Treatments
As with all chronic diseases, the treatment of systemic lupus erythematosus (SLE) must be a balanced consideration of multiple disease-related and patient-specific aspects. SLE is associated with symptomatology and may also engender significant functional
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Treatments 5.1 Goals of treatment and treatment strategies As with all chronic diseases, the treatment of systemic lupus erythematosus (SLE) must be a balanced consideration of multiple disease-related and patient-specific aspects. SLE is associated with symptomatology and may also engender significant functional impairment and restrictions of activities. SLE also has the potential to cause severe and irreversible damage in the affected organs and tissues, and preventing such damage must be an important consideration as well. From these disease characteristics follow the treatment goals for SLE. First, the patient’s symptomatic suffering must be alleviated. Patients generally see this as the most obvious and clear goal of the treatment and will seek medical care primarily to obtain such relief. However, the very important second goal must be to prevent, as much as possible, the accumulation of damage caused by the disease or by its treatment. These two goals are not always aligned. Simple analgesics and non-steroidal anti-inflammatory drugs (NSAIDs) may provide some symptomatic relief but there is no evidence that they prevent any damage. Thus, the approach to SLE must always be based on multiple goals and this can be regarded as part of the more extensive framework articulated by Fries [1] who identified the five dimensions of treating chronic illnesses as the ‘five D’s’: • death: preventing mortality • discomfort: relieving symptoms • disability: preventing functional decline • drug side effects: minimizing toxicities due to the treatment • dollar cost: finding an appropriate health-economic balance © Springer International Publishing Switzerland 2018 L. Arnaud and R. van Vollenhoven, Advanced Handbook of Systemic Lupus Erythematosus, https://doi.org/10.1007/978-3-319-43035-5_5
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86 • ADVA N C E D H A ND B O O K O F S YS T E M IC LU P U S E RY T H E MATO S U S
In the case of SLE, mortality that is directly attributable to the disease is uncommon but remains a concern in patients with the most severe forms of the disease. In addition to mortality caused by the disease itself, the treatments given to combat it may contribute to short-term mortality (for example, immunosuppression leading to fatal infections) and long-term morbidity (for example, treatments that accelerate arteriosclerosis), and more effective therapies used in a judicious manner might therefore improve outcomes. In addition to the goals of limiting discomfort and disability the therapeutic discussions around SLE are frequently dominated by considerations of risks from the treatments. This is most clearly the case for corticosteroids. These medications, which will be discussed in more detail below, can be highly effective but are often associated with significant adverse health consequences, posing major challenges to the clinician. The final consideration is one of costs. In the treatment of SLE, older established medications such as corticosteroids are very inexpensive but newer approved biologic agents (belimumab) or unapproved but plausible
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