈시간 (PT) 98%,

 활성부분 트롬보플라스틴 시간(aPTT) 43초,

 lupus anticoagulant (+),

 anticardiolipin antibody (+)

① Low dose steroid (5-10mg/day)

② Low-dose aspirin

③ Prophylactic heparin + low-dose aspirin

④ Warfarin

⑤ Hydroxychloroquine

J Thromb Haemost 2006;4:295

Definite APS is present if at least one of the clinical criteria and one of the labor atory criteria are met

Clinical Criteria

Vascular thrombosis One or more clinical episodes of arterial, venous, or small vessel thrombosis in any tissue or organ

Pregnancy morbidity

One or more unexplained deaths of a morphologically normal fetus at or beyond the 10th wk of gestation, or

One or more premature births of a morphologically normal neonate before the 34th wk of gestation because of eclampsia, severe preeclampsia, or recognized features of placental ins ufficiency or

Three or more unexplained consecutive spontaneous abortions before the 10th wk of gestat ion, with maternal anatomic or hormonal abnormalities and paternal and maternal chromos omal causes excluded

Laboratory Criteria

Lupus anticoagulant present in plasma on two or more occasions at least 12 wk apart, detected according to the guideline s of the International Society on Thrombosis and Hemostasis

Anticardiolipin antibody of immunoglobulin (Ig)G or IgM isotype in serum or plasma, present in medium or high titer (>40 GPL or MPL, or >99th percentile), on two or more occasions at least 12 wk apart, measured by a standardized ELISA

Anti–β₂-glycoprotein I antibody of IgG or IgM isotype in serum or plasma (in titer >99th percentile) present on two or mo re occasions at least 12 wk apart, measured by a standardized ELISA

Kelley's Textbook of Rheumatology, 9th ed.

Clinical Circumstance Recommendation

Asymptomatic No treatment*

Venous thrombosis Warfarin INR 2.5 indefinitely

Arterial thrombosis Warfarin INR 2.5 indefinitely

Recurrent thrombosis Warfarin INR 3-4 ± low-dose aspirin

Pregnancy:

•First pregnancy No treatment

•Single pregnancy loss at <10 wk No treatment

•≥1 Fetal or ≥3 (pre)-embryonic losses, no

thrombosis Prophylactic heparin + low-dose aspirin throughout pregnan cy, discontinue 6-12 wk postpartum

•Thrombosis regardless of pregnancy histor

y Therapeutic heparinor low-dose aspirin throughout pregnan

cy, warfarin postpartum

Valve nodules or deformity No known effective treatment; full anticoagulation if emboli or intracardiac thrombi demonstrated

Thrombocytopenia >50,000/mm³ No treatment

Thrombocytopenia <50,000/mm³ Prednisone, IVIG

Catastrophic antiphospholipid syndrome Anticoagulation + corticosteroids + IVIG or plasmapheresis

문서에서 32세 여자 (페이지 35-51)