What is first line treatment for lupus?

Lupus is an autoimmune disease that can affect multiple organ systems in the body. It is characterized by chronic inflammation that can lead to tissue damage and organ dysfunction. There is no cure for lupus, so treatment focuses on controlling symptoms and minimizing flares. The main goals of treatment are to prevent organ damage, reduce pain and inflammation, and improve quality of life. The specific treatments used depends on the type and severity of symptoms.

First Line Medications

The most common medications used for first line treatment of lupus are antimalarials, corticosteroids, and nonsteroidal anti-inflammatory drugs (NSAIDs).


Antimalarials such as hydroxychloroquine and chloroquine have immunomodulatory effects, meaning they help regulate the overactive immune system in lupus. They are considered a cornerstone treatment for lupus as they can help control overall disease activity, prevent flares, protect organs from damage, and reduce the need for steroids. Side effects are generally mild and include stomach upset, headache, and rash. All patients with lupus should be on an antimalarial unless they cannot tolerate the medication.


Corticosteroids such as prednisone, methylprednisolone, and dexamethasone are very effective at quickly reducing inflammation and symptoms during a flare. Because of rapid action, they are often used to gain control when the disease is very active. Side effects depend on the dose and duration of treatment but may include weight gain, high blood pressure, bone loss, and increased risk of infection. The goal is to use the lowest dose necessary to control symptoms.


NSAIDs such as ibuprofen, naproxen, and celecoxib help relieve muscle aches, joint pain and swelling. They do not treat the underlying disease so are used mainly for symptom management. NSAIDs carry side effects like stomach irritation and increased risk of bleeding. They should be taken with food and avoided in those with certain conditions like kidney disease or ulcers.

Second Line Medications

If first line treatments are not sufficient to control active lupus, the following medications may be added:


Immunosuppressives like methotrexate, azathioprine, and mycophenolate mofetil dampen the overactive immune system. They may take several weeks to months to take effect. Blood monitoring is required to check for side effects like low blood counts. Immunosuppressives are often used with corticosteroids to allow lower steroid doses.


Biologic drugs like belimumab (Benlysta) reduce activity of certain immune cells. Belimumab is currently the only FDA approved biologic for lupus. It is used for lupus patients with ongoing disease activity despite standard therapies. Common side effects include nausea, diarrhea, and upper respiratory infections.

Calcineurin inhibitors

Calcineurin inhibitors like tacrolimus and cyclosporine inhibit certain immune cell functions. In lupus, they may be an option for lupus nephritis and certain skin manifestations. Side effects include high blood pressure, kidney problems, tremors, and increased risk of infections.

Treatment Considerations

When determining the best treatment approach, the doctor considers several factors:

  • Which organs and systems are affected
  • Severity of symptoms
  • Presence of complications like nephritis
  • Previous response to medications
  • Co-existing health conditions
  • Risk of side effects
  • Lifestyle factors and preferences

Treatment must be individualized to each patient. Medications may be changed over time if they are not providing adequate benefit or are causing troublesome side effects. Adding a second medication may allow lower doses of an individual drug. Frequent follow-up is necessary to monitor disease activity and adjust therapies accordingly.

Role of Physical Therapy and Exercise

Physical therapy and regular exercise are important components of lupus treatment. Physical therapists can help maintain strength, flexibility, and function. They also teach techniques for joint protection and pain management. Exercise helps counteract fatigue, prevents muscle atrophy, and improves cardiovascular health.

Low impact aerobic exercise such as walking, swimming, and cycling is recommended. yoga and Pilates can help improve muscle strength, balance, and relaxation. It is important to avoid overexertion and stay hydrated during physical activity. Use of braces, splints, or assistive devices may be beneficial.

Lifestyle Measures

Making healthy lifestyle choices is also imperative in lupus management. Key recommendations include:

  • Avoid sunlight exposure: Use broad spectrum sunscreen and protective clothing when outside. Exposure to UV light can trigger lupus flares.
  • Do not smoke: Smoking worsens lupus symptoms and increases risk of heart disease and blood clots.
  • Eat a balanced diet: Emphasize fruits, vegetables, whole grains, and lean protein. Limit processed foods, salt, and saturated fats.
  • Reduce stress: Make time for relaxing activities and get psychological help if needed. Stress can exacerbate lupus.
  • Get enough rest: Allow time for sleep and naps, especially during flares when fatigue increases.

Treatment for Lupus Flares

Lupus flares are periods of increased disease activity and worsening symptoms. They can occur periodically throughout the disease course. Flares are treated by:

  • Increasing corticosteroid dose to quickly dampen inflammation.
  • Adding or maximizing other immunosuppressive medications.
  • Avoiding triggers like sun exposure, stress, infections.
  • Getting extra rest and allowing time to recover.
  • Working closely with the healthcare team to modify treatment regimens.

Strong medication regimens are often instituted to induce remission of severe flares. As symptoms improve, medications can be gradually tapered to previous maintenance doses. Preventing flares and minimizing their severity is an important treatment goal.

Treatment for Specific Organ Involvement

Specific organ manifestations of lupus may require targeted therapies in addition to systemic treatments. Some examples include:

Lupus nephritis

Inflammation of the kidneys occurs in a significant portion of lupus patients. Immunosuppressives like cyclophosphamide and mycophenolate mofetil are commonly used to treat severe nephritis. Corticosteroids reduce inflammation. Blood pressure medications help protect the kidneys.

Lupus headache/neuropsychiatric lupus

Lupus can cause neurologic symptoms like headache, mood disorders, and cognitive dysfunction. High dose corticosteroids and immunosuppressives treat major neuropsychiatric manifestations. Migraine medications may help lupus headaches.

Skin manifestations

Skin issues like rashes and photosensitivity are common with lupus. Topical steroids, immunomodulators, and calcineurin inhibitors (tacrolimus) are used for skin disease. Diligent sun protection is a must.

Serositis – Inflammation of lining around lungs (pleuritis) or heart (pericarditis)

Nonsteroidal anti-inflammatories (NSAIDs), corticosteroids, immunosuppressives, and analgesics provide relief. Pericarditis may require drainage of fluid around heart.

Organ System Manifestations Treatment Approaches
Kidney Inflammation of kidneys (nephritis) Immunosuppressives, corticosteroids, blood pressure medications
Neurologic Headaches, cognitive dysfunction, mood disorders High dose corticosteroids, immunosuppressives, migraine medications
Skin Rashes, photosensitivity Topical steroids, immunomodulators, sun protection
Lung Inflammation of lung lining (pleuritis) NSAIDs, corticosteroids, immunosuppressives
Heart Inflammation of heart lining (pericarditis) NSAIDs, corticosteroids, immunosuppressives, pericardial drainage

Monitoring Treatment Effectiveness

Ongoing monitoring and follow-up are crucial when treating lupus. This allows assessment of how well medications are controlling the disease. Monitoring may involve:

  • Tracking symptoms in a journal to identify flares or side effects.
  • Regular physical exams to pick up problems early.
  • Repeat blood work to ensure cell counts or organ function remain stable.
  • Urine tests to monitor for kidney inflammation.
  • Imaging like x-rays or echocardiograms if certain organs are affected.

Results of monitoring allow medications to be adjusted. For example, doses may be reduced if blood work normalizes or increased if inflammation markers remain elevated. Reporting all new or concerning symptoms to the doctor is imperative.

Emerging Treatments for Lupus

Researchers are investigating new therapeutic approaches to better treat lupus and improve quality of life. Some emerging treatments showing promise in studies include:

New Biologics

New biologic drugs are being developed that target specific parts of the immune system, such as B cells and interferon pathways. Examples are anifrolumab, ustekinumab, and rituximab.

JAK Inhibitors

Janus kinase (JAK) inhibitors such as baricitinib disrupt certain chemical messengers involved in inflammation. Early research indicates they may be beneficial in lupus.

Anti-Platelet Agents

Platelets play a role in inflammation and tissue damage in lupus. Medications like anti-CD40L antibodies (ruplizumab) help modulate platelet function and vascular damage.

Autologous Stem Cell Transplant

In stem cell transplants, a patient’s own blood stem cells are infused back into the body to regrow the immune system. Small studies show this approach induces lengthy lupus remission in some people.

More clinical trials are underway to evaluate long term efficacy and safety of emerging lupus therapies. While current treatments focus mainly on controlling symptoms, future advances may allow a greater chance at sustained remission.

Role of the Interdisciplinary Care Team

Successfully managing moderate to severe lupus requires an interdisciplinary care team. Key members may include:

  • Rheumatologist: Leads treatment and monitors disease activity.
  • Primary care provider: Oversees preventive care and co-existing conditions.
  • Nephrologist: Helps care for kidney disease if present.
  • Dermatologist: Treats severe skin manifestations.
  • Neurologist: Addresses neurologic symptoms.
  • Psychiatrist/psychologist: Manages mood disorders and cognitive dysfunction.
  • Ophthalmologist: Monitors for retina damage from steroids.
  • Physical/occupational therapist: Improves strength, functioning and teaches joint protection.

Open communication between providers ensures the best care. The team will also include nurses, pharmacists, social workers, and dietitians. Support groups and online resources provide additional help in living with lupus.


While a complex condition, lupus can be successfully managed with a comprehensive treatment approach. Foundations of therapy include antimalarials, corticosteroids, and immunosuppressives tailored to each patient’s needs. Participating in physical therapy, making healthy lifestyle modifications, and monitoring disease activity also play key roles. Emerging research brings hope for more targeted medications with fewer side effects. A coordinated care team provides optimal support for lupus patients dealing with this life-long condition.

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