Clinical Practice Points
Current recommendations regarding pregnancy in women with systemic lupus erythematosus
(SLE) are based on limited data. In this large multicenter study that enrolled a multiethnic
cohort of women with inactive or stable mild/moderate SLE during the first trimester,
most pregnancies were uncomplicated, and fewer than 3% of women had severe SLE flares.
Use this study to:
- Start a teaching session with a multiple-choice question. We've provided one below!
- Generate a list of potential lupus-related complications of pregnancy with your learners.
Use the information in DynaMed Plus: Lupus in Pregnancy (a benefit of your ACP membership).
- Ask your learners how the results of this study can be helpful in counseling women
with SLE about pregnancy. The accompanying editorial provides useful advice. Consider inviting a high-risk obstetrician to join your
- Review the commonly used drugs for the management of SLE and determine whether each
is safe in pregnancy. Review the FDA pregnancy categories for drugs.
This study focused on the number of cardiac catheterizations that did not result in
revascularization within 1 year and found no significant difference between coronary
computed tomography angiography and radionuclide stress myocardial perfusion imaging
for the evaluation of patients presenting with acute chest pain.
Use this study to:
- Review the diagnostic algorithm for patients presenting with acute chest pain. How
do your learners decide which of their patients require coronary angiography?
- Ask your learners why the authors chose to assess the number of catheterizations that
did not result in revascularization as this trial's primary end point, and why they
chose to assess it at 1 year. The authors explain the rationale in the first paragraph
of the “Outcomes and Follow-up” section in the Methods. Do your learners
think this is a useful end point?
- Ask a radiologist to show your team the results of a positive computed tomography
angiogram. Visit your nuclear medicine department and review the results of radionuclide
myocardial perfusion scans.
This study of motor vehicle crash fatalities between 2001 and 2010 found that primary
seat belt laws (citations can be issued to vehicle occupants for not wearing seat
belts) were associated with lower fatality rates than secondary laws (citations can
be issued only within the context of other traffic violations).
Use this study to:
- Ask your learners if they ask their patients about seat belt use (in the back seat
as well as the front seat). Should we be asking these questions? Do your learners
make “buckling up” a rule in their own cars? Do they enforce it? Ask
if they are comfortable telling others to buckle up if they do not.
- The accompanying editorial notes that preventing motor vehicle injuries has been identified by the CDC as one of
7 “winnable battles.” Look at the full list with your team.
- Assign each member of your team to review the CDC's information about a different
winnable battle. Have each tell the rest of the team about the issue and if there
are things we can do in our practices to help win the battle.
A 22-year-old woman seeks preconception counseling and treatment of recently diagnosed
systemic lupus erythematosus. She reports fatigue and hand pain accompanied by morning
stiffness lasting 15 minutes.
On physical examination, vital signs are normal. Malar erythema is noted. There is
tenderness of the proximal interphalangeal joints bilaterally; no other synovitis
is present. Recent ophthalmologic examination findings, including visual fields, are
|| 3300/µL (3.3 × 10^9/L), with an absolute lymphocyte count of 1200/µL (1.2 × 10^9/L)
|| Titer of 1:160 (homogeneous pattern)
|Anti–double-stranded DNA antibodies
|IgG-specific anticardiolipin antibodies
Which of the following is the most appropriate treatment?
C. Mycophenolate mofetil
E. No treatment at this time
Although hydroxychloroquine is a pregnancy category C medication, this agent is relatively
safe in pregnancy and can reduce lupus flares without harm to the fetus.
Manage systemic lupus erythematosus in a patient considering pregnancy.
Treatment with hydroxychloroquine is indicated for this patient with systemic lupus
erythematosus (SLE). Although hydroxychloroquine has been used anecdotally for many
years in patients with SLE, numerous recent studies document significant benefits
of this agent. High levels of evidence show that hydroxychloroquine prevents lupus
flares and increases survival in patients with SLE; there also is moderate evidence
suggesting protection against irreversible organ damage, thrombosis, and bone mass
loss. Hydroxychloroquine should be continued indefinitely to prevent disease reactivation,
even if the disease has been quiescent for many years. This patient has mild SLE without
evidence of significant internal organ involvement; she is also trying to conceive,
which further impacts choice of medication. Although hydroxychloroquine is a pregnancy
category C medication, expert consensus states that this agent is relatively safe
in pregnancy, and studies support a reduction in flares without harm to the fetus.
Given the demonstrated benefits of hydroxychloroquine in patients with SLE, which
are suggested to be time-dependent, it is appropriate to treat this patient at this
time, unless the patient refuses or has a contraindication to therapy. Pregnancy outcomes
in patients with SLE are better in the absence of active disease, and patients should
be counseled to wait to try to conceive until they have had quiescent disease for
a minimum of 6 months.
Azathioprine and mycophenolate mofetil have a steroid-sparing effect and have been
shown to improve outcomes in patients with severe SLE, particularly those with kidney
involvement. Azathioprine, but not mycophenolate mofetil, is generally considered
the most acceptable of these agents for use during pregnancy, despite its pregnancy
category D rating. This patient does not have severe disease and is not currently
taking corticosteroids; therefore, treatment with these medications is not indicated.
This patient is stable with minimal disease activity, both clinically and serologically;
therefore, there is no indication for treatment with prednisone unless her symptoms
worsen. Prednisone, when necessary, is considered relatively safe for use in pregnancy;
about two thirds of the active drug is metabolized by placental enzymes to an inactive
form, limiting the amount of fetal exposure.
Ruiz-Irastorza G, Ramos-Casals M, Brito-Zeron P, Khamashta MA. Clinical efficacy and
side effects of antimalarials in systemic lupus erythematosus: a systematic review.
Ann Rheum Dis. 2010;69(1):20-28. PMID: 19103632
This question was derived from MKSAP® 16, the latest edition of the Medical Knowledge Self-Assessment Program.