Optimizing the use of existing therapies in lupus

Int J Rheum Dis. 2015 Feb;18(2):129-37. doi: 10.1111/1756-185X.12551.


The management of systemic lupus erythematosus (SLE) is complicated by heterogeneous clinical presentations, a lack of universally accepted tools for the measurement of disease activity and a lack of powerful, safe, specific targeted therapies. Current medical treatment of disease activity relies on glucocorticoids as well as agents including hydroxychloroquine (HCQ), mycophenolate mofetil (MMF) azathioprine (AZA), and less frequently cyclophosphamide. These agents are generally used in fixed, weight-based dosing regimens, and both incomplete response and adverse effects are common. An emerging literature in SLE and other inflammatory diseases in which these drugs are used suggests that improved patient outcomes could be achieved through a different approach to their use. Measurement of drug or metabolite concentrations has been shown in a number of studies to identify under- and over-dosing, predict efficacy and detect non-adherence to therapy, with positive associations between optimum drug or metabolite levels and improved outcomes. In this paper, we will review the literature regarding the measurement of HCQ, MMF, AZA and cyclophosphamide drug and metabolite levels in SLE and inflammatory disease, and make recommendations for future research that could facilitate improved outcomes for patients with SLE.

Keywords: azathioprine; drug treatment; erythematous; hydroxychloroquine; mycophenolate; systemic lupus; systemic lupus erythematous.

Publication types

  • Review

MeSH terms

  • Antimetabolites, Antineoplastic / therapeutic use*
  • Azathioprine / therapeutic use
  • Cohort Studies
  • Cyclophosphamide / therapeutic use
  • Dose-Response Relationship, Drug
  • Drug Therapy, Combination
  • Female
  • Humans
  • Hydroxychloroquine / therapeutic use
  • Immunosuppressive Agents / pharmacology
  • Immunosuppressive Agents / therapeutic use*
  • Long-Term Care
  • Lupus Erythematosus, Systemic / diagnosis*
  • Lupus Erythematosus, Systemic / drug therapy*
  • Lupus Erythematosus, Systemic / mortality
  • Male
  • Mycophenolic Acid / analogs & derivatives
  • Mycophenolic Acid / therapeutic use
  • Prognosis
  • Prospective Studies
  • Risk Assessment
  • Severity of Illness Index
  • Survival Rate
  • Treatment Outcome


  • Antimetabolites, Antineoplastic
  • Immunosuppressive Agents
  • Hydroxychloroquine
  • Cyclophosphamide
  • Mycophenolic Acid
  • Azathioprine