[Immunosuppressive and immunomodulator treatment of severe systemic lupus]

Immunosuppressor and immunomodulator therapies are widely used for the treatment of patients with severe systemic lupus erythematosus. In case of certain organ involvement (kidney, brain, heart), corticosteroids should be associated with immunosuppressors, especially cyclophosphamide. Cyclophosphamide, a powerful immunosuppressor, is generally given in an intravenous bolus rather than orally. Aziathioprine is proposed after cyclophosphamide or in less forms at onset. The therapeutic strategy in severe forms may require plasma exchange, carefully synchronized with the cyclophosphamide bolus. Depleted antibodies following plasma exchange induces a stimulation of B clones which produce antibodies sensitive to cyclophosphamide. Other immunomodulator treatments have also been used, for example cyclosporine or intravenous immunoglobulins. Cyclosporine has not been shown to be effective in severe lupus. Inversely, in certain conditions, cyclosporine can be used to limit other treatments although it does not have a significant effect on autoantibody levels. Intravenous immunoglobulins have been used at high dosages but only in selected cases due to undesirable side effects. Certain cases of renal failure induced by immunoglobulins have been described. Immunosuppressor or immunomodulator therapy is often required in systemic lupus erythematosus. Treatment modalities must however be carefully established in order to limit the predictable side effects while achieving maximal efficacy.