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    "titulosAlternativos" => array:1 [
      "es" => array:1 [
        "titulo" => "Gu&#237;a de pr&#225;ctica cl&#237;nica para el manejo del lupus eritematoso sist&#233;mico propuesta por el Colegio Mexicano de Reumatolog&#237;a"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Systemic lupus erythematosus &#40;SLE&#41; is an autoimmune disease that behaves very heterogeneously&#44; and is characterised by remissions and exacerbations&#46; Its incidence and prevalence adjusted by age is 5&#46;5 per 100&#44;000 persons &#40;95&#37; CI&#58; 5&#46;0&#8211;6&#46;1&#41; and 72&#46;8 &#40;95&#37; CI&#58; 70&#46;8&#8211;74&#46;8&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> There is no national registry of cases in Mexico but it is known that there are substantial differences in the load of the disease in different populations and countries&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> For example&#44; the black American population have an incidence and prevalence more than twice that of the Caucasian population&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Even among &#8220;Hispanic&#8221; populations &#8211; as Latin Americans are often grouped in clinical studies &#8211; there are significant differences in the presentation of the disease&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">There are several national and international clinical practice guidelines &#40;CPG&#41; for the treatment of SLE&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#8211;7</span></a> However&#44; the majority of those available are not designed for the Mexican population or only seek to manage specific manifestations&#44; such as lupus nephritis&#44; or physiological conditions&#44; such as pregnancy&#46; National guidelines facilitate the inclusion of certain disease in national health plans&#46; There is no proposal as yet in this country for managing this disease that encompasses representatives of the principal health systems in a global and standardised way&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The disease has distinct features in the different ethnic groups&#44; as reported in cohorts such as LUMINA and GLADEL&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;9</span></a> Mixed race people suffer severe forms&#44; with a higher frequency of glomerulonephritis&#44; higher mortality and accumulated damage&#46; Similarly&#44; some manifestations&#44; such as demyelinating neuropathies and transverse myelitis&#44; are more frequent in Latin American populations&#44; although they usually respond better to treatment than Caucasian populations&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;11</span></a> Some studies have been published on Mexican patients&#44; that assess biochemical variants that might be related to therapeutic response&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> and specific lupus nephritis induction treatments<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> or specific response to biological drugs&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> However&#44; these studies have the weakness that they were performed on captive populations&#44; with a limited number of participants&#44; and therefore general peculiarities of Mexican patients or generalised recommendations cannot be established based on this local evidence&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">These facts justify the drawing up of national guidelines in a country where most of the population is of mixed race and requires access to public health systems for medical advice and treatment&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Based on the above&#44; the Mexican College of Rheumatology &#40;MCR&#41; set out to draw up a CPG that would combine the majority of the disease&#39;s manifestations&#44; and which would also include guidelines for controversial situations such as vaccination and the perioperative period&#46; Although the recommendations provided in this CPG are based on scientific evidence&#44; all guidelines have limitations in terms of individual decision-making&#44; since each patient has unique features&#44; and therefore this document&#44; as its name states&#44; is only intended as a guide and in no way attempts to substitute or limit the clinical judgement of the physician&#46; Publishing this CPG marks the start of process of continuous updating which the MCR will undertake every 2 years or when appropriate in light of new evidence&#46; The report on the evidence to support the recommendations is being drawn up to complement this guideline&#44; and will be published later&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In preparing this guideline&#44; we endeavoured to cover a wide range of patients&#46; To make the recommendations we took into account publications on patients with SLE&#44; and all organ and systemic involvement&#44; with possible comorbidities&#46; The only two cases that we did not consider were the paediatric population and lupus during pregnancy since the MCR already has a guideline to cover these groups&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Because response to treatment and the presentation of the disease can differ in different ethnic groups&#44; the recommendations were made with the Mexican population in mind&#46; The country&#39;s socioeconomic context was taken into consideration&#44; because the cost of some drugs can be very high for patients who are not insured or who are not right holders&#44; and for the health institutions themselves&#46; The recommendations included in this guideline&#44; therefore&#44; apply to adult&#44; non-pregnant&#44; Mexican patients with SLE&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">This document was undertaken to provide the most complete guideline possible to serve as support particularly for non-rheumatologist doctors who have to treat patients with SLE and lack the training of rheumatology specialists&#46; It is common for primary care doctors and those of other specialties to have to manage patients with SLE due to the lack of rheumatologists in the health institutions&#46; It is important to stress that patients with SLE should always be treated by rheumatologists&#44; but&#44; where this option does not exist&#44; this guideline can provide useful evidence-based information and serve as support in decision-making in the treatment of these patients&#46; This guideline presents recommendations on the management of general&#44; articular&#44; renal&#44; cardiovascular&#44; pulmonary&#44; neurological&#44; haematological and gastrointestinal manifestations&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Methodology</span><p id="par0040" class="elsevierStylePara elsevierViewall">The rheumatologists who formed the panel of experts drawing up this CPG were chosen by the governing board of the MCR based on their expertise in the treatment of lupus&#46; Senior rheumatologists from various states of the Mexican Republic were included&#44; and young rheumatologists who had shown great interest in participating in the academic activities of the MCR were invited to form part of the teams&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The panel of experts met for the first time in Mexico City in December 2016 to draft this document&#46; The working groups were formed during this meeting&#44; and the methodology outlined for the preparation of this document&#46; After this meeting&#44; there were 2 face-to-face meetings to check that the proposed methodology was being followed&#44; and the findings from the literature were presented by each of the teams&#46; In addition&#44; there was constant electronic communication&#46; The teams&#44; after presenting their results to the other panellists&#44; prepared their recommendations and sent them to the methodologist coordinating the work&#44; who in turn drafted a document with all the recommendations&#46; This document was submitted electronically to all the panellists for their consideration&#44; and the final recommendations were chosen by consensus&#58; there was no disagreement between the team members&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The author responsible for publication submitted the subjects that the guideline needed to cover to the Research Committee&#44; and together they made the final decision to produce recommendations per type of manifestation&#44; and include recommendations on general management&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Literature Search</span><p id="par0055" class="elsevierStylePara elsevierViewall">For the literature search&#44; a series of research questions were generated for the general management of the disease&#44; and for each of its manifestations&#46; Each research question resulted in one or more than one search&#44; depending on its complexity&#46; The PICO methodology was used&#44; for searches clearly identifying the population &#40;P&#41;&#44; intervention &#40;I&#41;&#44; comparator &#40;C&#41;&#44; and outcome &#40;O&#41;&#46; In sum&#44; the target population were patients with SLE&#44; the interventions and comparators were all the treatments presented in this document&#44; and there were multiple outcomes&#46; Not only were the most clinically relevant outcomes considered&#44; such as prevention of renal damage or reducing progression of the disease&#44; remission after induction&#44; prevention of relapse&#44; the control or reduction of the manifestations of the disease&#44; but also those relevant to the patients&#44; such as fatigue and pain reduction&#46; The searches were performed from 2000 to 2016&#44; they were limited to adults and&#44; given the limited scientific literature&#44; the search was not restricted to publications on Mexican populations&#44; although the articles that did cover this population bore more weight when making the recommendations&#46; Given the absence of direct evidence&#44; most of the recommendations were made based on the results from other populations&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Each team received from the methodologist the PICO search mechanisms for the subject that they had been allocated&#46; Each team reviewed the articles and&#44; based on the review of related articles and the references cited in the publications of interest&#44; completed their search&#46; The team members checked that the articles that were to be used to make the recommendations answered the research questions&#44; and met the selection criteria that had been determined beforehand by the governing board of the MCR&#46; Any disagreements among the teams were resolved through discussion between team members&#46; Once all the scientific literature had been reviewed&#44; the recommendations were drafted&#46; Unlike most Mexican CPG that use the levels of evidence of Shekelle et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> the GRADE<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> system was used to draw up the recommendations of this CPG&#44; and rate the level of evidence and strength of the recommendations&#46; This is the system currently recommended by the same authors who developed the levels of evidence used in previous years in the new guideline for drawing up CPG&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> The GRADE method has proved superior to other systems for evaluating CPG<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> recommendations&#44; and has now been adopted by the Cochrane Collaboration&#46;</p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Quality of the Evidence</span><p id="par0065" class="elsevierStylePara elsevierViewall">The quality of the body of the evidence used to make the recommendations was classified as very low&#44; low&#44; moderate and high&#44; depending on its characteristics&#46; Expert opinion was not considered evidence&#59; therefore it was classified as very low quality of evidence&#46; A classification of high quality means that further research is very unlikely to change confidence in the estimate of effect&#44; moderate quality means that that further research is likely to have an important impact on confidence in the estimate of effect and may change the estimate&#59; low quality means that further research is very likely to have an important impact on confidence in the estimate of effect and is likely to change the estimate and&#44; finally&#44; very low quality means that any estimate of effect is very uncertain&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Strong or Weak Recommendation or Good Practice Recommendation</span><p id="par0070" class="elsevierStylePara elsevierViewall">Once the quality of the evidence had been assessed&#44; the recommendations were determined as either strong or weak&#46; It is said that when a strong recommendation is made&#44; the desirable consequences of the intervention clearly outweigh the undesirable consequences&#59; by contrast&#44; with weak recommendations it is uncertain whether the desirable consequences substantially outweigh the undesirable consequences or are similar&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> The recommendations that were considered important but that could not be rated in terms of quality of evidence or strength of recommendation were classified as &#8220;good practice&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Results and Discussion</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Treatment of Systemic Lupus Erythematosus</span><p id="par0075" class="elsevierStylePara elsevierViewall">There is no general treatment for SLE because of the heterogeneity of its behaviour&#44; and its management must be individualised based on patient features and the activity of the disease&#44; and even with the possibility of access to certain drugs&#44; such as the biological therapies&#46; Treatment is based on the use of glucocorticoids &#40;GC&#41;&#44; nonsteroidal anti-inflammatory drugs &#40;NSAIDs&#41;&#44; antimalarials and various immunosuppressants&#46; The prognosis of these patients has notably improved with these treatments&#44; although there can be frequent relapses as well as&#44; in some cases&#44; therapeutic failure&#46; The toxicity of these drugs must be monitored&#46; The aim of treatment is to achieve remission<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> &#40;absence of perceived clinical activity&#41; or&#44; at least&#44; achieve minimum disease activity<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22&#44;23</span></a> for the patient enabling immunosuppressants and GC to be stopped or at least maintained at the lowest possible doses to prevent their associated adverse effects&#46; There are patients who are refractory to treatment&#44; do not respond to standard treatment or require an unacceptable dose of GC to maintain remission&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> Before a patient refractory is considered refractory&#44; their adherence to the therapy should be checked&#44; as well as any accumulated damage that is not likely to improve with treatment&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#44;26</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">For the purposes of these recommendations&#44; severe lupus is understood to be when treatment is needed for potentially fatal manifestations such as lupus nephritis&#44; neuropsychiatric involvement&#44; haemolytic anaemia &#40;Hb<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>7<span class="elsevierStyleHsp" style=""></span>g&#47;dL&#41;&#44; thrombocytopenia &#40;&#60;30&#44;000 platelets&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> vasculitis&#44; pulmonary haemorrhage&#44; myocarditis&#44; lupus pneumonitis&#44; severe myositis&#44; lupus enteritis&#44; lupus pancreatitis&#44; lupus hepatitis&#44; protein-losing enteropathy&#44; severe keratitis&#44; retinal vasculitis&#44; severe scleritis&#44; optic neuritis&#46; Non-severe lupus is understood as the involvement of a minor organ &#40;mucocutaneous&#44; articular&#44; serous lupus&#41;&#44; and when the manifestations of the disease do not warrant treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">As we have already mentioned&#44; treatment of SLE must be individual and will depend on the type of manifestation&#44; the organ&#47;s or system&#47;s involved&#44; and the severity of the disease&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> Classification of the manifestations according to severity are given in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">General Considerations on the Use of Drugs</span><p id="par0090" class="elsevierStylePara elsevierViewall">The evidence-based recommendations for each type of manifestation that form part of this CPG for the management of SLE are found in the tables of recommendations for each manifestation&#46; In addition&#44; the section below and <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> present some generalities regarding the drug groups most used in the treatment of SLE&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Glucocorticoids</span><p id="par0095" class="elsevierStylePara elsevierViewall">GC are the cornerstone of treatment for SLE&#46; It is common for GC pulses to be administered that&#44; for the purposes of this document and unless otherwise specified&#44; will be defined as the intravenous administration of high doses of steroids&#46; Generally 1<span class="elsevierStyleHsp" style=""></span>g of methylprednisolone succinate is administered over a period of 2<span class="elsevierStyleHsp" style=""></span>h&#59; an average of 3 pulses is given&#44; one per day&#44; for 3 consecutive days&#46; Although there is no consensus on standardised recommendations&#44; comorbidities and risk factors for adverse advents should be assessed in patients treated with GC&#44; and treated if appropriate&#46; During treatment the patient&#39;s body weight&#44; blood pressure&#44; peripheral oedema&#44; heart failure&#44; serum lipids and glucose must be monitored&#44; and they must undergo an ophthalmological assessment&#46; If the patient has a dose &#62;75<span class="elsevierStyleHsp" style=""></span>mg&#47;day of prednisone and requires treatment for more than 3 months&#44; a calcium and vitamin D supplement should be started&#46; The use of antiresorptive agents must be assessed based on the patient&#39;s risk factors&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> Considerations on their use in the remission induction and maintenance schemes are shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Antimalarials</span><p id="par0100" class="elsevierStylePara elsevierViewall">Antimalarials have been used in the treatment of SLE since the nineteenth century and&#44; although there are few studies that aim to demonstrate their efficacy&#44; the current evidence suggests the use of hydroxychloroquine &#40;HCQ&#41; &#40;at 20&#8211;400<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#41; or chloroquine &#40;at 150&#8211;300<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#41;&#46; There is no evidence that higher doses are more effective than low doses&#44; and the appropriate dose must be left to the judgement of the clinician&#46; Antimalarials have photoprotective&#44; lipid lowering&#44; antiangiogenic&#44; antithrombotic effects&#44; and also inhibit the function of the B cell-activating factor and phospholipase A2-activating factor&#44; which means that they are indicated in the treatment of skin lupus&#44; of SLE with mild to moderate activity&#44; as concomitant treatment to prevent relapses and damage to major organs&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> Provided there are no contradictions&#44; antimalarials are recommended for all patients with SLE&#46; HCQ is associated with longer damage-free survival than when it is not used &#40;45&#46;1&#37; vs 26&#46;5&#37;&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#44; and correlates negatively with accumulated damage measured by SLICC &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;&#46;22&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;015&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> reducing the probability of accumulated renal damage &#40;HR &#46;68&#59; 95&#37; CI&#58; &#46;53&#8211;&#46;93&#41;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> &#40;OR &#46;38&#59; 95&#37; CI&#58; &#46;25&#8211;&#46;58&#41;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> in those who use them compared to those who do not&#46; They are also useful in the prevention of morbidity due to atherosclerosis&#44; and in the management of antiphospholipid antibody syndrome associated with SLE&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">34&#44;35</span></a> Discontinuing HCQ has been reported to increase the relative risk of relapse by 2&#46;5 &#40;95&#37; CI&#58; 1&#46;08&#8211;5&#46;58&#41; over a period of 6 months&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> A baseline and subsequent annual ophthalmological assessment should be performed to monitor adverse events&#46;</p><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Non-steroidal Anti-inflammatory Drugs</span><p id="par0105" class="elsevierStylePara elsevierViewall">NSAIDs are recommended in rheumatic diseases for treating pain and inflammation&#46; The consensus on the use of NSAIDs of the Spanish Rheumatology Society and the MCR recommends individualising their use based on each patient&#39;s variability of response&#44; gastrointestinal toxicity&#44; cardiovascular&#44; renal and hepatic risk factors&#46; One NSAID cannot be considered better than another &#40;traditional or COXIBS&#41;&#46; Simultaneous use of more than one NSAID must be avoided&#44; since this only increases toxicity&#44; and does not increase efficacy &#40;ceiling effect&#41;&#46; In acute processes&#44; they should be used for the shortest possible time at the maximum recommended dose&#44; and in chronic processes&#44; the minimum dose necessary to maintain the desired clinical response should be used&#46; Risk factors&#44; adverse effects and indication for use should be assessed periodically&#46; Concomitant use with GC increases gastrointestinal toxicity&#46; Interactions with other drugs such as antihypertensives&#44; glucose-lowering drugs&#44; oral anticoagulants&#44; etc&#46; should be assessed&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a></p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Immunosuppressants</span><p id="par0110" class="elsevierStylePara elsevierViewall">Most rheumatologists agree on the use of immunomodulators for moderate to severe SLE during an intense period of immunosuppression known as induction therapy&#44; followed by a longer period of maintenance therapy&#46; The three main objectives of induction therapy are to halt damage&#44; recover function&#44; and control immunological activity&#46; Maintenance therapy is used to consolidate remission and prevent relapse with a treatment programme with a low risk of complications and more convenient for the patient&#44; under the current concept of &#8220;personalised treatment&#8221;&#46; The drugs that are traditionally used with these aims are the following&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8211;</span><p id="par0115" class="elsevierStylePara elsevierViewall">Mycophenolic acid &#40;MMF&#41;&#58; the dose varies widely depending on the organ involved and the severity of the manifestation&#59; it can range from 1 to 3<span class="elsevierStyleHsp" style=""></span>g&#46; Adverse events that must be monitored are cytopenia&#44; altered LFT&#44; diarrhoea and teratogenicity&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">38&#8211;41</span></a></p></li><li class="elsevierStyleListItem" id="lsit0010"><span class="elsevierStyleLabel">&#8211;</span><p id="par0120" class="elsevierStylePara elsevierViewall">Cyclophosphamide &#40;CYC&#41;&#58; the dose can vary from 500 to 1000<span class="elsevierStyleHsp" style=""></span>mg&#47;m<span class="elsevierStyleSup">2</span> of body surface area&#46; Adverse events that must be monitored are cytopenia&#44; teratogenicity&#44; infertility&#44; myeloproliferative disorders&#44; haemorrhagic cystitis&#44; and bladder cancer&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a></p></li><li class="elsevierStyleListItem" id="lsit0015"><span class="elsevierStyleLabel">&#8211;</span><p id="par0125" class="elsevierStylePara elsevierViewall">Azathioprine&#58; the dose varies between 1 and 3<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day and the adverse events to be monitored are myelosuppression&#44; hepatotoxicity&#44; lymphoproliferative disorders and teratogenicity&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">41&#44;42</span></a></p></li><li class="elsevierStyleListItem" id="lsit0020"><span class="elsevierStyleLabel">&#8211;</span><p id="par0130" class="elsevierStylePara elsevierViewall">Methotrexate&#58; can be used in doses from 7&#46;5 to 25<span class="elsevierStyleHsp" style=""></span>mg&#44; orally or parenterally&#44; and the adverse events to be monitored are myelosuppression&#44; hepatotoxicity&#44; pneumonitis&#44; alopecia&#44; stomatitis&#44; and teratogenicity&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">39&#8211;42</span></a></p></li><li class="elsevierStyleListItem" id="lsit0025"><span class="elsevierStyleLabel">&#8211;</span><p id="par0135" class="elsevierStylePara elsevierViewall">Cyclosporine&#58; principally used in resistant nephropathy&#44; and the main adverse events are gingival hyperplasia&#44; high blood pressure&#44; hirsutism&#44; renal failure&#44; and anaemia&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a></p></li></ul></p><p id="par0140" class="elsevierStylePara elsevierViewall">Other drugs used in SLE are the biologics belimumab and rituximab&#46; Belimumab is used in mild to moderate manifestations such as arthritis&#44; serositis or if there is a skin infection &#40;dsDNA&#43; or C3&#47;C4 consumption&#41;&#46; B-lymphocyte depletion is the most common adverse event with this biologic&#46; Rituximab is also used when there is joint involvement resistant to conventional treatment&#44; haematological involvement&#44; involvement of the central nervous system or resistant nephritis&#44; and the principal adverse events are allergy&#44; serum sickness&#44; and progressive multifocal leukoencephalopathy&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Recommendations Based on the Review of the Scientific Evidence</span><p id="par0145" class="elsevierStylePara elsevierViewall">The tables below show the recommendations resulting from the literature review and the work by consensus of the participants in the working group who are the signatories of this CPG&#46; <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a> presents the recommendations for managing the general manifestations of SLE&#44; and <a class="elsevierStyleCrossRefs" href="#tbl0025">Tables 5&#8211;10</a> present the recommendations for the treatment of the renal&#44; cardiovascular&#44; pulmonary&#44; neurological&#44; haematological&#44; and gastrointestinal manifestations of the disease&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><elsevierMultimedia ident="tbl0030"></elsevierMultimedia><elsevierMultimedia ident="tbl0035"></elsevierMultimedia><elsevierMultimedia ident="tbl0040"></elsevierMultimedia><elsevierMultimedia ident="tbl0045"></elsevierMultimedia><elsevierMultimedia ident="tbl0050"></elsevierMultimedia></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Research Needs</span><p id="par0150" class="elsevierStylePara elsevierViewall">SLE&#44; because it is a rare disease&#44; is a less frequent subject of research than other diseases&#46; Therefore&#44; there is a significant need for evidence on effective treatments that also have a lower rate of adverse events&#46; The working panel identified a series of knowledge gaps&#44; and made recommendations so that clinicians&#44; researchers and the pharmaceutical industry can focus their efforts on these research needs to provide increasingly better treatments for patients with this disease&#46;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsit0030"><span class="elsevierStyleLabel">1&#41;</span><p id="par0155" class="elsevierStylePara elsevierViewall">In general&#44; the following need to be designed&#58;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsit0035"><span class="elsevierStyleLabel">a&#41;</span><p id="par0160" class="elsevierStylePara elsevierViewall">National multicentre prospective cohort studies&#46;</p></li><li class="elsevierStyleListItem" id="lsit0040"><span class="elsevierStyleLabel">b&#41;</span><p id="par0165" class="elsevierStylePara elsevierViewall">Comparative studies with populations from other countries&#46;</p></li><li class="elsevierStyleListItem" id="lsit0045"><span class="elsevierStyleLabel">c&#41;</span><p id="par0170" class="elsevierStylePara elsevierViewall">Controlled clinical trials on treatment of the neuropsychiatric manifestations of lupus&#46;</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsit0050"><span class="elsevierStyleLabel">2&#41;</span><p id="par0175" class="elsevierStylePara elsevierViewall">There is a need for clinical trials for the treatment of the articular manifestations of SLE&#46;</p></li><li class="elsevierStyleListItem" id="lsit0055"><span class="elsevierStyleLabel">3&#41;</span><p id="par0180" class="elsevierStylePara elsevierViewall">More evidence is required on the efficacy and safety of tacrolimus in severe SLE&#44; calcium antagonists and immunosuppressant medication &#40;MMF and CYC&#41; in patients with pulmonary hypertension&#44; of CYC&#44; azathioprine&#44; mycophenolate mofetil&#44; danazol&#44; antimalarials in the treatment of patients with SLE and thrombocytopenia or haemolytic anaemia&#44; of CYC for haemophagocytic syndrome and thrombotic thrombocytopenic purpura&#44; giving multiple vaccinations at one visit and tetanus vaccination&#44; recombinant human papilloma virus quadrivalent vaccine&#44; hepatitis B virus and zoster herpes in patients with moderate and severe disease activity&#46;</p></li><li class="elsevierStyleListItem" id="lsit0060"><span class="elsevierStyleLabel">4&#41;</span><p id="par0185" class="elsevierStylePara elsevierViewall">Therapeutic evidence of the use of splenectomy will require more evidence from retrospective studies&#44; since it is not very feasible to undertake a controlled clinical trial&#46;</p></li><li class="elsevierStyleListItem" id="lsit0065"><span class="elsevierStyleLabel">5&#41;</span><p id="par0190" class="elsevierStylePara elsevierViewall">Studies are required on the optimal duration of treatment&#44; and dose tapering schemes when remission of symptoms has been achieved&#46;</p></li><li class="elsevierStyleListItem" id="lsit0070"><span class="elsevierStyleLabel">6&#41;</span><p id="par0195" class="elsevierStylePara elsevierViewall">Studies with greater statistical power are required on gastrointestinal involvement in lupus&#44; since the current studies are case series&#46;</p></li><li class="elsevierStyleListItem" id="lsit0075"><span class="elsevierStyleLabel">7&#41;</span><p id="par0200" class="elsevierStylePara elsevierViewall">Studies are required to determine the required dose of CYC for haemophagocytic syndrome&#44; and thrombotic thrombocytopenic purpura&#46;</p></li></ul></p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflict of Interests</span><p id="par0205" class="elsevierStylePara elsevierViewall">Daniel Xibille-Friedman has received honoraria from GlaxoSmithKline for training activities and in clinical trials&#46; Sandra Carrillo-V&#225;zquez has received honoraria from Abbvie&#44; Bristol Myers Squibb&#44; Eli Lilly&#44; Novartis&#44; Pfizer&#44; Roche&#44; Takeda and Janssen&#46; Lilia Andrade-Ortega has received honoraria from Bristol Myers Squibb&#44; Novartis&#44; Pfizer&#44; Roche&#44; Janssen&#46; Miguel &#193;ngel Saavedra has received honoraria from UCB and Pfizer&#46; Leonardo Lim&#243;n-Camacho has received honoraria from Bristol Myers Squibb&#44; UCB&#44; Pfizer&#44; Janssen&#44; Roche&#44; Lilly and Amgen&#46; Leonor Barile Fabris has received honoraria from Abbvie&#44; Jansen&#44; Roche&#44; Bristol Myers Squibb&#44; UCB&#44; Novartis&#44; Pfizer and GlaxoSmithKline&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">Marcela P&#233;rez-Rodr&#237;guez&#44; Everardo &#193;lvarez-Hern&#225;ndez&#44; Francisco Javier Aceves&#44; Mario C&#46; Ocampo-Torres&#44; Conrado Garc&#237;a-Garc&#237;a&#44; Jos&#233; Luis Garc&#237;a-Figueroa&#44; Javier Merayo-Chalico&#44; Ana Barrera-Vargas&#44; Margarita Portela-Hern&#225;ndez&#44; Sandra Sicsik&#44; V&#237;ctor Manuel Rosales-Don Pablo&#44; Aline Mart&#237;nez&#44; Pilar Prieto-Seyffert&#44; Mario P&#233;rez-Crist&#243;bal&#44; Zully Castro-Col&#237;n&#44; Azucena Ramos&#44; Gabriela Huerta-Sil&#44; Mar&#237;a Fernanda Hern&#225;ndez-Cabrera&#44; Luis Javier Jara and Lizbet Tinajero-Nieto have no conflict of interests to declare&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">There are national and international clinical practice guidelines for systemic lupus erythematosus treatment&#46; Nonetheless&#44; most of them are not designed for the Mexican population or are devoted only to the treatment of certain disease manifestations&#44; like lupus nephritis&#44; or are designed for some physiological state like pregnancy&#46; The Mexican College of Rheumatology aimed to create clinical practice guidelines that included the majority of the manifestations of systemic lupus erythematosus&#44; and also incorporated guidelines in controversial situations like vaccination and the perioperative period&#46; The present document introduces the &#8220;Clinical Practice Guidelines for the Treatment of Systemic Lupus Erythematosus&#8221; proposed by the Mexican College of Rheumatology&#44; which could be useful mostly for non-rheumatologist physicians who need to treat patients with systemic lupus erythematosus without having the appropriate training in the field of rheumatology&#46; In these guidelines&#44; the reader will find recommendations on the management of general&#44; articular&#44; kidney&#44; cardiovascular&#44; pulmonary&#44; neurological&#44; hematologic and gastrointestinal manifestations&#44; and recommendations on vaccination and treatment management during the perioperative period&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Existen varias gu&#237;as de pr&#225;ctica cl&#237;nica tanto nacionales como internacionales para el tratamiento del lupus eritematoso sist&#233;mico&#46; No obstante&#44; la mayor&#237;a de las gu&#237;as disponibles no est&#225;n dise&#241;adas para poblaci&#243;n mexicana o solamente son para el manejo de manifestaciones espec&#237;ficas como nefritis l&#250;pica o para alg&#250;n estado fisiol&#243;gico como el embarazo&#46; El Colegio Mexicano de Reumatolog&#237;a se propuso elaborar unas gu&#237;as de pr&#225;ctica cl&#237;nica que conjuntaran la mayor parte de las manifestaciones de la enfermedad y que incluyeran adicionalmente pautas en situaciones controversiales como lo son la vacunaci&#243;n y el periodo perioperatorio&#46; En el presente documento se presenta la &#171;Gu&#237;a de pr&#225;ctica cl&#237;nica para el manejo del lupus eritematoso sist&#233;mico&#187; propuesta por el Colegio Mexicano de Reumatolog&#237;a&#44; que puede ser de utilidad principalmente a m&#233;dicos no reumat&#243;logos que se ven en la necesidad de tratar a pacientes con lupus eritematoso sist&#233;mico sin tener la formaci&#243;n de especialistas en reumatolog&#237;a&#46; En esta gu&#237;a se presentan recomendaciones sobre el manejo de manifestaciones generales&#44; articulares&#44; renales&#44; cardiovasculares&#44; pulmonares&#44; neurol&#243;gicas&#44; hematol&#243;gicas&#44; gastrointestinales&#44; respecto a la vacunaci&#243;n y al manejo perioperatorio&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Please cite this article as&#58; Xibill&#233;-Friedmann D&#44; P&#233;rez-Rodr&#237;guez M&#44; Carrillo-V&#225;zquez S&#44; &#193;lvarez-Hern&#225;ndez E&#44; Aceves FJ&#44; Ocampo-Torres MC&#44; et al&#46; Gu&#237;a de pr&#225;ctica cl&#237;nica para el manejo del lupus eritematoso sist&#233;mico propuesta por el Colegio Mexicano de Reumatolog&#237;a&#46; Reumatol Clin&#46; 2019&#59;15&#58;3&#8211;20&#46;</p>"
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Minor manifestations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Moderate manifestations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Severe manifestations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8211; Are not function or life-threatening<br>&#8211; Do not cause irreversible damage or any relevant sequelae &#40;e&#46;g&#46;&#44; fatigue&#44; fever&#44; arthralgia&#44; mild or intermittent arthritis&#44; some skin manifestations and mild serositis&#41;<br>&#8211; Can be treated with NSAIDs&#44; antimalarials and GC at low doses &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211; Are not life-threatening&#44; but do cause functional limitation &#40;e&#46;g&#46;&#44; persistent arthritis&#44; severe or extensive skin lesions&#44; mild thrombocytopenia and moderate serositis&#41;<br>&#8211; Can be treated with GC at low to medium doses&#44; antimalarials and oral immunosuppressants such as methotrexate&#44; leflunomide and azathioprine &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211; Affect a major organ and are life or function-threatening<br>&#8211; Have a risk of chronic damage with major organic sequelae &#40;e&#46;g&#46;&#44; lupus glomerulonephritis&#44; severe neurological involvement&#44; pulmonary haemorrhage&#44; vasculitis&#44; bullous lupus&#44; etc&#46; These manifestations can be treated with GC at high doses or with pulses of cyclophosphamide or mycophenolic acid or other immunosuppressants&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Classification of Clinical Manifestations in SLE Based on Their Impact on Patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#44;26</span></a></p>"
        ]
      ]
      1 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at2"
            "detalle" => "Table "
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        ]
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Drug&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Indication according to severity</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Indications according to manifestation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Safety recommendations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Mild&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Severe&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Glucocorticoids&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">X&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">X&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">X&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Generalised used according to the type and severity of the manifestation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Metabolic monitoring of the patient&#44; blood pressure and weight&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Chloroquine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">X&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">X&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Musculo-skeletal&#44; skin&#44; cardiovascular&#44; kidney &#40;to maintain remission&#41;&#44; haematological&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Annual visit to the ophthalmologist&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hydroxychloroquine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">X&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">X&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Musculo-skeletal&#44; skin&#44; cardiovascular&#44; kidney &#40;to maintain remission&#41;&#44; haematological&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Annual visit to the ophthalmologist&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Azathioprine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">X&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">X&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Haematological&#44; cardiovascular&#44; kidney&#44; gastrointestinal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Monitor haematic cytometry&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Methotrexate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">X&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">X&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Musculo-skeletal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Monitor liver and kidney function&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Leflunomide&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">X&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">X&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Musculo-skeletal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Monitor liver and kidney function&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mycophenolate mofetil&#47;mycophenolic acid&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">X&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">X&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">X&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Kidney&#44; haematological&#44; cardiopulmonary&#44; gastrointestinal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Do not use during pregnancy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cyclophosphamide&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Musculo-skeletal&#44; kidney&#44; haematological&#44; cardiopulmonary&#44; neurological&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Use with care in people of reproductive age due to association with gonadal dysfunction&#59; do not use during pregnancy&#44; monitor haematic cytometry&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cyclosporine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">X&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">X&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Kidney&#44; haematological&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Monitor blood pressure and kidney function&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Belimumab&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">X&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">X&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Musculo-skeletal&#44; skin&#44; general manifestations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Monitor in patients with depression or suicidal ideation&#59; monitor associated infections&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Rituximab&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">X&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Manifestations that are refractory to treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Monitor associated infections&#59; monitor allergic reactions during administration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Immunoglobulin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">X&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Manifestations that are refractory to treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Monitor blood pressure&#59; monitor allergic reactions to administration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">General Considerations on the Use of Drugs for the Treatment of SLE&#46;</p>"
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      2 => array:8 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
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            "identificador" => "at3"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Remission induction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Maintenance&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">The initial dose of GC &#40;prednisone or equivalent&#41; depends on the activity of the SLE<br><span class="elsevierStyleHsp" style=""></span>&#8211; Low activity&#58; low doses &#40;&#60;7&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Moderate activity&#58; intermediate doses &#40;7&#46;5&#8211;30<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Severe activity&#58; high doses &#40;30&#8211;100<span class="elsevierStyleHsp" style=""></span>mg&#47;day or pulses with doses &#62;250<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#44; usually intravenous for 1&#8211;5 days&#41;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">45&#44;46</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Once reduction of activity or remission has been achieved&#44; start tapering regimen&#46; Usually started after 6 weeks of high doses<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a><br><span class="elsevierStyleHsp" style=""></span>&#8211; Reduce 10&#37;&#8211;20&#37; every 7&#8211;15 days until 30<span class="elsevierStyleHsp" style=""></span>mg&#47;day<br><span class="elsevierStyleHsp" style=""></span>&#8211; Then&#44; reduce 10&#37; every 15 days until discontinued or continue with maintenance dose &#40;&#60;7&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#41;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">29&#44;46</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Considerations on the Use of Glucocorticoids in the Remission Induction and Maintenance Regimen for SLE&#46;</p>"
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        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
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            "identificador" => "at4"
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        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
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              "tabla" => array:1 [
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Fatigue&#44; pain and fever</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8211; Dehydroepiandrosterone or fish oil are not suggested for the management of fatigue&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">47&#8211;49</span></a> &#40;Moderate quality of evidence&#44; weak recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Cholecalciferol 50&#44;000<span class="elsevierStyleHsp" style=""></span>IU&#47;week could be considered for the management of fatigue&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">50</span></a> &#40;Moderate quality of evidence&#44; weak recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Due to their cost&#44; abatacept&#44; belimumab or rituximab should not be considered for use in first-line management of fatigue&#46;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">51&#8211;56</span></a> &#40;High quality of evidence&#44; strong recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; There is insufficient evidence to recommend the use of acupuncture&#44; phototherapy&#44; psychological approach or diet in treating the pain and fatigue experienced by people with SLE&#46;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">48&#44;49&#44;57</span></a> &#40;Low quality of evidence&#44; weak recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Both aerobic and isotonic exercise for at least 15<span class="elsevierStyleHsp" style=""></span>min&#44; 3 times a week&#44; is useful in reducing fatigue &#40;measured by the FSS&#41; in SLE with no disease activity&#46;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">48&#44;58&#44;59</span></a> &#40;Moderate quality of evidence&#44; strong recommendation&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Differential diagnosis of fever</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8211; First infection and the toxic effect of drugs must be ruled out&#44; respectively&#44; before attributing the manifestation to disease activity&#46; To determine whether the fever is associated with the activity of SLE it should be borne in mind that fever due to activity is usually coincident with low complement levels&#44; raised anti-DNA counts&#44; and slightly raised CRP&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">57</span></a> &#40;Moderate quality of evidence&#44; strong recommendation&#41;&#46; In patients with no initial signs of infectious process&#44; medium to high doses of GC are recommended &#40;prednisone at 20&#8211;40<span class="elsevierStyleHsp" style=""></span>mg&#47;day with a response in 1&#8211;5 days&#41;&#59; if there has been no response within 72<span class="elsevierStyleHsp" style=""></span>h&#44; consider a different aetiology&#46;<a class="elsevierStyleCrossRefs" href="#bib0295"><span class="elsevierStyleSup">59&#44;60</span></a> &#40;Moderate quality of evidence&#44; strong recommendation&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Biopsy</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8211; Whenever possible and if there is no formal contraindication&#44; a biopsy should be performed on patients with signs suggestive of lupus nephritis to classify the type of glomerulonephritis&#44; and to evaluate signs of activity&#44; chronicity&#44; vascular and tubular changes&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;61&#44;62</span></a> &#40;High quality of evidence&#44; strong recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; In the event of relapse where a change to nephritis is suspected or scarring nephropathy&#44; a repeat biopsy should be considered&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;63&#44;64</span></a> &#40;Moderate quality of evidence&#44; weak recommendation&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Vaccination</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8211; It is recommended that vaccinations given to patients diagnosed with SLE and&#44; if possible&#44; the date they were given&#44; should be recorded at the time of the patient&#39;s first contact with the rheumatology specialist&#46; &#40;Good practice&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; It is recommended that degree of disease activity should be established using the SLEDAI &#40;Systemic Lupus Erythematosus Activity Index&#41;&#44; as well as the current immunosuppressant treatment&#46; &#40;Good practice&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; In patients with SLE who are vaccinated&#44; it is recommended that events appearing within the first 48<span class="elsevierStyleHsp" style=""></span>h temporarily associated with the vaccination should be monitored&#44; such as hyperthermia&#44; erythema and pain at the injection site&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">65</span></a> &#40;Low quality of evidence&#44; strong recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Both seasonal and epidemic influenza vaccinations are recommended&#58;<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8211; For patients with SLE in remission &#40;SLEDAI 0&#41; or with mild &#40;SLEDAI 2&#8211;4&#41; to moderate activity &#40;SLEDAI 4&#8211;8&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">66&#8211;80</span></a> &#40;High quality of evidence&#44; strong recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8211; When the equivalent dose of prednisone is less than 20<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">69</span></a> &#40;Moderate quality of evidence&#44; strong recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8211; For patients with SLE treated with MMF&#44; methotrexate&#44; azathioprine or CYC&#44; even if these patients have a lesser response&#46;<a class="elsevierStyleCrossRefs" href="#bib0345"><span class="elsevierStyleSup">69&#44;72&#44;73&#44;76</span></a> &#40;Moderate quality of evidence&#44; strong recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; It is recommended that the 23-valent pneumococcal vaccine should be given to patients with SLE in remission or with mild to moderate disease activity&#46;<a class="elsevierStyleCrossRefs" href="#bib0390"><span class="elsevierStyleSup">78&#44;81&#8211;84</span></a> &#40;High quality of evidence&#44; strong evidence&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; It is suggested that the quadrivalent human papilloma virus vaccine should be given to patients with SLE&#58;<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8211; Who are under the age of 25&#44; with no history of thrombophilia or other risk factors for thrombosis &#40;immobility&#44; smoking&#44; use of hormonal drugs&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">85</span></a> &#40;Moderate quality of evidence&#44; weak recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8211; With doses of prednisone under 10<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#46;<a class="elsevierStyleCrossRefs" href="#bib0425"><span class="elsevierStyleSup">85&#44;86</span></a> &#40;Moderate quality of evidence&#44; weak recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8211; With immunosuppressants &#40;MMF&#41;&#44; even though these patients might have a lesser response&#46;<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">85</span></a> &#40;Moderate quality of evidence&#44; weak recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; The hepatitis B vaccine and booster vaccine are recommended for patients with SLE in remission&#44; and with mild &#40;SLEDAI 2&#8211;4&#41; to moderate &#40;SLEDAI 4&#8211;8&#41; activity&#46;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">87</span></a> &#40;Moderate quality of evidence&#44; strong recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; The tetanus and <span class="elsevierStyleItalic">Haemophilus influenza</span> B vaccine and their boosters are recommended for patients with SLE&#58;<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8211; In remission&#44; mild &#40;SLEDAI 2&#8211;4&#41; to severe &#40;SLEDAI &#62;8&#41; activity 77&#46;78&#46; &#40;Moderate quality of evidence&#44; strong recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8211; Receiving treatment with methotrexate&#44; azathioprine or CYC&#44; although these patients can have a lesser response&#46;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">78</span></a> &#40;Moderate quality of evidence&#44; weak recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Live attenuated virus vaccinations are not recommended&#44; such as the herpes zoster vaccine&#44; for patients with SLE with disease activity&#46;<a class="elsevierStyleCrossRefs" href="#bib0440"><span class="elsevierStyleSup">88&#44;89</span></a> &#40;Low quality of evidence&#44; weak recommendation&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Perioperative recommendations</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8211; For patients scheduled for orthopaedic surgery or other types of surgery with similar risk such as laparoscopy &#40;fundoplication&#44; appendectomy&#44; cholecystectomy&#41; the following is recommended<a class="elsevierStyleCrossRefs" href="#bib0450"><span class="elsevierStyleSup">90&#8211;92</span></a> &#40;moderate quality of evidence&#44; strong recommendation&#41;&#58;<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8211; An SLEDAI score prior to surgery of between 0 and 3 in order to proceed with surgery&#46;<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8211; Patients with a surgical risk&#44; ASA score of IV or V&#44; should not be operated until their general condition improves&#46;<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8211; Before undergoing surgery&#44; patients with SLE should have negative urine and oropharyngeal cultures with no symptoms or signs of active infection&#46;<br><span class="elsevierStyleHsp" style=""></span>&#8211; It is suggested that NSAIDs should be discontinued at least 3 to 4 times their half life or 2&#8211;3 days before orthopaedic surgery &#40;especially surgery involving the tendons and soft tissues&#41; and restarted only when wound healing has taken place &#40;6 weeks at least&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">93</span></a> &#40;Low quality of evidence&#44; weak recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Patients receiving treatment with GC who are to be operated&#44; should be given the following according to the type of surgery they are to undergo<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">94</span></a> &#40;low quality of evidence&#44; weak recommendation&#41;&#58;<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8211; 25<span class="elsevierStyleHsp" style=""></span>mg hydrocortisone &#40;or the equivalent dose of GC&#41;&#44; a single dose on the day of surgery for minor surgery &#40;abdominal wall plasty&#44; colonoscopy&#44; for example&#41;<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8211; From 50 to 75<span class="elsevierStyleHsp" style=""></span>mg of hydrocortisone &#40;or the equivalent dose of GC&#41; on the day of surgery and at 24<span class="elsevierStyleHsp" style=""></span>h resume the usual dose for moderate surgery &#40;cholecystectomy&#44; hemicolectomy&#41;<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8211; From 100 to 150<span class="elsevierStyleHsp" style=""></span>mg of hydrocortisone &#40;or the equivalent dose of GC&#41; on the day of surgery and resume the usual dose at 24<span class="elsevierStyleHsp" style=""></span>h for major surgery &#40;major cardiothoracic surgery&#44; Whipple&#39;s procedure&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; It is recommended that haemostasis-altering drugs should be managed as follows<a class="elsevierStyleCrossRefs" href="#bib0475"><span class="elsevierStyleSup">95&#8211;97</span></a> &#40;moderate quality of evidence&#44; weak recommendation&#41;&#58;<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8211; Acetylsalicylic acid and clopidogrel&#58; suspend 7 days before surgery and restart 24&#8211;48<span class="elsevierStyleHsp" style=""></span>h after the event<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8211; Dipyridamole&#58; suspend from 7 to 14 days before surgery<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8211; Direct-Acting Oral Anticoagulants &#40;DOACs&#41; &#40;rivaroxaban&#44; dabigatran and apixaban&#41;&#58; suspend from 24<span class="elsevierStyleHsp" style=""></span>h to 48<span class="elsevierStyleHsp" style=""></span>h before surgery<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8211; Unfractionated heparin&#58; suspend from 4<span class="elsevierStyleHsp" style=""></span>h to 6<span class="elsevierStyleHsp" style=""></span>h prior to surgery<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8211; Low-molecular weight heparin&#58; suspend at least 12&#8211;18<span class="elsevierStyleHsp" style=""></span>h prior to the surgical event&#44; and restart 48<span class="elsevierStyleHsp" style=""></span>h to 72<span class="elsevierStyleHsp" style=""></span>h after it<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8211; Warfarin&#58; suspend 5 days before surgery&#46; For elective surgery&#44; it is recommended that patients using warfarin should have an international normalized ratio less than 1&#46;5&#44; with an international normalized ratio &#40;INR&#41; of over 1&#46;8 it is recommended that 1<span class="elsevierStyleHsp" style=""></span>mg vitamin K should be administered intravenously&#46;<a class="elsevierStyleCrossRefs" href="#bib0475"><span class="elsevierStyleSup">95&#8211;97</span></a> &#40;Moderate quality of evidence&#44; weak recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; In the event of emergency surgery give 5<span class="elsevierStyleHsp" style=""></span>mg of vitamin K intravenously or fresh frozen plasma&#44; start with 2 units of Prothrombinex-HT&#46;<a class="elsevierStyleCrossRefs" href="#bib0475"><span class="elsevierStyleSup">95&#8211;97</span></a> &#40;Moderate quality of evidence&#44; weak recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; For patients who are not taking anticoagulant medication and who require major surgery&#44; thromboprophylaxis with low molecular weight heparin is suggested 12<span class="elsevierStyleHsp" style=""></span>h before surgery and extended to 35 days after it&#46;<a class="elsevierStyleCrossRefs" href="#bib0475"><span class="elsevierStyleSup">95&#8211;97</span></a> &#40;Moderate quality of evidence&#44; weak recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; For patients with severe lupus undergoing orthopaedic surgery &#40;such as to the hip or knee&#41; it is recommended that the current doses of MMF&#44; azathioprine&#44; cyclosporine and tacrolimus should be continued&#46;<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">98</span></a> &#40;Low quality of evidence&#44; weak recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; For patients with non-severe lupus undergoing orthopaedic surgery &#40;such as to the hip or knee&#41;&#44; it is recommended that MMF&#44; azathioprine&#44; cyclosporine and tacrolimus should be suspended one week before the surgery&#44; and resumed 5 days after it if there is no infection or complication in wound healing&#46;<a class="elsevierStyleCrossRefs" href="#bib0490"><span class="elsevierStyleSup">98&#44;99</span></a> &#40;Low quality of evidence&#44; weak recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; It is recommended that current doses of methotrexate&#44; HCQ&#44; antimalarials&#44; sulfasalazine should be continued during the perioperative period&#46;<a class="elsevierStyleCrossRefs" href="#bib0490"><span class="elsevierStyleSup">98&#44;99</span></a> &#40;Low quality of evidence&#44; weak recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; For hip surgery&#44; it is recommended that broad spectrum antibiotics at conventional doses should be given one day before surgery&#44; and continued from 5 to 7 days after it&#46;<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">92</span></a> &#40;Low quality of evidence&#44; weak recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; For patients using rituximab&#44; it is recommended that surgery should be scheduled for month 7 after it has been given&#46;<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">99</span></a> &#40;Low quality of evidence&#44; weak recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; For patients using belimumab&#44; it is recommended that surgery should be scheduled in week 5 after it has been given&#46;<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">99</span></a> &#40;Low quality of evidence&#44; weak recommendation&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Nephritis in Mexican patients &#40;Latin and Central Americans&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8211; Remission induction treatment with MMF &#40;2&#8211;3<span class="elsevierStyleHsp" style=""></span>g&#47;day&#41; or CYC &#40;1<span class="elsevierStyleHsp" style=""></span>g&#47;m<span class="elsevierStyleSup">2</span> of body surface area per month&#41;<a class="elsevierStyleCrossRefs" href="#bib0500"><span class="elsevierStyleSup">100&#44;101</span></a> is recommended for this population&#46; &#40;Moderate quality of evidence&#44; strong recommendation&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Nephritis I and II</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8211; Treatment with immunosuppressants is recommended for nephritis I and II with impaired kidney function&#44; active sediment or proteinuria &#8805;1<span class="elsevierStyleHsp" style=""></span>g&#47;day&#46;<a class="elsevierStyleCrossRefs" href="#bib0510"><span class="elsevierStyleSup">102&#8211;104</span></a> &#40;Low quality of evidence&#44; weak recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; For the treatment of nephritis I or II&#44; evaluating toxicity&#47;benefit&#44; aziathioprine &#40;from 1 to 2<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day&#41;&#44; MMF &#40;from 1 to 2<span class="elsevierStyleHsp" style=""></span>g&#47;day&#41; or CYC &#40;from &#46;750 to 1<span class="elsevierStyleHsp" style=""></span>g&#47;m<span class="elsevierStyleSup">2</span> of body surface area per month&#41; combined with GC&#44; at medium doses &#40;&#46;5<span class="elsevierStyleHsp" style=""></span>g&#47;kg prednisone&#41; with gradual tapering&#44; for a minimum period of 6 months&#46;<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">103</span></a> &#40;Low quality of evidence&#44; weak recommendation&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Induction treatment for nephritis III&#47;IV and V with proliferative component</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8211; Patients with nephritis class III&#47;IV and V with a proliferative component require a remission induction treatment regimen which could comprise MMF &#40;2&#8211;3<span class="elsevierStyleHsp" style=""></span>g&#47;day&#41; or CYC &#40;monthly pulses of 1<span class="elsevierStyleHsp" style=""></span>g&#47;m<span class="elsevierStyleSup">2</span> of body surface area or reduced dose according to Euro-Lupus&#41;&#44; combined with gradual tapering of steroids&#44; for a minimum period of 6 months&#46;<a class="elsevierStyleCrossRefs" href="#bib0525"><span class="elsevierStyleSup">105&#8211;108</span></a> &#40;High quality of evidence&#44; strong recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; If there is no response to these regimens&#44; rituximab&#44; tacrolimus&#44; azathioprine or combined therapy with different therapeutic targets are recommended&#46;<a class="elsevierStyleCrossRefs" href="#bib0535"><span class="elsevierStyleSup">107&#44;109&#8211;113</span></a> &#40;Moderate quality of evidence&#44; strong recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; GC should be used in pulses &#40;1<span class="elsevierStyleHsp" style=""></span>g methylprednisolone for 3 days&#41; or orally &#40;from &#46;5 to 1<span class="elsevierStyleHsp" style=""></span>g&#47;kg of prednisone&#41; as concomitant initial treatment&#44; with gradual tapering&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> &#40;Moderate quality of evidence&#44; strong recommendation&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Class V nephritis with no proliferative component</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8211; MMF should be considered &#40;from 2 to 3<span class="elsevierStyleHsp" style=""></span>g&#47;day&#41; or azathioprine &#40;from 1 to 3<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0500"><span class="elsevierStyleSup">100&#44;112&#44;115</span></a> &#40;High quality of evidence&#44; strong recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Tacrolimus&#44; cyclosporine A&#44; cyclophosphamide or rituximab could be considered for patients who are refractory to treatment&#46;<a class="elsevierStyleCrossRefs" href="#bib0550"><span class="elsevierStyleSup">110&#44;116&#44;117</span></a> &#40;Moderate quality of evidence&#44; weak recommendation&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Maintenance therapy for nephritis III&#47;IV and V with proliferative component</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8211; MMF should be considered &#40;from 2 to 3<span class="elsevierStyleHsp" style=""></span>g&#47;day&#41; or azathioprine &#40;from 1 to 3<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day&#41; long term &#40;a minimum follow-up of 18 months&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0570"><span class="elsevierStyleSup">114&#44;118&#44;119</span></a> &#40;High quality of evidence&#44; strong recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; For patients who are intolerant to MMF or azathioprine&#44; quarterly CYC&#44; tacrolimus&#44; cyclosporine A or rituximab could be considered&#46;<a class="elsevierStyleCrossRef" href="#bib0550"><span class="elsevierStyleSup">110</span></a> &#40;Moderate quality of evidence&#44; weak recommendation&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Rapidly progressive nephritis&#47;with cellular crescents</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8211; Induction management with CYC 750<span class="elsevierStyleHsp" style=""></span>mg to 1<span class="elsevierStyleHsp" style=""></span>g&#47;m<span class="elsevierStyleSup">2</span> of body surface area monthly is recommended&#44; or&#44; MMF &#40;from 2 to 3<span class="elsevierStyleHsp" style=""></span>g&#47;day for 6 months&#41;&#46; Both options with administration of pulses of methylprednisone 1<span class="elsevierStyleHsp" style=""></span>g&#47;day for 3 days or prednisone at high doses &#40;1<span class="elsevierStyleHsp" style=""></span>g&#47;kg&#47;day with gradual tapering according to outcome&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0600"><span class="elsevierStyleSup">120&#44;121</span></a> &#40;Moderate quality of evidence&#44; strong recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Tacrolimus is recommended at doses of &#46;1&#8211;&#46;15<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day orally in two divided doses&#44; titrated to maintain minimum levels of 6 to 8<span class="elsevierStyleHsp" style=""></span>ng&#47;for 12<span class="elsevierStyleHsp" style=""></span>h&#44; and should be considered as an alternative induction treatment to iv CF or MMF&#46;<a class="elsevierStyleCrossRef" href="#bib0605"><span class="elsevierStyleSup">121</span></a> &#40;Moderate quality of evidence&#44; strong recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Rituximab could be considered<a class="elsevierStyleCrossRefs" href="#bib0610"><span class="elsevierStyleSup">122&#44;123</span></a> or multitarget therapy<a class="elsevierStyleCrossRef" href="#bib0620"><span class="elsevierStyleSup">124</span></a> for the management of refractory cases&#44; assessing risk over benefit&#46; &#40;Low quality of evidence&#44; weak recommendation&#41;&#46;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Maintenance treatment can be with MMF &#40;from 2 to 3<span class="elsevierStyleHsp" style=""></span>g&#47;day&#41;&#44; azathioprine &#40;from 2 to 3<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day&#41; and prednisone at a tapering dose&#46;<a class="elsevierStyleCrossRef" href="#bib0570"><span class="elsevierStyleSup">114</span></a> &#40;Low quality of evidence&#44; strong recommendation&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Adjuvant management</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8211; Weight control is recommended for obese patients&#44; because of the benefits in preventing progression of kidney disease and controlling blood pressure&#46;<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">125</span></a> &#40;High quality of evidence&#44; strong recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; ACE-I and AIIRA are recommended as antiproteinuric agents&#46;<a class="elsevierStyleCrossRefs" href="#bib0625"><span class="elsevierStyleSup">125&#44;126</span></a> &#40;High quality of evidence&#44; strong recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Strict control of blood pressure with goals at lower than 130&#47;80<span class="elsevierStyleHsp" style=""></span>mmHg&#44; and control of other cardiovascular risk factors such as smoking&#46;<a class="elsevierStyleCrossRefs" href="#bib0625"><span class="elsevierStyleSup">125&#44;127</span></a> &#40;High quality of evidence&#44; strong recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Control of dyslipidaemia is recommended&#44; with goals of LDL cholesterol &#60;100<span class="elsevierStyleHsp" style=""></span>mg&#47;dl and triglycerides &#60;<span class="elsevierStyleHsp" style=""></span>150<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#46;<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">125</span></a> &#40;Moderate quality of evidence&#44; strong recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Permanent HCQ 5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day is recommended to reduce the likelihood of renal relapse&#44;<a class="elsevierStyleCrossRefs" href="#bib0640"><span class="elsevierStyleSup">128&#8211;130</span></a> and for its benefits on dyslipidaemia&#46;<a class="elsevierStyleCrossRef" href="#bib0655"><span class="elsevierStyleSup">131</span></a> &#40;High quality of evidence&#44; strong recommendation&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Periodic monitoring of response</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8211; Monitoring of the response to treatment of lupus nephritis should be individualised&#44; and urinary sediment&#44; 24<span class="elsevierStyleHsp" style=""></span>h urine protein or PR&#47;Cr ratio&#44; serum creatinine&#44; complement and anti-DsDNA tests are accepted as the most useful tools to that end&#46;<a class="elsevierStyleCrossRefs" href="#bib0515"><span class="elsevierStyleSup">103&#44;125</span></a> &#40;High quality of evidence&#44; strong recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Monthly monitoring is recommended during the remission induction period&#44; and quarterly for maintenance&#46;<a class="elsevierStyleCrossRefs" href="#bib0515"><span class="elsevierStyleSup">103&#44;132</span></a> &#40;High quality of evidence&#44; strong recommendation&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Treatment of relapses</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8211; It is recommended that remission induction treatment that has previously been effective should be repeated&#46;<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">125</span></a> &#40;Moderate quality of evidence&#44; strong recommendation&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Management with renal replacement therapy and transplantation</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8211; For patients with chronic kidney failure due to lupus nephritis&#44; renal transplantation is recommended as the best option for long-term treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0665"><span class="elsevierStyleSup">133</span></a> &#40;High quality of evidence&#44; strong recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8211; Haemodialysis is recommended as the first replacement therapy option for patients in chronic kidney failure due to lupus nephritis&#44; since peritoneal dialysis has been associated with a greater number of complications&#44; and mortality due to immunosuppressants&#46;<a class="elsevierStyleCrossRef" href="#bib0670"><span class="elsevierStyleSup">134</span></a> &#40;Moderate quality of evidence&#44; strong recommendation&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Lupus nephritis in patients wanting to become pregnant</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8211; It is recommended that all women desiring pregnancy should have been in remission from the disease for at least 6 months before conception&#46;<a class="elsevierStyleCrossRef" href="#bib0675"><span class="elsevierStyleSup">135</span></a> &#40;High quality of evidence&#44; strong recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Pregnancy is not recommended if creatinine levels exceed 2&#46;8<span class="elsevierStyleHsp" style=""></span>mg&#47;dl or there is clear evidence of disease activity&#46;<a class="elsevierStyleCrossRef" href="#bib0680"><span class="elsevierStyleSup">136</span></a> &#40;High quality of evidence&#44; strong recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; For patients with lupus nephritis we recommend a change of immunosuppressant medication and antihypertensives to those allowed in pregnancy to maintain remission&#44; and to prevent relapse&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;137</span></a> &#40;High quality of evidence&#44; strong recommendation&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Pericarditis</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8211; NSAIDs&#58; in cases of mild&#44; acute or chronic pericarditis&#44; with or without effusion&#44; aspirin &#40;500<span class="elsevierStyleHsp" style=""></span>mg orally every 12<span class="elsevierStyleHsp" style=""></span>h&#41; is recommended or indomethacine &#40;50<span class="elsevierStyleHsp" style=""></span>mg every 12<span class="elsevierStyleHsp" style=""></span>h orally&#41; or ibuprofen &#40;600<span class="elsevierStyleHsp" style=""></span>mg every 8<span class="elsevierStyleHsp" style=""></span>h orally&#41; until there is improvement in clinical symptoms&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">26&#44;138</span></a> &#40;Low quality of evidence&#44; weak recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Glucocorticoids&#58; in the case of acute or chronic pericarditis with pericardial effusion&#44; prednisone &#40;&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day&#41; is recommended for patients whose initial manifestation is mild to moderate pericarditis&#46; In the case of severe or constrictive pericarditis&#44; methylprednisolone pulses &#40;1<span class="elsevierStyleHsp" style=""></span>g&#47;day for 3 days&#41; are recommended&#46;<a class="elsevierStyleCrossRefs" href="#bib0695"><span class="elsevierStyleSup">139&#8211;143</span></a> &#40;Moderate quality of evidence&#44; strong recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Colchicine&#58; for patients with recurrent pericarditis or recent onset pericarditis&#44; 1<span class="elsevierStyleHsp" style=""></span>mg colchicine is recommended in combination with conventional treatment with steroids and immunosuppressants until remission is achieved&#46; In order to avoid relapse of pericarditis&#44; the addition of colchicine &#40;1<span class="elsevierStyleHsp" style=""></span>mg&#47;day for at least one month&#41; is recommended&#46;<a class="elsevierStyleCrossRefs" href="#bib0700"><span class="elsevierStyleSup">140&#44;144&#44;145</span></a> &#40;Moderate quality of evidence&#44; weak recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Surgery&#58; surgery for pericarditis is recommended for pericarditis that is resistant to treatment or tamponade that does not respond to pharmacological treatment&#46; &#40;Good practice&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Myocarditis</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8211; Steroids&#58; pulses of GC are recommended&#44; methylprednisolone &#40;1<span class="elsevierStyleHsp" style=""></span>g&#47;day for 3 days&#41; for cases of severe myocarditis with arrhythmia&#44; ventricular ejection fraction &#60;55&#37;&#44; and the administration of prednisone &#40;from &#46;5 to 1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day&#41; after pulse administration&#46;<a class="elsevierStyleCrossRef" href="#bib0730"><span class="elsevierStyleSup">146</span></a> &#40;Low quality of evidence&#44; strong recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Antimalarials&#58; HCQ at doses of 200&#8211;400<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#44; or chloroquine &#40;from 150 to 300<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#41; for the maintenance stage are recommended&#46;<a class="elsevierStyleCrossRef" href="#bib0730"><span class="elsevierStyleSup">146</span></a> &#40;Low quality of evidence&#44; weak recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Cyclophosphamide&#58; in the case of severe manifestation with arrhythmia or ventricular ejection fraction of less than 40&#37;&#44; the use of intravenous CYC at doses of &#46;5&#8211;1<span class="elsevierStyleHsp" style=""></span>g&#47;m<span class="elsevierStyleSup">2</span> of body surface area is recommended for 3&#8211;10 months as first line treatment together with steroids&#46;<a class="elsevierStyleCrossRef" href="#bib0735"><span class="elsevierStyleSup">147</span></a> Based on the experience of the panel of experts&#44; it is recommended that it should be administered for at least 3 months awaiting a response&#59; if there is no response&#44; discontinue to prevent the risk of toxicity&#44; and if there is a response&#44; a minimum of 6 months&#8217; treatment is recommended&#46; &#40;Moderate quality of evidence&#44; strong recommendation&#41;<br>Mycophenolic acid&#58; MMF is recommended at doses of 2<span class="elsevierStyleHsp" style=""></span>g&#47;day in divided doses&#44; as maintenance therapy after intravenous CYC&#44; to reduce relapses&#46;<a class="elsevierStyleCrossRef" href="#bib0730"><span class="elsevierStyleSup">146</span></a> &#40;Moderate quality of evidence&#44; weak recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Azathioprine&#58; Azathioprine &#40;from 2 to 3<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day&#41; is recommended as maintenance therapy after CYC in patients who are intolerant to MMF<a class="elsevierStyleCrossRef" href="#bib0730"><span class="elsevierStyleSup">146</span></a> and cytopenias should be monitored &#40;HB&#41;&#46; &#40;Low quality of evidence&#44; weak recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Gammaglobulin&#58; in the case of complicated myocarditis&#44; gammaglobulin at doses of 400<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day for 5 days is recommended for patients for whom standard induction therapy with oral or intravenous steroids and CYC has failed&#46;<a class="elsevierStyleCrossRef" href="#bib0730"><span class="elsevierStyleSup">146</span></a> The onset of hypertension during infusion&#44; as well as anaphylactic reactions&#44; should be considered&#46; &#40;Low quality of evidence&#44; weak recommendation&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Pulmonary hypertension</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8211; Steroids&#58; CG at doses of &#46;5 at 1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day for 4 weeks with gradual tapering to minimum doses of 5<span class="elsevierStyleHsp" style=""></span>mg daily for maintenance or until discontinued&#46;<a class="elsevierStyleCrossRefs" href="#bib0740"><span class="elsevierStyleSup">148&#44;149</span></a> &#40;Moderate quality of evidence&#44; strong recommendation&#41;&#46; The use of methylprednisolone pulses at doses of 1<span class="elsevierStyleHsp" style=""></span>g&#47;day for 3 days was suggested for severe cases when they coincide with the involvement of other organs and relapses&#46;<a class="elsevierStyleCrossRefs" href="#bib0750"><span class="elsevierStyleSup">150&#44;151</span></a> &#40;Low quality of evidence&#44; strong recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Cyclophosphamide&#58; it is recommended that CYC is used at doses of 600<span class="elsevierStyleHsp" style=""></span>mg&#47;m<span class="elsevierStyleSup">2</span> of body surface area for 3&#8211;6 months as immunosuppressant treatment combined with GC&#44; vasodilators&#44; diuretics&#44; and other support means&#46;<a class="elsevierStyleCrossRefs" href="#bib0750"><span class="elsevierStyleSup">150&#44;152</span></a> Other regimens suggested were 500&#8211;1000<span class="elsevierStyleHsp" style=""></span>mg&#47;m<span class="elsevierStyleSup">2</span> of body surface area monthly for 3&#8211;6 months&#46;<a class="elsevierStyleCrossRef" href="#bib0745"><span class="elsevierStyleSup">149</span></a> &#40;Moderate quality of evidence&#44; strong recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Mycophenolic acid&#58; MMF &#40;from 2 to 3<span class="elsevierStyleHsp" style=""></span>g&#47;day&#41; is recommended as maintenance after CYC or in the case of intolerance or if IV CYC is contraindicated&#46;<a class="elsevierStyleCrossRef" href="#bib0755"><span class="elsevierStyleSup">151</span></a> &#40;Low quality of evidence&#44; weak recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Calcium channel blockers&#58; calcium channel blockers cannot be recommended because there is insufficient evidence regarding their efficacy and safety in pulmonary hypertension associated with SLE&#46;<a class="elsevierStyleCrossRefs" href="#bib0765"><span class="elsevierStyleSup">153&#44;154</span></a> &#40;Low quality of evidence&#44; weak recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Prostanoids&#58; For patients with NYHA functional class III and IV&#44; the use of epoprostenol is recommended administered intravenously by central venous catheter with continuous infusion pump at doses of 2&#8211;40<span class="elsevierStyleHsp" style=""></span>ng&#47;kg&#47;min for 3&#8211;6 months&#44; starting with 2&#8211;4<span class="elsevierStyleHsp" style=""></span>ng&#47;kg<span class="elsevierStyleHsp" style=""></span>min&#44; and gradually increasing the dose&#46;<a class="elsevierStyleCrossRefs" href="#bib0765"><span class="elsevierStyleSup">153&#8211;156</span></a> &#40;High quality of evidence&#44; strong recommendation&#41;&#46; Treprostinil is recommended at doses of 1&#46;25&#8211;2&#46;5<span class="elsevierStyleHsp" style=""></span>ng&#47;kg&#47;min intravenously by continuous infusion pump increasing by 1&#46;25&#8211;2&#46;5<span class="elsevierStyleHsp" style=""></span>mg every 1&#8211;2 weeks&#44; to a maximum dose of 22&#46;5<span class="elsevierStyleHsp" style=""></span>ng&#47;kg&#47;min for 12 weeks for patients with SLE&#44; and NYHA functional class III and IV&#46;<a class="elsevierStyleCrossRefs" href="#bib0765"><span class="elsevierStyleSup">153&#44;154&#44;157</span></a> &#40;Moderate quality of evidence&#44; weak recommendation&#41;&#46;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Endothelin receptor antagonists&#58; bosentan is recommended at doses of 62&#46;5<span class="elsevierStyleHsp" style=""></span>mg twice daily for 4 weeks with follow-up 125<span class="elsevierStyleHsp" style=""></span>mg twice daily for 3&#8211;12 months combined with GC and immunosuppressants as first line management for patients with NYHA functional class II and III&#46;<a class="elsevierStyleCrossRefs" href="#bib0765"><span class="elsevierStyleSup">153&#44;158&#44;159</span></a> &#40;High quality of evidence&#44; strong recommendation&#41;&#46; Sitaxentan and ambisentan are not recommended since there is no evidence of their efficacy and safety in the management of PHT in SLE&#46;<a class="elsevierStyleCrossRef" href="#bib0765"><span class="elsevierStyleSup">153</span></a> &#40;High quality of evidence&#44; strong recommendation&#41;&#46;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Phosphodiesterase inhibitors &#40;PDE-5&#41;<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a>&#58; Sildenafil is recommended at initial doses of 20<span class="elsevierStyleHsp" style=""></span>mg&#44; 3 times a day&#59; it can be gradually increased to 80<span class="elsevierStyleHsp" style=""></span>mg&#44; 3 times a day&#44; as tolerated by the patient for better results long term or as first line management for patients with PHT and NYHA functional class II and III&#46;<a class="elsevierStyleCrossRefs" href="#bib0790"><span class="elsevierStyleSup">158&#44;159</span></a> &#40;High quality of evidence&#44; strong recommendation&#41;&#46; It is recommended that its use should be considered for patients of functional class IV&#46;<a class="elsevierStyleCrossRefs" href="#bib0790"><span class="elsevierStyleSup">158&#8211;161</span></a> &#40;Low quality of evidence&#44; weak recommendation&#41;&#46;<br><span class="elsevierStyleHsp" style=""></span>&#8211; For patients with pulmonary hypertension NYHA functional class III and IV&#44; doses of 20<span class="elsevierStyleHsp" style=""></span>mg&#47;day are recommended&#44; gradually increased to 40<span class="elsevierStyleHsp" style=""></span>mg&#47;day as tolerated by the patient&#44; as second line therapy and in combination with immunosuppressant therapy&#46;<a class="elsevierStyleCrossRefs" href="#bib0745"><span class="elsevierStyleSup">149&#44;153&#44;158&#44;159</span></a> &#40;Moderate quality of evidence&#44; weak recommendation&#41;&#46; Vardenafil is not recommended due to a lack of evidence for the treatment of pulmonary hypertension&#46;<a class="elsevierStyleCrossRef" href="#bib0795"><span class="elsevierStyleSup">159</span></a> &#40;Msoderate quality of evidence&#44; weak recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Combined therapy&#58; combined therapy with vasodilators&#44; PDE-5 inhibitors and endothelin-1 receptor antagonists is not recommended for patients with SLE due to a lack of evidence&#46;<a class="elsevierStyleCrossRefs" href="#bib0765"><span class="elsevierStyleSup">153&#44;154</span></a> &#40;Moderate quality of evidence&#44; weak recommendation&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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            0 => array:3 [
              "identificador" => "tblfn0010"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0010">The PPI sildenafil is not indicated in Mexico for pulmonary hypertension&#44; and is only available in presentations of 50 and 100<span class="elsevierStyleHsp" style=""></span>mg&#46; The dosage can be adjusted or start with doses of 25<span class="elsevierStyleHsp" style=""></span>mg&#44; lower than the 50 and 100<span class="elsevierStyleHsp" style=""></span>mg tablet fractions&#46;</p>"
            ]
          ]
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        "descripcion" => array:1 [
          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Recommendations for Cardiovascular Manifestations&#46;</p>"
        ]
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      6 => array:8 [
        "identificador" => "tbl0035"
        "etiqueta" => "Table 7"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at7"
            "detalle" => "Table "
            "rol" => "short"
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        ]
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Pleuritis with or without pleural effusion</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8211; NSAIDs&#58; these are recommended as a treatment group&#44; preferably naproxen at doses of 250&#8211;500<span class="elsevierStyleHsp" style=""></span>mg every 12<span class="elsevierStyleHsp" style=""></span>h for 1&#8211;2 weeks&#44; although any NSAID is acceptable&#46; It is recommended that contraindications &#40;gastrointestinal&#44; renal failure&#44; uncontrolled systemic arterial hypertension&#44; heart failure&#41; for NSAIDs should be assessed&#46;<a class="elsevierStyleCrossRefs" href="#bib0810"><span class="elsevierStyleSup">162&#44;163</span></a> &#40;Moderate quality of evidence&#44; strong recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Glucocorticoids&#58; these are indicated after there has been no therapeutic response with NSAIDs over a period of 1&#8211;2 weeks&#46; We recommend the use of prednisone in doses of 20<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#44; tapered over a period of 2&#8211;3 weeks&#46;<a class="elsevierStyleCrossRefs" href="#bib0810"><span class="elsevierStyleSup">162&#44;163</span></a> &#40;Moderate quality of evidence&#44; strong recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Other immunosuppressants&#58; These are not recommended due to a lack of evidence&#44; and because they are rarely required in this context&#46; &#40;Good practice recommendation&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Acute lupus pneumonitis</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8211; Glucocorticoids&#58; prednisone is recommended at doses of 1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day for 3 days&#44; and assessing the clinical response&#59; if there is no response&#44; then consider methylprednisolone pulses at doses of 1<span class="elsevierStyleHsp" style=""></span>g&#47;day for 3 days&#46;<a class="elsevierStyleCrossRef" href="#bib0820"><span class="elsevierStyleSup">164</span></a> &#40;Moderate quality of evidence&#44; strong recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Cyclophosphamide&#58; in cases refractory to GC&#44; CYC can be considered in monthly pulses &#40;from &#46;5 to 1<span class="elsevierStyleHsp" style=""></span>g&#47;m<span class="elsevierStyleSup">2</span> of body surface&#59; from 3 to 6 monthly pulses&#41; monitoring for toxic effects &#40;haemorrhagic cystitis&#44; myelotoxicity&#44; infections&#41;&#46; Premedicate with hydration&#44; antiemetic and MESNA&#46;<a class="elsevierStyleCrossRef" href="#bib0820"><span class="elsevierStyleSup">164</span></a> &#40;Low quality of evidence&#44; weak recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Intravenous immunoglobulin&#58; it is recommended for consideration in refractory cases or where treatment with immunosuppressants is contraindicated&#44; at a dose of 2<span class="elsevierStyleHsp" style=""></span>g&#47;kg for 5 days &#40;400<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0815"><span class="elsevierStyleSup">163&#8211;165</span></a> &#40;Low quality of evidence&#44; weak recommendation&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Interstitial lung disease in systemic lupus erythematosus</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8211; General measures&#58; Smoking must be given up&#44; consider supplementary oxygen as necessary&#44; and influenza and pneumococcal vaccination&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">65</span></a> &#40;Moderate quality of evidence&#44; strong recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8211; Glucocorticoids&#58; prednisone is recommended at doses of &#46;5&#8211;1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day&#44; monitor respiratory symptoms&#44; and carbon monoxide diffusion capacity to define response&#44; and monitor for adverse effects &#40;infections&#44; osteoporosis&#44; systemic arterial hypertension&#44; secondary diabetes mellitus&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0830"><span class="elsevierStyleSup">166</span></a> &#40;Moderate quality of evidence&#44; strong recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Immunosuppressants&#58; monthly pulses of CYC&#44; azathioprine&#44; MMF are recommended as steroid savers&#46;<a class="elsevierStyleCrossRef" href="#bib0835"><span class="elsevierStyleSup">167</span></a> Azathioprine and MMF are used at the usual doses in mild to moderate cases&#46; Monthly CYC pulses of &#46;5&#8211;1<span class="elsevierStyleHsp" style=""></span>g&#47;m<span class="elsevierStyleSup">2</span> of body surface area &#40;from 6 to 12 months&#41; is reserved for severe cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0825"><span class="elsevierStyleSup">165&#44;166</span></a> &#40;Moderate quality of evidence&#44; strong recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Rituximab&#58; rituximab is recommended for use in refractory cases at the usual doses of 375<span class="elsevierStyleHsp" style=""></span>mg&#47;m<span class="elsevierStyleSup">2</span> of body surface area in 4 weekly doses or 1<span class="elsevierStyleHsp" style=""></span>g total dose for administration in 2 separate doses&#44; separated by 15 days&#46;<a class="elsevierStyleCrossRefs" href="#bib0825"><span class="elsevierStyleSup">165&#44;166</span></a> &#40;Low quality of evidence&#44; weak recommendation&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Pulmonary haemorrhage in systemic lupus erythematosus</span><a class="elsevierStyleCrossRef" href="#bib0825"><span class="elsevierStyleSup">165</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8211; Glucocorticoids&#58; the use of methylprednisolone pulses at doses of 1<span class="elsevierStyleHsp" style=""></span>g&#47;day for 3&#8211;5 days is recommended&#46;<a class="elsevierStyleCrossRefs" href="#bib0840"><span class="elsevierStyleSup">168&#44;169</span></a> &#40;Moderate quality of evidence&#44; strong recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Immunosuppressants&#58; the use of CYC pulses is recommended at doses of &#46;5&#8211;1<span class="elsevierStyleHsp" style=""></span>g&#47;m<span class="elsevierStyleSup">2</span> of body surface area &#40;from 6 to 12 monthly pulses&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0845"><span class="elsevierStyleSup">169&#44;170</span></a> &#40;Low quality of evidence&#44; strong recommendation&#41;&#46; Use of MMF &#40;from 2 to 3<span class="elsevierStyleHsp" style=""></span>g&#47;day&#41; is recommended&#44; and azathioprine &#40;from 2 to 3<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0840"><span class="elsevierStyleSup">168&#44;170</span></a> &#40;Low quality of evidence&#44; strong recommendation&#46; Rituximab is recommended with or without pulses of CYC for refractory cases or cases intolerant to CYC pulses&#46;<a class="elsevierStyleCrossRef" href="#bib0855"><span class="elsevierStyleSup">171</span></a> &#40;Low quality of evidence&#44; strong recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Intravenous immunoglobulin&#58; recommended for cases that are refractory to the usual treatment at doses of 2<span class="elsevierStyleHsp" style=""></span>g&#47;kg by infusion for 5 days &#40;400<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0850"><span class="elsevierStyleSup">170</span></a> &#40;Low quality of evidence&#44; strong recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Factor VIIa activated recombinant&#58; consider the use of factor VIIa recombinant for refractory cases&#46;<a class="elsevierStyleCrossRef" href="#bib0860"><span class="elsevierStyleSup">172</span></a> &#40;Low quality of evidence&#44; weak recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Antibiotics&#58; in the event of pulmonary haemorrhage associated with pulmonary infectious processes&#44; bronchial secretion cultures are recommended&#44; and antibiotic coverage where necessary&#46;<a class="elsevierStyleCrossRef" href="#bib0850"><span class="elsevierStyleSup">170</span></a> &#40;Moderate quality of evidence&#44; strong recommendation&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Recommendations for Pulmonary Manifestations&#46;</p>"
        ]
      ]
      7 => array:8 [
        "identificador" => "tbl0040"
        "etiqueta" => "Table 8"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at8"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">General recommendations</span><a class="elsevierStyleCrossRef" href="#bib0825"><span class="elsevierStyleSup">165</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8211; Patients with SLE and a neurological or psychiatric manifestation must be studied in the same way as patients without lupus&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> &#40;Moderate quality of evidence&#44; strong recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; According to the neurological or psychiatric manifestation presented by the patient&#44; electroencephalogram&#44; nerve conduction velocities&#44; electomyography&#44; lumbar puncture&#44; neuropsychological tests&#44; somatosensorial evoked potentials&#44; and brain and spinal magnetic resonance imaging including conventional T1&#44; T2 and FLAIR sequences&#44; as well as T1 gadolinium-enhanced sequence should be performed&#46;<a class="elsevierStyleCrossRef" href="#bib0865"><span class="elsevierStyleSup">173</span></a> &#40;Moderate quality of evidence&#44; strong recommendation&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Cognitive dysfunction</span><a class="elsevierStyleCrossRef" href="#bib0825"><span class="elsevierStyleSup">165</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8211; Management of associated factors such as anxiety and depression is recommended&#44; and control of cardiovascular risk factors as well as psychological support&#44; since this can prevent major cognitive impairment&#46;<a class="elsevierStyleCrossRef" href="#bib0870"><span class="elsevierStyleSup">174</span></a> &#40;Low quality of evidence&#44; weak recommendation&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Seizures</span><a class="elsevierStyleCrossRef" href="#bib0825"><span class="elsevierStyleSup">165</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8211; Antiepileptic drugs&#58; antiepileptic drugs are recommended if there are recurrent seizures or if there have been at least 2 episodes in the first 24<span class="elsevierStyleHsp" style=""></span>h or there is epileptogenic activity on the electroencephalogram&#46;<a class="elsevierStyleCrossRef" href="#bib0875"><span class="elsevierStyleSup">175</span></a> &#40;Moderate quality of evidence&#44; strong recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Methylprednisolone&#58; For refractory seizures associated with SLE activity&#44; intravenous methylprednisolone is recommended &#40;1<span class="elsevierStyleHsp" style=""></span>g&#47;day for 3 days&#41;&#44; followed by prednisone &#40;1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day for no more than 3 months&#41;&#44; and tapered according to the activity of the disease&#46;<a class="elsevierStyleCrossRef" href="#bib0880"><span class="elsevierStyleSup">176</span></a> &#40;Moderate quality of evidence&#44; strong recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Cyclophosphamide&#58; Concomitant intravenous CYC &#46;75<span class="elsevierStyleHsp" style=""></span>g&#47;m<span class="elsevierStyleSup">2</span> of body surface area every month for 12 months is recommended&#46;<a class="elsevierStyleCrossRef" href="#bib0880"><span class="elsevierStyleSup">176</span></a> &#40;Moderate quality of evidence&#44; strong recommendation&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Peripheral neuropathy&#44; myelopathy and optic neuritis</span><a class="elsevierStyleCrossRef" href="#bib0825"><span class="elsevierStyleSup">165</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8211; Methylprednisolone&#58; Intravenous methylprednisolone is recommended at 1<span class="elsevierStyleHsp" style=""></span>g&#47;day for 3 days&#44; followed by prednisone &#40;1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day for no more than 3 months&#41;&#44; tapered according to the activity of the disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0880"><span class="elsevierStyleSup">176&#8211;179</span></a> &#40;Moderate quality of evidence&#44; strong recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Cyclophosphamide&#58; Concomitant intravenous CYC&#44; &#46;75<span class="elsevierStyleHsp" style=""></span>g&#47;m<span class="elsevierStyleSup">2</span> of body surface area every month for 12 months is recommended&#46;<a class="elsevierStyleCrossRefs" href="#bib0880"><span class="elsevierStyleSup">176&#8211;178</span></a> &#40;Moderate quality of evidence&#44; strong recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Immunoglobulin&#58; intravenous immunoglobulin can be used at a dose of 2<span class="elsevierStyleHsp" style=""></span>g&#47;kg&#44; divided over 5 days&#46;<a class="elsevierStyleCrossRefs" href="#bib0885"><span class="elsevierStyleSup">177&#44;178&#44;180&#8211;182</span></a> &#40;Moderate quality of evidence&#44; weak recommendation&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Movement disorders &#40;chorea&#41;</span><a class="elsevierStyleCrossRef" href="#bib0825"><span class="elsevierStyleSup">165</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8211; Antiplatelet drugs&#58; aspirin is recommended in chorea associated with antiphospholipid antibodies and anticoagulation associated with antiphospholipid antibody syndrome&#46;<a class="elsevierStyleCrossRefs" href="#bib0915"><span class="elsevierStyleSup">183&#8211;186</span></a> &#40;Low quality of evidence&#44; weak recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Dopamine antagonists&#58; symptomatic therapy with dopamine antagonists is recommended&#46;<a class="elsevierStyleCrossRef" href="#bib0875"><span class="elsevierStyleSup">175</span></a> &#40;Moderate quality of evidence&#44; strong recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Other&#58; there are case reports that recommend that methylprednisolone&#44; CYC&#44; azathioprine and rituximab could be a therapeutic option for refractory patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0915"><span class="elsevierStyleSup">183&#44;187</span></a> &#40;Low quality of evidence&#44; weak recommendation&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Psychosis</span><a class="elsevierStyleCrossRef" href="#bib0825"><span class="elsevierStyleSup">165</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8211; Prednisone&#58; Prednisone at 1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day for 8 weeks is recommended&#44; with gradual tapering to 5<span class="elsevierStyleHsp" style=""></span>mg a day&#46;<a class="elsevierStyleCrossRef" href="#bib0940"><span class="elsevierStyleSup">188</span></a> &#40;Moderate quality of evidence&#44; strong recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Cyclophosphamide&#58; concomitant use of intravenous CYC is recommended at a dose of &#46;75<span class="elsevierStyleHsp" style=""></span>g&#47;m<span class="elsevierStyleSup">2</span> of body surface area every month for 6 months&#46;<a class="elsevierStyleCrossRefs" href="#bib0940"><span class="elsevierStyleSup">188&#44;189</span></a> &#40;Moderate quality of evidence&#44; strong recommendation&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Thrombocytopenia</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8211; Glucocorticoids&#58; in cases of thrombocytopenia&#44; 1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day of prednisone &#40;or equivalent&#41; is recommended until platelet counts above 100&#44;000 cell&#47;mcl are achieved&#44; with no signs of bleeding&#44; tapering the dose of GC until discontinuing it&#44; and adding another immunosuppressant to reduce the risk of relapse&#46;<a class="elsevierStyleCrossRefs" href="#bib0950"><span class="elsevierStyleSup">190&#8211;192</span></a> &#40;Moderate quality of evidence&#44; strong recommendation&#41;&#46; In cases of severe thrombocytopenia &#40;fewer than 15<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>&#47;cell&#47;mcl&#41; or with signs of life-threatening bleeding&#44; methylprednisolone pulses are recommended &#40;1<span class="elsevierStyleHsp" style=""></span>g&#47;24<span class="elsevierStyleHsp" style=""></span>h&#44; intravenous&#44; for 3&#8211;5 days&#44; according to the gravity of symptoms&#41; to obtain more rapid responses&#44; ensuring continuation at between &#46;5 and 1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day of prednisone or its equivalent to prevent the risk of relapse&#46; It is recommended that these doses should be continued until counts above 50&#44;000 cell&#47;mcl are achieved&#44; and further immunosuppressant should be considered&#46;<a class="elsevierStyleCrossRefs" href="#bib0950"><span class="elsevierStyleSup">190&#8211;192</span></a> &#40;Moderate quality of evidence&#44; strong recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Intravenous immunoglobulin&#58; is recommended as rescue therapy only for patients with a poor response to GC &#40;i&#46;e&#46;&#44; who have received pulses of methylprednisolone for 3&#8211;5 days or prednisone or its equivalent&#44; at 1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day for more than 4 weeks&#44; and platelet counts do not exceed 50&#44;000 cel&#47;mcl or there are signs of active life-threatening bleeding&#41;&#46; It is recommended at a dose of 1<span class="elsevierStyleHsp" style=""></span>g&#47;kg of weight on day 1 and day 2&#46; Response is usually transient &#40;10 days on average&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0965"><span class="elsevierStyleSup">193&#8211;196</span></a> &#40;Moderate quality of evidence&#44; strong recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Danazol&#58; is recommended as combined therapy with oral GC&#44; at a dose of 200&#8211;800<span class="elsevierStyleHsp" style=""></span>mg&#47;day according to the severity of the throbocytopenia&#46;<a class="elsevierStyleCrossRefs" href="#bib0985"><span class="elsevierStyleSup">197&#44;198</span></a> &#40;Moderate quality of evidence&#44; strong recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Antimalarials&#58; are used as adjunct therapy with oral GC at doses between 200 and 400<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#44; according to the severity of the thrombocytopenia&#46;<a class="elsevierStyleCrossRef" href="#bib0995"><span class="elsevierStyleSup">199</span></a> &#40;Low quality of evidence&#44; weak recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Biologics &#40;rituximab&#41;&#58; recommended principally in the event of failure with other immunosuppressants&#46; The regimen of 375<span class="elsevierStyleHsp" style=""></span>mg&#47;m<span class="elsevierStyleSup">2</span> of body surface area is recommended every week for 4 weeks or the regimen of 1<span class="elsevierStyleHsp" style=""></span>g intravenously on day zero and day 15&#46; The best response is observed when combined with oral GC 1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day of prednisone or its equivalent and with tapering doses over 3 months or less&#46;<a class="elsevierStyleCrossRefs" href="#bib01000"><span class="elsevierStyleSup">200&#44;201</span></a> &#40;High quality of evidence&#44; strong recommendation&#41;&#46; The low dose regimen is also recommended for consideration&#44; which comprises 100<span class="elsevierStyleHsp" style=""></span>mg intravenously on days 0&#44; 7&#44; 14 and 21 &#40;i&#46;e&#46;&#44; 4 doses&#44; one per week&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib01000"><span class="elsevierStyleSup">200&#44;201</span></a> &#40;Moderate quality of evidence&#44; weak recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Splenectomy&#58; principally recommended if thrombocytopenia has been refractory to various immunosuppressant treatments &#40;i&#46;e&#46;&#44; final line treatment&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib01010"><span class="elsevierStyleSup">202&#8211;205</span></a> &#40;Low quality of evidence&#44; weak recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Cyclophosphamide&#58; recommended principally for use in patients who have not responded to the previous treatment&#59; it can even be used as rescue therapy after splenectomy&#46; Intravenous doses of 500<span class="elsevierStyleHsp" style=""></span>mg to 1&#46;2<span class="elsevierStyleHsp" style=""></span>g&#47;month for 3&#8211;6 months are recommended&#44; according to the severity of the thrombocytopenia&#44; and clinical response&#46; In very GC-dependent patients&#44; it can be considered as a saving agent for this group of drugs&#46;<a class="elsevierStyleCrossRefs" href="#bib01030"><span class="elsevierStyleSup">206&#8211;208</span></a> &#40;Low quality of evidence&#44; weak recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Mycophenolate mofetil&#58; recommended for patients who are refractory to the other lines of treatment&#46; The usual dose is between 1 and 2&#46;5<span class="elsevierStyleHsp" style=""></span>g&#47;day&#44; according to tolerance and clinical response&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">38&#44;209</span></a> &#40;Low quality of evidence&#44; weak recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Azathioprine recommended for use in patients refractory to the other lines of treatment&#46; The recommended dose ranges from &#46;5 to 2<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day&#44; according to tolerance and response&#46;<a class="elsevierStyleCrossRefs" href="#bib0950"><span class="elsevierStyleSup">190&#44;210&#44;211</span></a> &#40;Low quality of evidence&#44; weak recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Eltrombopag&#58; not recommended for routine use due to a lack of evidence&#46;<a class="elsevierStyleCrossRefs" href="#bib01060"><span class="elsevierStyleSup">212&#44;213</span></a> &#40;Low quality of evidence&#44; strong recommendation&#41;<br>Platelet transfusion&#58; recommended for patients with platelet counts below 10&#44;000 cell&#47;mcl irrespective of whether there are signs of bleeding or counts below 50&#44;000 cell&#47;mcl with active bleeding&#46; In counts above 50&#44;000 cell&#47;mcl&#44; it is only recommended if there is active life or function-threatening bleeding&#46; Ideally&#44; all patients who are to undergo a minor invasive procedure &#40;for example&#44; central line placement&#44; thoracocentesis&#44; etc&#41; require at least 50&#44;000 cell&#47;mcl&#46; With procedures such as surgical interventions or higher risk procedures &#40;kidney biopsy&#44; for example&#41;&#44; preferably counts above 100&#44;000 cell&#47;mcl should be maintained&#46;<a class="elsevierStyleCrossRef" href="#bib01070"><span class="elsevierStyleSup">214</span></a> &#40;Moderate quality of evidence&#44; strong recommendation&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Autoimmune haemolytic anaemia</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8211; Biologics &#40;rituximab&#41;&#58; principally recommended for use when treatment with other immunosuppressants has failed&#46; The regimen of 375<span class="elsevierStyleHsp" style=""></span>mg&#47;m<span class="elsevierStyleSup">2</span> of body surface area &#40;intravenous&#41; can be used every week for 4 weeks or a regimen of 1<span class="elsevierStyleHsp" style=""></span>g intravenously on day zero and day 15&#46;<a class="elsevierStyleCrossRefs" href="#bib01075"><span class="elsevierStyleSup">215&#44;216</span></a> &#40;Good quality of evidence&#44; strong recommendation&#41;&#46; The low-dose regimen comprising 100<span class="elsevierStyleHsp" style=""></span>mg intravenously on days 0&#44; 7&#44; 14 and 21 &#40;4 doses&#44; one per week&#41; can be considered&#46; The best response to this regimen is observed when combined with oral GC 1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day of prednisone or equivalent&#44; with tapering doses over 3 months or less&#46;<a class="elsevierStyleCrossRefs" href="#bib01075"><span class="elsevierStyleSup">215&#8211;219</span></a> &#40;Low quality of evidence&#44; weak recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Glucocorticoids&#58; to attempt to obtain rapid responses &#40;in approx 48&#8211;72<span class="elsevierStyleHsp" style=""></span>h&#41; in situations where the anaemia is life-threatening&#44; pulses of intravenous methylprednisolone are recommended &#40;1<span class="elsevierStyleHsp" style=""></span>g&#47;day&#44; for 3&#8211;5 days&#44; according to the severity of the anaemia&#41;&#46; It is recommended that when going on to oral GC &#40;1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day of prednisone or equivalent&#41;&#44; this dose should be maintained for 4 weeks at least&#44; and subsequent tapering should be slow and gradual to prevent relapses&#44; until there is a different immunosuppressant and the haemoglobin count is stable and above 7<span class="elsevierStyleHsp" style=""></span>g&#47;dl&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">43&#44;220&#8211;223</span></a> &#40;Good quality of evidence&#44; strong recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Azathioprine&#58; recommended for use as a GC saving agent in cases where there has been relapse on discontinuation or tapering&#44; at doses of &#46;5&#8211;2<span class="elsevierStyleHsp" style=""></span>mg&#47;kg day&#44; according to tolerance and clinical response&#46;<a class="elsevierStyleCrossRefs" href="#bib01055"><span class="elsevierStyleSup">211&#44;224</span></a> &#40;Moderate quality of evidence&#44; strong recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Danazol&#58; recommended for refractory patients at doses of 200&#8211;800<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#44; but as a coadjuvant with other immunosuppressants&#46;<a class="elsevierStyleCrossRefs" href="#bib0985"><span class="elsevierStyleSup">197&#44;225&#8211;227</span></a> &#40;Moderate quality of evidence&#44; strong recommendation&#41;<br>Intravenous immunoglobulin&#58; not recommended due to a lack of sufficient evidence for its recommendation&#46;<a class="elsevierStyleCrossRef" href="#bib01140"><span class="elsevierStyleSup">228</span></a> &#40;Low quality of evidence&#44; weak recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Mycophenolate mofetil&#58; recommended for use in patients refractory to the other treatment lines&#46; Doses of 1&#8211;2&#46;5<span class="elsevierStyleHsp" style=""></span>g&#47;day&#44; according to tolerance and clinical response&#46; It can also operate as a GC saver&#46;<a class="elsevierStyleCrossRefs" href="#bib01145"><span class="elsevierStyleSup">229&#8211;231</span></a> &#40;Low quality of evidence&#44; weak recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Cyclophosphamide&#58; recommended principally for use in patients who have not responded to first or second line treatments&#59; doses of between 500 and 1&#46;2<span class="elsevierStyleHsp" style=""></span>g&#47;month &#40;intravenous&#41; for 3&#8211;6 months&#44; according to the severity of the anaemia and clinical response&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">43&#44;232</span></a> &#40;Low quality of evidence&#44; weak recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Splenectomy&#58; not recommended while there is no available information on their efficacy and safety as routine treatment&#44; except in refractory patients where it is considered that the possible benefit outweighs the risks&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">43&#44;233</span></a> &#40;Low quality of evidence&#44; weak recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Blood transfusion&#58; not recommended except in life-threatening situations or conditions such as low cardiac output&#44; ischaemic heart disease&#44; severe neurological disorders&#44; etc&#46;&#44; always combined with the supervision of haematological doctors before using packs of red cells&#46;<a class="elsevierStyleCrossRef" href="#bib01170"><span class="elsevierStyleSup">234</span></a> &#40;Moderate quality of evidence&#44; strong recommendation&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Neutropenia</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8211; Infection vs manifestation of the disease&#58; infection and the toxic effect of drugs&#44; respectively&#44; must be discounted first&#44; before attributing the manifestation to activity of the disease&#46; &#40;Good practice recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Granulocyte-colony stimulating factor&#58; in neutropenia &#60;1000&#47;&#956;l&#44; associated with fever or infection starting with 300<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;day is recommended&#44; and continuing with the minimum effective dose to achieve a neutrophil count above 1000&#47;&#956;l&#46;<a class="elsevierStyleCrossRefs" href="#bib01175"><span class="elsevierStyleSup">235&#8211;240</span></a> &#40;Low quality of evidence&#44; strong recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Glucocorticoids&#58; doses of between &#46;5 and 1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day are recommended of prednisone or its equivalent&#46;<a class="elsevierStyleCrossRefs" href="#bib01175"><span class="elsevierStyleSup">235&#44;236&#44;241</span></a> &#40;quality of evidence&#44; weak recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Azathioprine&#58; doses of up to 2&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day are recommended&#44; according to response and tolerance&#46;<a class="elsevierStyleCrossRef" href="#bib01205"><span class="elsevierStyleSup">241</span></a> &#40;Very low quality of evidence&#44; weak recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Mycophenolate mofetil&#58; not recommended for use due to the lack of evidence on the optimal dose&#46;<a class="elsevierStyleCrossRefs" href="#bib01175"><span class="elsevierStyleSup">235&#44;241</span></a> &#40;Very low quality of evidence&#44; weak recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Cyclosporine&#58; not recommended due to the lack of evidence on the optimal dose&#46;<a class="elsevierStyleCrossRefs" href="#bib01175"><span class="elsevierStyleSup">235&#44;241</span></a> &#40;Very low quality of evidence&#44; weak recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Rituximab&#58; recommended in disease refractory to doses of 375<span class="elsevierStyleHsp" style=""></span>mg&#47;m<span class="elsevierStyleSup">2</span> of body surface area weekly for 4 weeks or doses of 1<span class="elsevierStyleHsp" style=""></span>g day zero&#44; and day 14&#46;<a class="elsevierStyleCrossRefs" href="#bib01175"><span class="elsevierStyleSup">235&#44;241</span></a> &#40;Very low quality of evidence&#44; weak recommendation&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Thrombotic thrombocytopenic purpura</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8211; Plasmapheresis&#58; it is recommended that plasmapheresis should be started as soon as a diagnosis is suspected &#40;in the first 4&#8211;8<span class="elsevierStyleHsp" style=""></span>h&#41;&#46; Replacement should be with fresh frozen plasma&#46;<a class="elsevierStyleCrossRefs" href="#bib01210"><span class="elsevierStyleSup">242&#8211;245</span></a> &#40;Low quality of evidence&#44; strong recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Glucocorticoids&#58; recommended for use in combination with plasmapheresis&#46; Pulse methylprednisolone &#40;1<span class="elsevierStyleHsp" style=""></span>g daily for 5 days&#41; or prednisone &#40;or equivalent&#41; at doses of 1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day&#46;<a class="elsevierStyleCrossRefs" href="#bib01210"><span class="elsevierStyleSup">242&#8211;245</span></a> &#40;Low quality of evidence&#44; strong recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Cyclophosphamide&#58; is recommended&#44; even though there is no consensus as to the dose&#46;<a class="elsevierStyleCrossRefs" href="#bib01210"><span class="elsevierStyleSup">242&#8211;244</span></a> &#40;Very low quality of evidence&#44; weak recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Mycophenolate mofetil&#58; recommended if CYC is contraindicated or has reached its maximum effect&#59; there is no consensus as to the dose&#46;<a class="elsevierStyleCrossRef" href="#bib01220"><span class="elsevierStyleSup">244</span></a> &#40;Very low quality of evidence&#44; weak recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Rituximab&#58; recommended for refractory cases&#44; increasing the response percentage&#46; The recommended dose is 375<span class="elsevierStyleHsp" style=""></span>mg&#47;m<span class="elsevierStyleSup">2</span> of body surface area weekly for 4 weeks&#46; It is recommended that plasmapheresis should be delayed for at least 4<span class="elsevierStyleHsp" style=""></span>h after rituximab infusion&#46;<a class="elsevierStyleCrossRefs" href="#bib01210"><span class="elsevierStyleSup">242&#44;244&#44;245</span></a> &#40;Very low quality of evidence&#44; weak recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Vincristine&#58; could be used for refractory cases &#40;as an option after rituximab&#41; at single doses of 1&#46;4<span class="elsevierStyleHsp" style=""></span>mg&#47;m<span class="elsevierStyleSup">2</span> of body surface&#44; with a maximum of 2<span class="elsevierStyleHsp" style=""></span>mg as the total dose&#46;<a class="elsevierStyleCrossRefs" href="#bib01210"><span class="elsevierStyleSup">242&#44;243&#44;245&#44;246</span></a> &#40;Very low quality of evidence&#44; weak recommendation&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Haemophagocytic syndrome</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8211; General measures&#58; provide support treatment &#40;fluid resuscitation&#44; antibiotics&#44; cover transfusion requirements&#41;&#46; Look for and treat foci of infection&#46; &#40;Good practice&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Glucocorticoids&#58; pulse methylprednisolone or prednisone &#40;or equivalent&#41; is recommended&#44; there is no consensus as to dose&#46;<a class="elsevierStyleCrossRefs" href="#bib01225"><span class="elsevierStyleSup">245&#44;247</span></a> &#40;Low quality of evidence&#44; strong recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Cyclophosphamide&#58; pulses of 500<span class="elsevierStyleHsp" style=""></span>mg to 1<span class="elsevierStyleHsp" style=""></span>g monthly for 6 months<a class="elsevierStyleCrossRef" href="#bib01235"><span class="elsevierStyleSup">247</span></a> are recommended&#46; &#40;Low quality of evidence&#44; weak recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Cyclosporine&#58; doses of 2&#8211;5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day<a class="elsevierStyleCrossRef" href="#bib01235"><span class="elsevierStyleSup">247</span></a> are recommended&#46; &#40;Low quality of evidence&#44; weak recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Intravenous immunoglobulin&#58; not recommended&#46;<a class="elsevierStyleCrossRef" href="#bib01235"><span class="elsevierStyleSup">247</span></a> &#40;Low quality of evidence&#44; strong recommendation&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Recommendations for Haematological Manifestations&#46;</p>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Intestinal pseudo-obstruction</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8211; Glucocorticoids&#58; the use of GC at high doses should be considered &#40;intravenous methylprednisolone 1<span class="elsevierStyleHsp" style=""></span>g every 24<span class="elsevierStyleHsp" style=""></span>h for 3&#8211;5 days followed by the equivalent of prednisone 1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day&#41; for patients with intestinal pseudo-obstruction&#46;<a class="elsevierStyleCrossRefs" href="#bib01240"><span class="elsevierStyleSup">248&#44;249</span></a> &#40;Low quality of evidence&#44; strong recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Immunosuppressants&#58; the concomitant use of GC with immunosuppressants such as CYC&#44; cyclosporine A&#44; methotrexate&#44; azathioprine or tacrolimus<a class="elsevierStyleCrossRefs" href="#bib01245"><span class="elsevierStyleSup">249&#44;250</span></a> should be considered&#46; &#40;Low quality of evidence&#44; strong recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Intravenous immunoglobulin&#58; should be considered for use in patients who are refractory to massive doses of GC&#46;<a class="elsevierStyleCrossRefs" href="#bib01245"><span class="elsevierStyleSup">249&#44;250</span></a> &#40;Low quality of evidence&#44; strong recommendation&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Autoimmune pancreatitis</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8211; Glucocorticoids&#58; GC should be considered for use at high doses &#40;equivalent to prednisone 1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day&#41; in patients with acute pancreatitis&#46; For patients who do not respond to the initial dose of prednisone at 1<span class="elsevierStyleHsp" style=""></span>mg per kg of weight&#44; pulse methylprednisolone 1<span class="elsevierStyleHsp" style=""></span>g i&#46;v&#46; could be used every 24<span class="elsevierStyleHsp" style=""></span>h in 3 doses&#46;<a class="elsevierStyleCrossRefs" href="#bib1255"><span class="elsevierStyleSup">251&#44;252</span></a> &#40;Low quality of evidence&#44; strong recommendation&#41;&#46;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Immunosuppressants&#58; concomitant use of GC and immunosuppressants such as CYC&#44; methotrexate or azathioprine is recommended for consideration&#46;<a class="elsevierStyleCrossRefs" href="#bib1255"><span class="elsevierStyleSup">251&#44;252</span></a> &#40;Low quality of evidence&#44; weak recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Plasmapheresis&#58; the use of plasmapheresis should be considered for patients refractory to GC therapy&#46;<a class="elsevierStyleCrossRef" href="#bib1265"><span class="elsevierStyleSup">253</span></a> &#40;Moderate quality of evidence&#44; strong recommendation&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Protein losing enteropathy</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8211; Glucocorticoids&#58; high doses of GC are recommended &#40;equivalent of prednisone 1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day&#41; for patients with protein losing enteropathy&#46; Methylprednisolone pulses should be considered if the patient has other severe complications of the disease&#44; such as hypoalbuminaemia causing capillary leakage&#44; and secondarily severe pleural or pericardial effusion or severe liver involvement&#46;<a class="elsevierStyleCrossRefs" href="#bib1270"><span class="elsevierStyleSup">254&#8211;256</span></a> &#40;Moderate quality of evidence&#44; strong recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Immunosuppressants&#58; concomitant use of GC and immunosuppressants such as CYC&#44; cyclosporine A&#44; methotrexate&#44; azathioprine or MMF<a class="elsevierStyleCrossRefs" href="#bib1270"><span class="elsevierStyleSup">254&#8211;256</span></a> should be considered&#46; &#40;Low quality of evidence&#44; strong recommendation&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Intestinal vasculitis</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8211; Glucocorticoids&#58; GC at high doses should be considered &#40;methylprednisolone&#58; 1<span class="elsevierStyleHsp" style=""></span>g intravenously every 24<span class="elsevierStyleHsp" style=""></span>h for 3&#8211;5 days followed by the equivalent of prednisone 1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day&#41; for patients with intestinal vasculitis&#46;<a class="elsevierStyleCrossRefs" href="#bib1285"><span class="elsevierStyleSup">257&#8211;259</span></a> &#40;Low quality of evidence&#44; strong recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Immunosuppressants&#58; concomitant use of GC and intravenous CYC should be considered for patients with intestinal vasculitis associated with other severe manifestations of the disease &#40;SLE&#41; or patients with recurring vasculitis&#46;<a class="elsevierStyleCrossRef" href="#bib1290"><span class="elsevierStyleSup">258</span></a> &#40;Low quality of evidence&#44; strong recommendation&#41;<br><span class="elsevierStyleHsp" style=""></span>&#8211; Surgery&#58; consider abdominal laparotomy if there is no improvement in pain in the first 24&#8211;48<span class="elsevierStyleHsp" style=""></span>h from initiating GC pulse therapy&#46; &#40;Good practice&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                  "referenciaCompleta" => "Diagn&#243;stico y tratamiento de lupus eritematoso mucocut&#225;neo&#46; CENETEC&#46; Available from&#58; <a id="intr0010" class="elsevierStyleInterRef" href="http://www.cenetec.salud.gob.mx/descargas/gpc/CatalogoMaestro/533_GPC_Lupusmucocutxneo/GER_LupusEritematoso.pdf">http&#58;&#47;&#47;www&#46;cenetec&#46;salud&#46;gob&#46;mx&#47;descargas&#47;gpc&#47;CatalogoMaestro&#47;533&#95;GPC&#95;Lupusmucocutxneo&#47;GER&#95;LupusEritematoso&#46;pdf</a> &#91;accessed 7&#46;12&#46;2017&#93;&#46;"
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                  "referenciaCompleta" => "Pr&#225;ctica cl&#237;nica sobre lupus eritematoso sist&#233;mico&#46; Ministerio de Sanidad&#44; Servicios Sociales e Igualdad&#46; Servicio de Evaluaci&#243;n del Servicio Canario de la Salud&#59; 2015&#46; Available from&#58; <a id="intr0015" class="elsevierStyleInterRef" href="http://www.guiasalud.es/GPC/GPC_549_Lupus_SESCS_compl.pdf">http&#58;&#47;&#47;www&#46;guiasalud&#46;es&#47;GPC&#47;GPC&#95;549&#95;Lupus&#95;SESCS&#95;compl&#46;pdf</a> &#91;accessed 7&#46;12&#46;2017&#93;&#46;"
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        "texto" => "<p id="par0215" class="elsevierStylePara elsevierViewall">We would like to thank M&#46; en C&#46; Guadalupe Olvera Soto for her invaluable support in the search of the articles used in the literature review&#59; we would also like to thank GlaxoSmithKline for their unconditional educational support&#46;</p>"
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