Treatment of systemic lupus erythematosus in 2006

After many barren years, conceptual advances and the introduction of new biotherapies are yielding improvements in the management of systemic lupus erythematosus (SLE). The result is a radical change in the management strategy. The main therapeutic advances rest on new discoveries (or rediscoveries), some of which are original. They can be summarized under 12 headlines. - Smoking is inadvisable, as it promotes not only atheroma but also lupus flares. - Hydroxychloroquine and conventional drugs (cyclophosphamide) are helpful provided they are used appropriately. - Combined oral contraception and hormone replacement therapy may be less hazardous than previously thought, although caution remains in order. - - Drugs used in transplant recipients, such as mycophenolic acid, are generating optimism as treatments for SLE. - Rituximab and new anti-B-cell drugs hold promise for the treatment of severe SLE. - Efforts to develop an "etiologic" treatment for SLE based on type 1 (alpha/beta) interferon blockade still face a number of obstacles. - Peptide vaccines, whose main effect is stimulation of regulator T cells, hold promise-but confirmation is needed. - Whether TNF antagonists can be used in lupus with skin and joint manifestations or in SLE is generating debate. - Complement blockade for treating SLE and anti phospho lipid syndrome is an attractive avenue of research. - Numerous new immunotherapy modalities based on modulating intracellular signaling are being evaluated. - In the most severe forms of SLE, autologous peripheral stem cell transplantation deserves consideration. - A key component of the treatment of SLE is control of atheroma, which is among the most severe complications. This rich harvest of new treatment possibilities can be expected to radically modify the prognosis of SLE, whose more aggressive forms remain severe. (C) 2006 Elsevier Masson SAS. All rights reserved.