Timing of immunosuppression in the natural history of autoimmune diseases

We have insufficient data to guide us to the optimal timing of immunosuppression in the natural history of any autoimmune disease. Moreover, there are differences among the many autoimmune diseases and the many drugs available for use. Nevertheless, certain principles have emerged. Prophylactic non-specific immunosuppression prior to the onset of the immune-mediated process often is of minimal benefit. Vigorous immunosuppression shortly after the onset of the immune-mediated process is most effective; many agents are of benefit at such times. If the disease has progressed to substantial clinical involvement, certain drugs previously useful may no longer be effective. At such a time of moderately advanced clinical involvement, only selected agents may suppress the disease. With substantial loss of function of irreplaceable organs, or parts thereof, immunosuppression becomes progressively less effective. Such drugs can interfere with inflammatory processes, but are of little benefit after deletion of cells or scarring of an organ. Therefore, to have any benefit, immunosuppression must be instituted prior to the time of irreversible loss of critical organs or parts thereof.