What medical treatments are available for lupus?

The diagnosis of lupus marks the beginning of a course of management that does not necessarily aim for complete cure but rather for remission, that is, 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, coexisting conditions, etc.). It ranges from basic monitoring combined with the prescription of antimalarial drugs for mild cases, to intensive protocols that include immunosuppressive or biological therapies for severe situations. Each approach aims to maintain the balance of the immune system, prevent flares 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 treatment is strictly adhered to.

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

Synthetic antimalarial agents as first-line treatment in lupus.

In practice, hydroxychloroquine is almost always recommended. It forms the basis of long-term disease-modifying treatment for the majority of patients. It offers multiple advantages, notably a reduction in the frequency of flares and long-term protection of organs. Its mechanism relies on modulation of the immune system: it inhibits certain enzymes in lysosomes, limits lymphocyte activation, 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, in particular 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 patients with lupus 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 at the level of the retina. Over time, this accumulation can disrupt the functioning of the cells responsible for capturing light (photoreceptors), as well as the cells that support them, 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 ventricular electrical conduction, promoting arrhythmias that are sometimes benign but may be more serious. Caution is also required to avoid drug interactions, particularly with certain antiarrhythmics, digoxin, or medicines that affect 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 milder manifestations, such as joint pain or a low-grade fever, non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or naproxen, may be prescribed. These medicines act rapidly by inhibiting cyclo-oxygenase enzymes (COX-1 and COX-2), which reduces the production of prostaglandins responsible for inflammation, pain and fever, without any hormonal influence or direct action on the immune system. However, they must be used with caution. The main contraindications include renal insufficiency, 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 restrict their use to short, intermittent periods. 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 a day, always adjusted according to the patient’s tolerance and body weight. Adverse effects may include gastrointestinal disorders (stomach pain, ulcers, bleeding), long-term renal toxicity, increased blood pressure, cutaneous reactions, or coagulation disturbances.

Clinical research has shown that the 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 having a striking impact on symptoms. The prescribed doses vary according to the type and severity of the condition, and once 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 may be administered by infusion. However, this efficacy is accompanied by significant side 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%. The immunosuppressive effect also increases the risk of infections, and comorbidities may accumulate, such as cataracts or metabolic disorders.

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 goal remains to find the minimum effective dose (often < 7.5 mg/day) and to taper it down as soon as possible. Clinical studies show that the continuous administration of high-dose corticosteroids, generally above 20 mg/day of prednisone or equivalent for several months to several years, is the main factor contributing to accumulated organ damage over a decade. Current protocols therefore favour high-dose administration over a short period (bolus), followed by a rapid taper 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.

Immunosuppressive therapies 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 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 stop, corticosteroids, which helps to limit their adverse effects. However, they require strict medical monitoring, in particular through regular blood tests, because in around 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 strictly 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 in inducing renal remission, sometimes with a tendency towards better outcomes.

Biotherapies in the treatment of lupus.

Biotherapies (monoclonal antibodies) have represented a major 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), acts by blocking a key protein, BAFF (B‑cell Activating Factor), which is required for the survival of 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 molecules, such as anifrolumab, administered by monthly infusion, target even more specific pathways, particularly 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 activity of the disease, assessed in particular by the SLEDAI index, but that they also provide tangible improvements in everyday life. In a large number of patients, there is a significant 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, as well as 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 offered when the disease remains active despite conventional therapies. They help to reduce the overall activity of lupus, to improve persistent symptoms and to decrease dependence on corticosteroids. However, their use requires certain precautions: they are contraindicated in the event of an active infection and must be used with caution in immunocompromised patients. Updating vaccination status is often recommended before starting these therapies, and regular monitoring is essential. The most common adverse effects include reactions at the injection site or during infusions, headaches, fatigue, or 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 its management more complex. This severity is explained by a combination of factors. Children’s immune systems often respond 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 far as possible, favouring so‑called “steroid‑sparing” therapies instead. 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 the event of severe manifestations, with strict adherence to dosing and avoidance of certain medicines, such as methotrexate, during the first trimester of any future pregnancy. For treatment‑resistant forms, some biotherapies, such as belimumab from the age of 5 years, may be considered under close supervision.

However, treatment is not limited to medication. Preventive measures are also essential: strict sun protection, up-to-date vaccinations, and psychological support. This last aspect is often underestimated, yet it is of crucial importance. It helps the child to cope better with the disease, particularly in relation to physical changes associated with 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 to 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 are not intended to directly halt the attack on the immune system, they nevertheless fulfil several functions, notably protecting organs from collateral damage, reducing the adverse effects of intensive treatments, and maintaining a stable level of daily comfort.

Lupus and the topical use of botanical extracts.

Topical treatments most often constitute the first line of defence against the 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 helping to reduce tissue damage without entering the systemic circulation. One study suggests that the use of high-potency topical corticosteroids leads to a complete resolution 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 restore the often-altered lipid barrier. In addition, true lavender essential oil or Boswellia carterii exhibit soothing properties and inhibit the enzyme 5-lipoxygenase, which converts arachidonic acid into leukotrienes. These molecules act as powerful alarm signals, causing swelling, redness and the influx of immune cells into the skin. This helps to calm skin irritation and limit tissue damage around lupus lesions. Moreover, studies on Boswellia extracts support their noteworthy anti-inflammatory potential, suggesting that these botanical preparations could help to reduce the excessive use of topical steroids.

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

Dietary supplements for lupus.

In the management of lupus, certain dietary supplements can provide beneficial support. They are always taken in addition to medical treatment, and their effectiveness is mainly linked to how regularly they are taken. Vitamin D plays a central role. Its functions go beyond its ability to protect bones, which are weakened in patients receiving corticosteroid therapy. It also plays a role 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, which are mainly found 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 a dose of 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, however, remains moderate and primarily preventive. One study highlights that although some plants can provide long-term support and may help reduce corticosteroid use, they are not sufficient to manage an acute flare-up.

Although certain supplements provide varying degrees of support in managing lupus, some plant species should be avoided. Alfalfa, for example, contains a substance that can overstimulate the immune system and trigger or worsen a flare.

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