Treatment. Disease-modifying therapies.

Many patients with systemic lupus can be treated effectively with antimalarials and nonsteroidal anti-inflammatory drugs without ever having to take systemic corticosteroids at all or for any significant length of time. On the other hand, some patients with life-threatening disease, active major organ disease, or intolerable corticosteroid toxicities should be given immunosuppressive drugs, plasmapheresis, and/or other therapies in addition to corticosteroids early in their disease course, before permanent, end-organ damage occurs and before the predictable serious and debilitating toxicities of prolonged, daily high-dose corticosteroids develop. Just as lupus patients now routinely undergo detailed serologic testing, it is conceivable that, in the future, routine determination of human leukocyte antigen (HLA) haplotypes45 and T-cell subsets88a will help define, at disease onset, those patients who are destined to have severe disease. Perhaps this knowledge, combined with a better understanding of the exact mechanisms of action of these disease-modifying therapies, will allow a more rational approach to the treatment of SLE.