The treatment of SLE is as varied as its course.

Although there is no cure for lupus and it is difficult to predict which treatment will be most effective for each patient, there have been significant gains in treating patients, and there is general consensus on several treatments.

A conservative regimen of physical and emotional rest, protection from direct sunlight, a healthful diet, prompt treatment of infections, and avoidance of aggravating factors are the mainstays of lupus therapy. In addition, for female patients, pregnancy must be planned for times when the disease is under control, and the patient is on allowable medications.

Physical Rest

This basic component of everyone's good health is essential for the person with lupus. The fatigue of lupus is not sleepiness or tiredness from physical exertion, but rather a frequent, persistent complaint often described as a "bone-tired feeling" or a "paralyzing fatigue."

Normal rest often does not refresh the patient or eliminate the tiredness due to lupus, and fatigue may persist despite normal laboratory test results.

The patient and family need instruction on how to use this tiredness as a guide for scheduling activity and rest. It must be reinforced that this need for rest is not laziness.

Eight to 10 hours a night of restful sleep, naps, and "timeouts" during the day are basic guidelines.

Physical activity should be encouraged as the patient can tolerate it. However, in some patients, the fatigue is more related to fibromyalgia than to the activity of their lupus.

An individualized exercise routine may promote well being, especially in a patient with fibromyalgia.

Some scientists believe that the incidence of fibromyalgia is increased in patients with lupus.

They do not know why, but one hypothesis is that inflammation from lupus may lead to the rewiring of the pain pathways in the central nervous system.

Emotional Rest A patient's emotional stressors should be carefully assessed, because they may play a role in triggering a flare. The patient should be instructed on how to avoid these stressful situations. However, the physical manifestations of lupus must be treated as they present themselves while the emotional stresses are explored.

Discussions with family members on this issue are essential for providing them with information and obtaining their support. Counseling for both the patient and the family may be an option. Chapter 6, Psychosocial Aspects of Lupus, explores these issues in further detail. Protection from Direct

Sunlight

An abnormal reaction to the ultraviolet (UV) rays of the sun, photosensitivity results in the development or exacerbation of a rash that is sometimes accompanied by systemic symptoms. Photosensitivity is common in Caucasian patients.

All people with lupus should avoid direct, prolonged exposure to the sun. Sun-sensitive patients should frequently apply a sunscreen. The best sunscreen is one that protects against both UVA and UVB rays.

To get adequate protection, patients should be advised to select either a "broad-spectrum protection" sunscreen with an SPF of at least 15, or one that contains micronized zinc oxide or titanium dioxide, both of which block UVA and UVB light.

Sun-sensitive patients should also avoid unprotected exposure between 10 a.m. and 4 p.m., and wear protective clothing, such as wide-brimmed hats and long sleeves.

In severe cases, patients may wish to purchase special UV-blocking clothing. People with lupus should be aware that UV rays are reflected off water and snow, and that glass, such as car windows, does not provide total protection from UV rays.

People with lupus should also know that fluorescent and halogen lights may emit UV rays and can aggravate lupus.

This may be an issue for patients who work indoors, in places with these kinds of lights.

Sunscreen and protective clothing can help minimize exposure, and plastic devices are available that block UV emissions from fluorescent or halogen light bulbs.

Diet and Nutrition

A well-balanced diet is essential in maintaining good health for all people, including people with lupus.

A low-fat, low-cholesterol diet is recommended, given the increased risk of heart disease in SLE.

When fluid retention, hypertension, kidney disease, or other problems are present, a restricted diet plan may be prescribed. Also, food intolerances and allergies may occur.

The health professional should make a note of the patient's dietary history and suggest diet counseling if appropriate, especially if the patient has a problem with weight gain, weight loss, gastrointestinal (GI) distress, or food intolerances. Nutritional considerations in treating people with lupus are discussed further in Chapter 4, Care of the Lupus Patient.

Treatment of Infection

Prompt recognition and treatment of infection is essential for those with lupus.

However, cardinal signs of infection may be masked because of SLE treatments.

For example, a fever may be suppressed because anti inflammatory therapy is being given.

When an infection is being treated, the health professional should be alert to medication reactionsreactions, especially to antibiotics. Sulfonamide antibiotics may increase the risk of a lupus flare.

Pregnancy and Contraception

Spontaneous abortion and premature delivery are more common for women with SLE than for healthy women.

To minimize risks to both mother and baby, a pregnant woman with lupus should be closely supervised by an obstetrician familiar with lupus and high-risk pregnancies.

As long as a woman is not hypercoagulable, oral contraceptives may be considered for contraception, as they do not increase flares.

Surgery

Surgery may exacerbate the symptoms of SLE.

Hospitalization may be required for otherwise minor procedures, and postoperative discharge may be delayed.

If it is elective, the surgery should be postponed until lupus activity is under control.

Immunizations

Immunizations with killed vaccines have not been shown to exacerbate SLE.

Influenza and pneumococcal vaccines are routinely recommended for SLE patients.

A patient with lupus should consult her or his doctor before receiving any immunizations, even routine ones.