Systemic lupus erythematosus (SLE) is a chronic, inflammatory autoimmune collagen disease that affects nearly every organ in the body. It occurs 6 to 10 times more frequently in women than in men and occurs three times more in African American populations than among Caucasians. SLE results from disturbed immune regulation that causes an exaggerated production of autoantibodies.
This disturbance is brought about by some combination of genetic, hormonal (as evidenced by the usual onset during the childbearing years), and environmental factors (exposure to a virus, sunlight, stress, or diet). Certain medications, such as hydralazine (Apresoline), procainamide (Pronestyl), isoniazid or INH (Nydrazid), chlorpromazine (Thorazine), and some anticonvulsant medications, have been implicated in chemical or drug-induced SLE. Specifically, B cells and T cells both contribute to the immune response in SLE. B cells are instrumental in promoting the onset and flares of the disease.
Onset is insidious or acute. SLE can go undiagnosed for many years. The clinical course is one of exacerbations and remissions.
- Systemic symptoms include fever, fatigue, weight loss and, possibly, arthritis and pleurisy.
- Musculoskeletal system: Arthralgias and arthritis (synovitis) are common presenting features; joint swelling, tenderness, and pain on movement are common, accompanied by morning stiffness.
- Integumentary system: Several different types are seen (e.g., subacute cutaneous lupus erythematosus [SCLE], discoid lupus erythematosus [DLE]). A butterfly rash across the bridge of the nose and cheeks occurs in more than half of patients and may be a precursor to systemic involvement. Lesions worsen during exacerbations (flares) and may be provoked by sunlight or artificial ultraviolet light. Oral ulcers may involve buccal mucosa or hard palate; papular, erythematous, and purpuric lesions may occur on fingertips, elbows, toes, and extensor surfaces of forearms (or on lateral sides of the hands) and may progress to necrosis.
- Cardiovascular system: Pericarditis is the most common clinical cardiac manifestation. Women who have SLE are also at risk for early atherosclerosis.
- Renal system: Nephritis, referred to as lupus nephritis, occurs; high serum creatinine levels and hypertension are seen.
- Neurologic: Neuropsychiatric presentations are varied and frequent and generally are demonstrated by subtle changes in behavior or cognitive ability.
Diagnosis is based on a complete history, physical examination, and blood tests. No single laboratory test confirms SLE. Blood testing reveals moderate to severe anemia, thrombocytopenia, leukocytosis, or leukopenia and positive antinuclear antibodies. Other diagnostic immunologic tests support, but do not confirm, the diagnosis. Inspect the skin for erythematous rash, hyperpigmentation, or depigmentation. Auscultate for pericardial friction rub and assess for abnormal lung sounds. The antinuclear antibody (ANA) test is positive in more than 95% of patients with SLE.
Treatment includes management of acute and chronic disease. Goals of treatment include preventing progressive loss of organ function, reducing the likelihood of acute disease, minimizing disease-related disabilities, and preventing complications from therapy. Monitoring is performed to assess disease activity and therapeutic effectiveness.
Pharmacologic Therapy
- Nonsteroidal anti-inflammatory drugs (NSAIDs) are used with corticosteroid agents to minimize corticosteroid requirements.
- Corticosteroid medications are used topically for cutaneous manifestations.
- IV administration of corticosteroid drugs is an alternative to traditional high-dose oral use.
- Cutaneous, musculoskeletal, and mild systemic features of SLE are managed with antimalarial drugs.
- Immunosuppressive agents are generally reserved for the most serious forms of SLE that have not responded to conservative therapies.
- Belimumab (Benlysta), a human antibody that specifically recognizes and binds to B-lymphocyte stimulator, is given to reduce disease activity and flares.
The nursing care of the patient with SLE is generally the same as that for the patient with rheumatic disease (see “Nursing Management” under Arthritis, Rheumatoid). The primary nursing diagnoses address fatigue, impaired skin integrity, disturbed body image, and deficient knowledge.
- Be sensitive to the psychological reactions of the patient due to the changes and the unpredictable course of SLE; encourage participation in support groups, which can provide disease information, daily management tips, and social support.
- Educate patient to avoid sun and ultraviolet light exposure and to use sunscreen or protective clothing.
- Because of the increased risk of involvement of multiple organ systems, educate patients about the importance of routine periodic screenings and health promotion activities.
- Refer to dietitian if necessary.
- Educate patient about the importance of continuing prescribed medications, and address the changes and potential side effects that are likely to occur with their use.
- Remind the patient of the importance of monitoring because of the increased risk of systemic involvement, including renal and cardiovascular effects.
For more information, see Chapter 38 in Hinkle, J. L., & Cheever, K. H. (2018). Brunner and Suddarth's textbook of medical-surgical nursing(14th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.