Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.
A 30-year-old woman is evaluated during a follow-up visit for systemic lupus erythematosus. She was diagnosed 3 months ago after presenting with pericarditis and arthritis. She was initially treated with prednisone, 40 mg/d, with improvement of her presenting symptoms. The prednisone has been tapered over 3 months to her current dose of 10 mg/d with no recurrence. She also takes vitamin D and a calcium supplement.
On physical examination, vital signs are normal. BMI is 25. Cardiac examination is normal. There is no evidence of arthritis. The remainder of the examination is normal.
Which of the following is the most appropriate next step in treating this patient?
A. Add azathioprine
B. Add hydroxychloroquine
C. Add mycophenolate mofetil
D. Add a scheduled NSAID
MKSAP Answer and Critique
The correct answer is B. Add hydroxychloroquine.
Hydroxychloroquine is an appropriate agent to address milder systemic manifestations of systemic lupus erythematosus (SLE) such as arthritis and pericarditis, and it can act as a glucocorticoid-sparing agent. All patients with SLE who can tolerate it should be taking hydroxychloroquine. Antimalarial therapy such as hydroxychloroquine in SLE has documented benefit for reducing disease activity, improving survival, and reducing the risk of SLE-related thrombosis and myocardial infarction.
Azathioprine is generally reserved for more severe manifestations of SLE not responsive to low-dose prednisone and hydroxychloroquine but can be associated with serious toxicity. Azathioprine has generally been supplanted by the use of mycophenolate mofetil in SLE.
Mycophenolate mofetil may be appropriate for this patient if she had more serious disease activity such as nephritis or if her arthritis or pericarditis recurred while taking hydroxychloroquine.
NSAIDs, often with colchicine, are first-line therapy for most patients with pericarditis, although glucocorticoids may be indicated in patients with pericarditis associated with a systemic inflammatory disease such as in this patient. However, there is no indication to start an NSAID now given resolution of her symptoms, and doing so would increase her risk of gastrointestinal complications if used along with her daily glucocorticoid.
Key Point
- Antimalarial therapy such as hydroxychloroquine in systemic lupus erythematosus (SLE) has documented benefit for reducing disease activity, improving survival, and reducing the risk of SLE-related thrombosis and myocardial infarction.
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