Laceration: a wound that is produced by the tearing of soft body tissue. A laceration wound is often contaminated with bacteria and debris from whatever object caused the cut.

2.      avoiding "live" vaccination if on immunosuppressive agents

3.      adherence to a diet low in saturated fat and high in fish oil

4.      stress avoidance

5.      smoking cessation.

-level rises in response to inflammation 

- has both proinflammatory and anti-inflammatory properties. It plays a role in the recognition and clearance of foreign pathogens and damaged cells

-when it’s activated by autoantibodies, worsen tissue damage in certain cases by activation of the complement system and thus inflammatory cytokines

-Creatinine. Creatinine is a waste product from the normal breakdown of muscles in your body

 Your kidneys remove creatinine from your blood. Health care professionals use the amount of creatinine in your blood to estimate your glomerular filtration rate (GFR). As kidney disease gets worse, the level of creatinine goes up.

2.      BUN

-The BUN test measures the amount of urea nitrogen in your blood. 

-Urea nitrogen is a waste product that your kidneys remove from your blood.

- Higher than normal BUN levels may be a sign that your kidneys aren't working well.

SLE flare is defined as the symptoms of SLE become worsen.

The most common type of biopsy is a percutaneous kidney biopsy. A doctor inserts a thin needle through the skin into the kidney to obtain samples of the kidney tissue for analysis. The doctor use imaging techniques, such as ultrasound to guide the biopsy needle into the kidney. 
Laparoscopic biopsy also called open biopsy. During a laparoscopic biopsy, a doctor collect the tissue sample from the kidney during surgery.

Less common side effects of prednisolone include:

See your doctor immediately or go to the emergency department of your nearest hospital if you experience any of these serious side effects:

-Supplements(Vit. A,D, E and fish oil)

-exercise

-consuming a diet high in anti-inflammatory foods (tomatoes, turmeric, tomatoes, berries, fatty fish, and leafy vegetables).

All of the approaches can help to manage symptoms and improve immune function, without raising the risk of complications

-cover the affected skin properly will help it heal and prevent irritation

-always keep the wound clean

Ethics:  African Americans, Latinos, Asians & American Indians are affected more than Caucasians

Erythema: Redness

Formation of autoantibodies against DNA and other nuclear antigens, resulting in accumulation of antigen-antibody complexes in blood vessels and other organs, where they trigger widespread connective tissue inflammation. 

Named for skin lesions once likened to a wolf bite. 

Causes fever, fatigue, joint pain, weight loss, intolerance of bright light and a butterfly rash across the nose and cheeks. Death may result from renal failure.

Most often caused by Group A B-hemolytic streptococci (Streptococcus pyogens) or Staphylococcus aureus

1. Family members of patients have an increased risk of developing SLE (20% of clinically unaffected first-degree relatives of SLE patients reveal autoantibodies and other immunoregulatory abnormalities)

2. Hi3. HLA associations – HLA-DQ locus have been linked to the production of anti-double-stranded DNA, anti-Sm, and antiphospholipid antibodies

4. Inherited deficiencies of early complement components, such as C1q , C2 or C4

5. Polymorphism in the inhibitory Fc receptor leads to inadequate control of B cell activation

• Environmental Factors – UV irradiation, Cigarette smoking, Sex hormones, Drugs (procainamide and hydralazine)

• Immunologic abnormalities –

1. Type 1 Interferons – for unknown reasons abnormally large amounts IFN alpha are produced

2. TLR signals – that recognize RNA and DNA, activate B cells specific for nuclear antigens

3. Failure of B cell tolerance – high frequency of auto-reactive B cell production compared to normal individuals

4. CD4 helper T cells, which escape tolerance

Cellulitis is treatable with antibiotics. But if it goes untreated, the infection can get into the bloodstream and become life-threatening.

Corticosteroid agents are used predominantly for anti-inflammatory activity and as immunosuppressants. 

Prednisone is an immunosuppressant for the treatment of autoimmune disorders.
It may decrease inflammation by reversing increased capillary permeability and suppressing polymorphonuclear neutrophil activity.

Prednisone stabilizes lysosomal membranes and suppresses lymphocytes and antibody production.

Low-dose oral prednisone can be used for milder SLE, but more severe involvement necessitates high doses of oral or intravenous therapy.

Antimalarial agents may work through numerous proposed mechanisms in SLE, mediating subtle immunomodulation without causing overt immunosuppression. 

These drugs are useful in preventing and treating lupus skin rashes, constitutional symptoms, arthralgias, and arthritis; antimalarials also help to prevent lupus flares and have been associated with reduced morbidity and mortality in SLE patients

-inhibits chemotaxis of eosinophils and locomotion of neutrophils and impairs complement-dependent antigen-antibody reactions. 

-This agent is also commonly used for suppression and treatment of malaria. Mechanisms underlying the anti-inflammatory and immunomodulatory effects of hydroxychloroquine are unknown

Disease-modifying antirheumatic drugs (DMARDS) are immunomodulatory agents that act as immunosuppressives and cytotoxic and anti-inflammatory medications.

Azathioprine, mycophenolate, and cyclosporine have all been studied for lupus manifestations such as nephritis.

Mycophenolate is useful for maintenance in lupus nephritis and other serious lupus cases. This agent inhibits inosine monophosphate dehydrogenase (IMPDH) and suppresses de novo purine synthesis by lymphocytes, thereby inhibiting their proliferation. Mycophenolate also inhibits antibody production.
Mechanism of Action

-Inhibits T- and B-cell proliferation, as well as antibody production

-Acts as noncompetitive, selective, and reversible inhibitor of inosine monophosphate dehydrogenase (IMPDH)

E.g. Naproxen sodium (Aleve) and Ibuprofen (Advil, Motrin IB, others)
MOA: inhibit both COX enzymes, thus decreasing prostaglandin production throughout the body as a result of which inflammation, pain, and fever are reduced
Therapeutic uses: treat pain, swelling and fever associated with lupus (Reduce pain and inflammation)
Side effects: stomach bleeding, kidney problems and an increased risk of heart problems.
Contraindications: 
1. Asthmatic patients
2. During the third trimester of pregnancy
3. Patients with impaired renal function
4. Patients who have experienced an allergic reaction (urticaria, asthma, etc.) after taking NSAIDs 
5. Patients with peptic ulcer disease
6. Patients with coagulation problems

E.g. Hydroxychloroquine (Plaquenil)
Therapeutic Uses: treat malaria, affect the immune system, help decrease the risk of lupus flares.
Side effects: stomach upset and, very rarely, damage to the retina of the eye.
Regular eye exams are recommended when taking these medications.
Contraindications: 

E.g. Prednisone, methylprednisolone (Medrol)
Therapeutic Uses: counter the inflammation of lupus, control serious disease that involves the kidneys and brain
Side effects: weight gain, easy bruising, thinning bones, high blood pressure, diabetes and increased risk of infection. 
The risk of side effects increases with higher doses and longer term therapy.
Contraindications:

E.g. Azathioprine (Imuran, Azasan), mycophenolate (Cellcept), Methotrexate (Trexall, Xatmep, others), Cyclosporine (Sandimmune, Neoral, Gengraf) and Leflunomide (Arava)
MOA (Cyclosporine): inhibit the production of cytokines involved in the regulation of T-cell activation, inhibit the production of NFAT1 transcription factor by calcineurin
Therapeutic Uses: suppress the immune system (may be helpful in serious cases of lupus)
Side effects: Increase the risk of infection, liver damage, decreased fertility and an increased risk of cancer.

E.g. Belimumab (Benlysta) i.v. route
MOA: Belimumab is a recombinant, fully human, monoclonal antibody directed against the B-cell activating factor (BAFF). It plays a central role in B-cell survival and function. Elevated circulating BAFF levels are common in SLE patients. Therefore, inhibiting the biological activity of BAFF is potentially helpful in the treatment of the disease.
Therapeutic Uses: reduces lupus symptoms in some people.
Side effects: nausea, diarrhea and infections. Rarely, worsening of depression can occur.
Contraindications: 

E.g. Rituximab (Rituxan, Truxima) i.v.r oute
may be beneficial for some people in whom other medications haven't helped.
MOA: Anti CD20 chimeric antibody with human IgG1 immunoglobulin. CD20 plays a role in the maturation and activation of B cells. The mechanism of action of rituximab in autoimmune disease is disrupting B cells' function in the immune system and decrease in plasma cell production of CD20.
Therapeutic Uses: decrease joint pain and swelling
Side effects: allergic reaction to the intravenous infusion and infections.
Contraindications:

- Pharmacist should educate the patient regarding lupus

- Pharmacist should provide counselling on the best ways to take medications and what to expect when starting or stopping them

- Pharmacists can also seek advice or help from a rheumatologist (for SLE) and a dermatologist (for skin lupus) to prescribe the most effective treatment and for consultation when medications are not working

- Dermatologist: A doctor who specializes in conditions involving the skin, hair, and nails

- Rheumatologist: A pediatrician who is trained in the diagnosis, and treatment of diseases that affect the muscles, bones, joints, ligaments and tendons

ii) Erythrocyte sedimentation rate: This blood test determines the rate at which red blood cells settle to the bottom of a tube in an hour. A faster than normal rate may indicate a systemic disease, such as lupus.

iii) Urinalysis: Examines a sample of your urine which may show an increased protein level or red blood cells in the urine, which may occur if lupus has affected your kidneys

iv) Antinuclear antibody (ANA) test: A blood test that looks for antinuclear antibodies in your blood. A positive ANA test indicates the patient may have lupus. Some who test positive may not have lupus. Therefore, if there is a positive test for ANA, doctor may advise more-specific antibody testing 

v) Kidney biopsy: The most definitive test for diagnosing lupus nephritis. A test where the doctor removes a small section of kidney tissue for lab analysis. 

*Patient’s heart rate is normal

*Patient’s respiratory rate is high

- Headache, dizziness, vision problems and even strokes & seizures

- Anemia & increase risk of bleeding or blood clotting

- Increase chances of developing inflammation of chest cavity lining & pneumonia (An infection that inflames the air sacs in one or both lungs)

- Inflammation of the heart muscle

- Miscarriage in pregnant women