What medical treatments are available for lupus?

The diagnosis of lupus marks the beginning of management that does not necessarily aim for a complete cure but rather for remission, that is, the control of inflammation to prevent irreversible damage. The management of lupus must be personalised, adjusted according to the severity of organ involvement and the patient’s profile (age, pregnancy, other existing diseases, etc.). It ranges from basic monitoring combined with the prescription of antimalarial drugs for mild cases, to intensive protocols that include immunosuppressive or biotherapeutic treatments for severe situations. Each approach seeks to maintain the balance of the immune system, prevent flare-ups and reduce the development of complications.

The current range of medical treatments now makes it possible to offer an almost normal life to most patients with lupus, provided that therapy is strictly adhered to.

Once the diagnosis has been made, the main objective becomes clear: to calm the inflammation immediately and restore some degree of balance within the immune system. This is the point at which the first level of treatment for lupus is introduced, which is generally effective in the management of mild to moderate forms. These treatments also play an essential long-term role: they help to reduce the frequency of flares, as well as to limit their severity when they occur.

Synthetic antimalarial agents as first-line treatment in lupus.

In clinical practice, hydroxychloroquine is almost always recommended. It forms the backbone of long-term (disease-modifying) therapy for the majority of patients. It offers multiple advantages, notably reducing the frequency of flares and providing long-term protection for organs. Its mechanism is based on modulation of the immune system: it inhibits certain enzymes in lysosomes, limits the activation of lymphocytes, and reduces both the production of autoantibodies and the stimulation of Toll-like receptors, which are responsible for inflammation. This treatment is generally well tolerated, even during pregnancy, but a few contraindications exist, particularly in the presence of severe renal disease, significant hepatic impairment, pre-existing cardiac disorders, or hypersensitivity to the drug.

According to a meta-analysis, prolonged use of hydroxychloroquine could reduce the risk of mortality in lupus patients by around 50%. Moreover, in addition to its ability to enhance immunity, it also has a beneficial effect on the lipid profile and reduces the risk of thrombosis.

However, prolonged use requires regular monitoring. Hydroxychloroquine tends to accumulate slowly in certain cells of the eye, particularly in the retina. Over time, this accumulation can disrupt the function of the cells responsible for detecting light (photoreceptors), as well as the supporting cells, leading to a rare but serious retinopathy. An electrocardiogram may also be recommended for patients with cardiac rhythm disorders, as hydroxychloroquine can, in rare cases, slow electrical conduction in the ventricles, promoting arrhythmias that are sometimes benign but can be more serious. Precautions are also necessary to avoid drug interactions, particularly with certain antiarrhythmic agents, digoxin, or medicines that alter heart rhythm. The usual adult dosage is 200 to 400 mg per day, adjusted according to the patient’s weight and tolerance.

Non-steroidal anti-inflammatory drugs (NSAIDs) for mild forms of lupus.

For less severe manifestations, such as joint pain or a mild fever, non-steroidal anti-inflammatory drugs, such as ibuprofen or naproxen, may be prescribed. These medicines act rapidly by inhibiting cyclo-oxygenase enzymes (COX-1 and COX-2), thereby reducing the production of prostaglandins responsible for inflammation, pain and fever, without any hormonal effect or direct action on the immune system. However, they must be used with caution. The main contraindications include renal impairment, gastritis or an active ulcer, a history of bleeding disorders, certain cardiovascular and neurological conditions, as well as hypersensitivity to NSAIDs.

During the third trimester of pregnancy, certain NSAIDs are also not recommended.

Precautions for use are necessary: monitor renal and hepatic function, avoid combining them with anticoagulants or high-dose corticosteroids, and limit their use to short, intermittent courses. The usual dosage for ibuprofen is 200 to 400 mg every six to eight hours, while naproxen is generally prescribed at 250 to 500 mg twice daily, always adjusted according to the patient’s tolerance and body weight. Adverse effects may include digestive disorders (gastric pain, ulcers, bleeding), long-term renal toxicity, increased blood pressure, cutaneous reactions or disturbances of coagulation.

Clinical research has shown that prolonged use of NSAIDs in patients with lupus can also mask the onset of nephritis, which requires careful medical monitoring.

Corticosteroid therapy for lupus.

When the state of health deteriorates, corticosteroids are used to rapidly control inflammatory flare‑ups, often producing a dramatic impact on symptoms. The prescribed doses vary according to the type and severity of the condition, and once the symptoms are controlled, the dose is gradually reduced to limit side effects. In the event of a severe flare or the need for a very rapid effect, corticosteroids can be administered by infusion. However, this efficacy is accompanied by significant adverse effects. Prolonged use can lead to weight gain in around 30 to 50% of patients, a risk of diabetes in 10 to 20%, and high blood pressure in up to 20 to 30%. Their immunosuppressive effect also increases the risk of infections, and comorbidities such as cataracts or metabolic disorders may accumulate.

In children, particular caution is required so as not to interfere with growth. Cortisone is also a frequent cause of osteoporosis. It is estimated thataround 30 to 50% of patients exposed over the long term develop bone fragility, with a real risk of fractures. The therapeutic objective remains to find the minimal effective dose (often < 7.5 mg/day) and to taper it progressively as soon as this is possible. Clinical studies show that the continuous administration of high-dose corticosteroids, generally more than 20 mg/day of prednisone or equivalent for several months to several years, is the main factor contributing to cumulative organ damage over a decade. Current protocols therefore favour high-dose administration over a short period (bolus), followed by rapid tapering in order to preserve the patient’s metabolism.

When the disease worsens or affects vital organs (kidneys, heart and brain), the use of agents capable of further suppressing the immune system becomes necessary.

Immunosuppressants in cases of severe or treatment-resistant organ involvement in lupus.

For moderate to severe forms of lupus, immunosuppressants such as azathioprine, methotrexate or mycophenolate mofetil may be prescribed. Their role is to calm the immune system by reducing the activity of the cells responsible for inflammation: they slow down the multiplication of T and B lymphocytes, decrease the production of pro-inflammatory substances and disrupt the mechanisms of immune activation.

Their main advantage is that they make it possible to reduce, or even discontinue, cortisone, which helps to limit its adverse effects. However, they require strict medical monitoring, in particular through regular blood tests, because in approximately 10 to 30% of cases, they can lower the blood level of white blood cells. Some of them, such as methotrexate, mycophenolate mofetil and cyclophosphamide, are formally contraindicated during pregnancy due to the risk of congenital malformations.

Conversely, the use of mycophenolate mofetil has revolutionised the prognosis of lupus nephritis. A comparative study has evaluated the effectiveness of immunosuppressive agents in lupus, particularly in lupus nephritis. Several randomised trials and meta-analyses show that mycophenolate mofetil is at least as effective as cyclophosphamide for inducing renal remission, with in some cases a tendency towards better outcomes.

Biologic therapies in the treatment of lupus.

Biotherapies (monoclonal antibodies) have represented a significant advance in the management of lupus in recent years. Unlike conventional medicines, they precisely target specific mechanisms of the immune system. Belimumab, administered subcutaneously (usually as a weekly injection), works by blocking a key protein, BAFF (B‑cell Activating Factor), which is required for the survival of the B lymphocytes involved in the disease. By preventing this protein from binding to its receptors, it deprives these cells of survival signals, leading to a gradual reduction in the most abnormal B lymphocytes. More recent agents, such as anifrolumab, administered as a monthly infusion, target even more specific pathways, in particular type I interferons, which play a major role in lupus-related inflammation.

The results of the phase III clinical trials (TULIP) are particularly promising. They show that biotherapies are not limited to reducing the overall disease activity, assessed in particular by the SLEDAI index, but that they also provide tangible improvements in everyday life. A large number of patients experience a marked reduction in persistent cutaneous damage and a relief of chronic joint pain. In a very large Italian observational study including 443 patients with lupus treated with belimumab, a significant reduction in the activity of joint and cutaneous manifestations was observed, along with high remission rates in certain clinical forms, for example up to approximately 76% cutaneous remission in some subgroups at 18 months.

These treatments are generally proposed when the disease remains active despite conventional therapies. They help to reduce the overall activity of lupus, improve persistent symptoms, and lessen dependence on corticosteroids. However, their use requires certain precautions: they are contraindicated in cases of active infection and must be used with caution in immunocompromised patients. Updating vaccination status is often recommended before starting these treatments, and regular monitoring is essential. The most common adverse effects include reactions at the injection site or during infusions, headaches, fatigue, and an increased risk of infections, particularly viral infections (such as shingles with anifrolumab). More rarely, hypersensitivity reactions may occur.

Lupus in children requires particular attention. In this age group, the disease is often more active, which makes management more complex. This intensity can be explained by a combination of factors. Children’s immune systems often react more vigorously, and kidney and neurological involvement tends to appear earlier and in a more severe form. The aim is to control inflammation without hindering growth or disrupting puberty. Thus, the treatment of juvenile lupus seeks to limit long-term cortisone use as much as possible, favouring so‑called “steroid‑sparing” therapies. This strategy helps to control the disease while reducing long‑term side effects. Among these treatments, hydroxychloroquine is often prescribed to reduce the frequency of flares, with regular ophthalmological monitoring, while certain immunosuppressants, such as azathioprine or mycophenolate, may be used in cases of severe manifestations, with strict adherence to dosing and avoiding certain agents, such as methotrexate, during the first trimester of any future pregnancy. For treatment‑resistant forms, certain biotherapies, such as belimumab from the age of 5 years, may be considered under close supervision.

However, treatment is not limited to medication alone. Preventive measures are also essential: complete sun protection, up-to-date vaccination, and psychological support. This last aspect is often underestimated, yet it is of crucial importance. It helps the child to cope better with the illness, particularly in relation to physical changes linked to treatment, such as facial swelling. Several clinical studies indicate that the early use of immunosuppressants, such as azathioprine, can reduce exposure to corticosteroids by around 40%. In the long term, this helps preserve metabolic health in adulthood and bone mineral density during the critical period of growth.

In addition to first- and second-line treatments, the management of lupus also involves another essential dimension: supportive care. Although these measures do not aim to directly halt the attack by the immune system, they nevertheless fulfil several roles, notably protecting organs from collateral damage, reducing the adverse effects of intensive treatments, and maintaining a stable level of day-to-day comfort.

Lupus and topical use of botanical extracts.

Topical treatments usually represent the first line of defence against cutaneous symptoms of the discoid form of lupus. Topical corticosteroids act by binding to specific nuclear receptors in order to inhibit the production of pro‑inflammatory mediators, thereby reducing tissue damage without entering the systemic circulation. One study suggests that the use of high‑potency topical corticosteroids leads to a complete healing of skin lesions in around 50% of patients with discoid lupus erythematosus. However, their prolonged use may cause skin atrophy.

The intake of evening primrose or borage seed oils, which are rich in gamma-linolenic acid (GLA), may help to restore the often-altered lipid barrier. In addition,true lavender essential oil or Boswellia carterii exhibits soothing properties and inhibits the enzyme 5-lipoxygenase, which converts arachidonic acid into leukotrienes. These molecules act as powerful alarm signals, causing swelling, redness, and an influx of immune cells into the skin. This helps to calm skin irritation and reduce tissue damage around lupus lesions. Furthermore, studies on Boswellia extracts confirm their noteworthy anti-inflammatory potential, suggesting that these botanical preparations could help to minimise the excessive use of topical steroids.

Although these treatments improve aesthetic appearance and skin comfort, they do not address the underlying immune cause. They may be used as an adjunct, without replacing medical treatments.

Dietary supplements for lupus.

In the management of lupus, certain dietary supplements may provide beneficial support. They are always taken in addition to medical treatment, and their effectiveness depends largely on consistent use. Vitamin D has a central role. Its functions go beyond its ability to protect bones, which are weakened in patients receiving corticosteroid therapy. It also plays a part in modulating the immune system. This is why a daily supplementation of 800 to 2000 IU, depending on individual needs, is recommended. Omega‑3 fatty acids, found mainly in fish oils, are also of interest. They act both on inflammation and on the health of the heart and blood vessels, which is an important issue in lupus. Taken at around 2 to 3 g per day, they may help to reduce joint pain and improve blood vessel function.

Certain plants are sometimes mentioned for their anti-inflammatory properties. For example, turmeric (Curcuma longa) contains curcumin, a substance that acts on mechanisms similar to those targeted by certain medicines. Its effect remains, however, moderate and preventive. One study emphasises that although some plants may provide long-term support and may possibly help to reduce corticosteroid use, they are not sufficient to manage an acute flare.

Although certain supplements can more or less support the management of lupus, some plant species should be avoided. Alfalfa, for example, contains a substance capable of excessively stimulating the immune system, which can trigger or worsen a flare.

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