Central nervous system lupus: a clinical approach to therapy

• Published in: Lupus 2003-01, Vol.12 (12), p.935-942
• Main Authors: Sanna, G, Bertolaccini, M L, Mathieu, A
• Format: Article
• Language: English
• Subjects: Adrenal Cortex Hormones - administration & dosage; Anticoagulants; Combined Modality Therapy; Drug Therapy, Combination; Female; Humans; Immunoglobulins, Intravenous - analysis; Immunosuppressive Agents - administration & dosage; Infections; Lupus; Lupus Vasculitis, Central Nervous System - diagnosis; Lupus Vasculitis, Central Nervous System - mortality; Lupus Vasculitis, Central Nervous System - therapy; Male; Methotrexate - administration & dosage; Nervous system; Patients; Plasmapheresis - methods; Prognosis; Rheumatology; Risk Assessment; Severity of Illness Index; Survival Analysis; Treatment Outcome
• ISSN: 0961-2033; 1477-0962
• DOI: 10.1191/0961203303lu505oa

Management of central nervous system (CNS) involvement still remains one of the most challenging problems in systemic lupus erythematosus (SLE). The best available evidence for the treatment of CNS lupus is largely based on retrospectiveseries, case reports and expert opinion. Current therapy is empirical and tailored to the individual patient. Symptomatic, immunosuppressiveand anticoagulant therapies are the main strategies for the management of CNS lupus. The choice depends on the most probable underlying pathogenic mechanism and the severity of the presenting neuropsychiatric symptoms. Thrombotic and nonthrombotic CNS disease needs to be differentiated and requires different management strategies. However, this is often challenging since many, if not most CNS manifestations, may be due to a combination of different pathogenic mechanisms and multiple CNS events may occur in the individual patient. Patients with mild manifestations may need symptomatic treatment only, whereas more severe acute nonthrombotic CNS manifestations may require pulse intravenouscyclophosphamide.Plasmapheresismay also be added in patients with more severe illness refractory to conventionaltreatment. Recently, the use of intrathecalmethotrexateand dexamethasone has been reported in a small series of patients, with a good outcome in patients with severe CNS manifestations.Anticoagulationis warranted in patients with thrombotic disease, particularlyin those with the antiphospholipid syndrome (APS). This article reviews the clinical approach to therapy in patients with CNS lupus.