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SLE is a fluctuating multisystem disease with a diversity of clinical presentations.

Patients with lupus experience a loss of self-tolerance as a result of abnormal immunological function and the production of autoantibodies, which lead to the formation of immune complexes that may adversely affect healthy tissue. The disease occurs predominantly in women, with a reported female-to-male ratio approaching 10:1 (Abdulaziz et al., 2012; Petri, 2011; Maidhof and Hilas, 2012). SLE is a chronic disease that affects various organ systems, primarily as a consequence of the formation and deposition of autoantibodies and immune complexes, leading to eventual organ damage. In summary, the presence of hyperactive B cells leading to the production of autoantibodies, in conjunction with the impaired other immune regulatory processes involving Tlymphocytes (suppressor Tcells), cytokines (e.g., interleukins, interferon-, tumor necrosis factor , transforming growth factor ), and natural killer cells results in the formation of immune complexes. In the microvasculature, these complexes induce inflammatory reactions, causing the tissue inflammation and damage associated with SLE. Many autoantibodies are directed against nuclear constituents of the cell and are called collectively antinuclear antibodies (ANA). Several antinuclear antibodies are important because in the diagnostic and clinical evaluation of patients with SLE. Antibodies also may be directed against the phospholipid moiety of the prothrombin activator complex (lupus anticoagulant) and against cardiolipin. The lupus anticoagulant and anticardiolipin antibodies constitute the two main types in a group of autoantibodies called antiphospholipid antibodies (Abdulaziz et al., 2012; Bertsias et al., 2012; Dipiro et al., 2007; Petri, 2011; Maidhof and Hilas, 2012). The presentation of SLE can be complex, considering the number of organ systems that can be affected by the disease. General symptoms observed in SLE include fever, fatigue, and weight loss. Musculoskeletal involvement includes arthralgias, myalgias, and arthritis. Arthritis can affect any minor or major joints, commonly presenting as painful, stiff joints accompanied by either occasional or persistent inflammation. SLE patients who report symptoms involving the skin most butterfly rash, which occurs over the bridge of the nose and the malar eminences. The classic butterfly rash is seen in approximately one-half of patients and often is observed after sun exposure. In fact, photosensitivity is common to many SLE patients who present with cutaneous manifestations. Other symptoms associated with skin manifestations include alopecia, Reynauds

phenomenon, and sores in the mouth or nose (Abdulaziz et al., 2012; Wajed et al., 2004; Dipiro et al., 2007; Maidhof and Hilas, 2012) This time to discuss the case study of a woman who had a miscarriage during pregnancy was 10 weeks. Today she still consult to the gynecologist after 6 weeks postabortus and patients complain that often got severe arthralgia and fatigue. Patients not currently taking any medication . She just taking a multivitamin. Other complaints include, loss of taste , joint swelling, and insomnia. After diagnostic test, the patient was diagnosed positive SLE . From patients medical record known that her mother suffered diabetes mellitus type 2 and her father had a history of hypertension who had received therapy anyway. Parents of both parents are known diabetes mellitus patients and heart disease. Based on the case, can predicted that the patient had been suffered SLE during pregnancy. Fetal loss may caused the availability of an abnormal immune system reaction to the fetus. Fetal loss may be due autoantibodies pass to the fetus by acrossing the placenta which may cause developmental abnormalities. Miscarriage of the fetus that is associated with the crossplacental transfer of anti-Ro/SS-A and/or anti-La/SS-B autoantibodies, which are highly prevalent in individuals with SLE. The Ro/SS-A antigen is a small nucleocytoplasmic RNA protein complex. The presence of these autoantibodies in the fetal circulation can lead to Congenital Heart Block (CHB). Other causes of fetal loss in SLE is the presence these antiphospholipid antibodies autoantibodies which can lead to abnormal clotting (thrombosis) and fetal loss (Frye, 2011; Bertsias et al., 2012Maidhof and Hilas, 2012). Symptoms that occur include severe arthtritis and fatigue are common symptoms in patients with SLE . The complaints generally suggest that patients suffering from SLE with mild to moderate levels. In this case, therapy for these patients can not be determined simply given patient has a risk factor for several serious diseases. Based on a family historical record, known that her these patients had risk factors for developing diabetes melitus and cardiovascular disease. In the past 23 decades it has become increasingly recognized that accelerated atherosclerosis and its sequelae are a major cause of morbidity and mortality in systemic lupus erythematosus (SLE). The consequences of this include an increased risk of cerebrovascular and coronary heart disease (CHD). Patients with SLE have 510 times the risk of CHD-related events compared with the background population. In particular, Manziet al.[4] found that women aged 3544 year with SLE had a 50-times greater risk of myocardial infarction (MI) relative to

healthy women in the Framingham Offspring Study cohort. Conventional risk factors of CVD are also associated with sub-clinical measures of atherosclerosis in SLE patients. Older age, hypertension, dyslipidaemia and diabetes are associated with the presence of carotid plaque (Abdulaziz et al., 2012; Wajed et al., 2004; Bertsias et al., 2012; Dipiro et al., 2007; Maidhof and Hilas, 2012). Regardless of risk factors for cardiovascular disease, these patients also have a risk factor for developing diabetes. Based research report found that approximately 57% of patients with SLE develop diabetes mellitus and patients with SLE are more likely to have diabetes than a control population. Based on the above explanation can be seen that the patient's risk factors possessed great influence on the development of SLE, considering that cardiovascular disease is the major cause mortality in systemic lupus erythematosus (SLE). Moreover, the occurrence of cardiovascular disease in SLE also can induce a variety of other diseases and potential complications of systemic disease. Therefore, selection of therapy should be considered the risk factors that are owned by the patient to avoid the complications of the disease or the treatment of unilateral disease and increased potential for other disease (Abdulaziz et al., 2012; Wajed et al., 2004; Bertsias et al., 2012; Dipiro et al., 2007; Maidhof and Hilas, 2012) Based on various considerations that treatment can be recommended for patients on this cases is: A. Nonpharmacologic Therapy Physicians should educate patients to avoid weight gain by promoting healthy eating and physical activity. Specific to lupus itself, aggressive control of joint and fatigue

symptoms and global lupus disease activity could help facilitate physical exercise. Abalanced routine of rest and exercise, while avoiding overexertion, is essential in managing fatigue. The AHA recommends 30 min of moderate-intensity (brisk walking) aerobic activity 5 days per week or 20 min of vigorous-intensity (jogging) 3 days a week for healthy adults. Resistance training (weight lifting) to improve muscle strength and endurance is advocated twice per week and should include all 10 major muscle groups. Patients should be encouraged to increase their daily lifestyle activities, such as walking to the store and using stairs instead of elevators. For those with cardiac history or recent vascular surgery, physicians should provide a medically supervised exercise program. Aerobic exercise can also improve quality of life in patients with SLE by improving both depression levels and

global sense of well-being (Abdulaziz et al., 2012; Dipiro et al., 2007; Maidhof and Hilas, 2012) Dietary program is very useful to improve quality of life and help to minimized development of the risk factor. Diet include a diet rich in fruits, vegetables and whole-grain, high-fiber foods, consuming fish (specifically oily fish) twice a week, limiting saturated fat to <7% (trans fat to <1%) and cholesterol to <300 mg /day by choosing lean meats and fatfree or low-fat dairy products, minimizing beverages and foods with added sugars, low or no salt diet and consuming alcohol in moderation. Lifestyle modifications regarding diet, specifically salt restriction, exercise, weight control and alcohol moderation, is recommended for all patients with a blood pressure >140/90 mmHg (for hypertension risk factor). Consultation with a nutritionist or dietitian is strongly encouraged. These dietary and exercise recommendations can also be applied to patients with dyslipidaemia, hypertension and diabetes (due to in patient with the risk factor) (Abdulaziz et al., 2012; Wajed et al., 2004). Smoking cessation, appropriate immunizations, limit exposure to sunlight and use sunscreens to block the possible exacerbating effects of ultraviolet light (if the patient is very sensitive to sunlight, preferably on while traveling using long underwear and sunglasses), avoid the use of contraceptives or other medications containing hormones estrogen, avoid strees and physical trauma and management of comorbid (Abdulaziz et al., 2012; Dipiro et al., 2007).

B. Pharmacologic Therapy Based on symptoms felt by patients, in the case SLE were classified into mild to moderate levels. Therefore the recommended medication for treat patients with mild-tomoderate lupus is NSAIDs, antimalarial agents, and corticosteroids. 1. NSAIDs In many patients with mild to moderate disease, initial treatment with a nonsteroidal anti-inflammatory drug (NSAID) for most common symptoms such as fever, arthritis, and serositis is a logical choice. NSAIDs may be used to alleviate musculoskeletal pain, swelling, and aches. These drugs possess pain-reducing, antiinflammatory, and

anticoagulant properties, which are beneficial in treating common lupus-associated manifestations (Abdulaziz et al., 2012; Dipiro et al., 2007; Petri, 2011). NSAIDs ussualy administrated orally in tablet dosage form. The dose used should be adequate to provide anti-inflammatory effects, although low-dose aspirin tablet may be useful in the management of patients with antiphospholipid syndrome and cardiovascular risk. These drugs possess pain-reducing, antiinflammatory, and anticoagulant properties, which are beneficial in treating common lupus-associated manifestations. Awareness of this effect is important because declining renal function may be attributed mistakenly to progression of lupus nephritis. Patients with SLE have a higher incidence of hepatotoxicity than other patients taking traditional NSAIDs (Abdulaziz et al., 2012; Bertsias et al., 2012; Dipiro et al., 2007; Petri, 2011; Maidhof and Hilas, 2012). 2. Antimalarial Use of antimalarial medications in all patients with SLE is recommended. Some antimalarial agents have proved effective in treating the various signs and symptoms of lupus and preventing subsequent flares. Although the exact mechanism is unclear. Antimalarials may interfere with T-cell activation and inhibit cytokine activity. These agents may also inhibit intracellular toll-like receptors, which recognize and bind foreign materials, thereby contributing to activation of the immune system (Bertsias et al., 2012; Dipiro et al., 2007; Petri, 2011). Hydroxychloroquine (e.g., Plaquenil, Sanofi) is the most commonly studied and used drug in its class, but it has the potential to cause serious visual and muscle disturbances. Antimalarial agents such as chloroquine and hydroxychloroquine have been used successfully in the management of discoid lupus and SLE. A few controlled trials provide evidence for the role of antimalarial therapy in controlling disease exacerbations and as steroid sparing agents. In general, the manifestations of SLE that can be managed with antimalarials are cutaneous manifestations, arthralgia, pleuritis, mild pericardial inflammation, fatigue, and leukopenia. Because these drugs are not effective immediately, they are best used in long-term management. Hydroxychloroquine is probably safer than chloroquine and is considered the antimalarial of first choice (Wajed et al., 2004Dipiro et al., 2007; Petri, 2011; Maidhof and Hilas, 2012).

Hydroxychloroquine (HCQ) therapy has been shown to have several beneficial cardiovascular effects in SLE patients. HCQ use in SLE patients has been shown to reduce cholesterol (TC), triglycerides (TG), low-density lipoprotein (LDL) levels. Lupus patients taking HCQ have had significantly lower mean glucose levels and markers of insulin resistance. HCQ has been postulated to prevent future thrombotic events and lupus patients on HCQ therapy are less likely than those not onit to have carotid plaque. Its protective effect on the vasculature may be in part due to inhibitionof aPL-mediated platelet activation (Abdulaziz et al., 2012). Other effects of antimalarials that may benefit patients with SLE include inhibition of cytokines, decreased sensitivity to ultraviolet light, anti-inflammatory activity, antiplatelet effects, and antihyperlipidemic activity. That several beneficial of using antimalarial drugs can not only increase the patient's condition but also can help minimize the development and complications that can occur because of disease risk factors possessed patients. Dosage and duration of therapy depend on patient response, tolerance of side effects and development of retinal toxicity, which is apotentially irreversible adverse reaction associated with long-term therapy, especially with chloroquine. Some patients may require only one or two tablets per week to suppress cutaneous manifestations. Side effects of these drugs include CNS effects, rashes, dermatitis, pigmentary changes of the skin and hair, gastrointestinal disturbance and reversible ocular toxicities such as cycloplegia and corneal deposits. Potentially serious retinal toxicity is uncommon, however the possibility of permanent damage associated with the retinopathy, an ophthalmologic. If retinal abnormalities are noted, antimalarial therapy should be discontinued or the dose reduced (Wajed et al., 2004; Bertsias et al., 2012; Dipiro et al., 2007; Maidhof and Hilas, 2012). Antimalarial include chloroquine and Hydroxychloroquine in tablet dosage form were administrated orally. 3. Corticosteroids Corticosteroid therapy in SLE patients is still one of the most effective therapies for managing lupus disease activity, but it has numerous metabolic side effects on blood pressure, blood glucose, lipids and weight. Lupus patients on corticosteroids are also likely to have greater inflammatory disease burden, placing them at higher CVD risk. It

has been theorized that used corticosteroids to treat SLE are risk factors for coronary artery disease in SLE patients along with the traditional risk factors observed in the general population, so this treatment not recommended for patients in this case (Abdulaziz et al., 2012; Wajed et al., 2004; Dipiro et al., 2007; Petri, 2011; Maidhof and Hilas, 2012). A patient with the diagnosis of SLE does not automatically require corticosteroid therapy, but patients with clinical manifestations that are more serious or unresponsive to other drugs may require corticosteroids. Because of their serious long-term side effects, corticosteroids should be used at the lowest possible dose and only for periods necessary to control an active exacerbation of lupus. Mechanism of action is multiple effects on immune system (e.g.,blocking cytokine activation and inhibiting interleukins, -interferon and tumor necrosis factor-). In this case the use of oral corticosteroids was not carried out considering because this drug can development of several risk factors. But its ussualy benefit to treat skin rash in topical dosage form (Abdulaziz et al., 2012; Wajed et al., 2004; Bertsias et al., 2012; Dipiro et al., 2007; Maidhof and Hilas, 2012)

At this level of disease, use of corticosteroids, immunosupresant, monoclonal antibodies and other drugs not recommended yet. If an increase of SLE disease levels, the use of combinations of these drugs should be considered. Setting the dose and duration of medication use is very important to note associated with side effects that can be caused. The emergence of other diseases from risk factor that can lead to more severe complications in patients must be treatment use the appropriate medication and its side effects without compromising attention to the main treatment for SLE (Abdulaziz et al., 2012; Dipiro et al., 2007; Maidhof and Hilas, 2012).

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DAFTAR PUSTAKA

Abdulaziz, S., Y. AlGhamdi, M. Samannodi and M. Shabrawishi. 2012. Systemic Lupus Erythematosus: Cardiovascular Involvement in Systemic Lupus Erythematosus. Editor: Hani Almoallim. Rijeka: InTech. P. 273-312 Wajed, J., Y. Ahmad, P. N. Durrington and I. N. Bruce. 2004. Review Prevention of Cardiovascular Disease in Systemic Lupus Erythematosus-Proposed Guidelines for Risk Factor Management. Rheumatology, Vol. 43. P. 712 Frye, E. 2011. The Effects of Maternal Systemic Lupus Erythematosus on the Developing Fetus. North California: Biology Department, North Carolina Agricultural and Technical State University. P. 1-22 Bertsias, G., R. Cervera and D. T. Boumpas. 2012. Systemic Lupus Erythematosus: Pathogenesis and Clinical Features. P. 476-505 Dipiro, J. T., R. L. Talbert, G. C. Yee, G. R. Matzke, B. G. Wells adn L. M. Posey. 2007. Pharmacotherapy A Pathophysiologic Approach. 6th Edition. U.S.A: The McGraw-Hill Companies. P. 1581-1591 Petri, M. 2011. Life-Threatening Complications of Systemic Lupus Erythematosus. Autoimmunie disease. Editor: M. A. Khamashta and M. R. Casals. London: Springer. P. 9-19 Maidhof, W. and O. Hilas. 2012. Lupus: An Overview of the Disease And Management Options. Lupus Overview, Vol. 37, No. 4. P. 240-247

Abdulaziz et al., 2012; Wajed et al., 2004; Frye, 2011; Bertsias et al., 2012; Dipiro et al., 2007; Petri, 2011; Maidhof and Hilas, 2012.