Acute neuropsychiatric lupus should be treated aggressively and quickly in the hope of reversing the process, which usually means high doses of prednisone (1 to 2 mg/kg), as well as antipsychotics. Once the psychosis has cleared, the dosage of steroids should be tapered rapidly because patients are at high risk for infection; adding immunosuppressives, particularly cyclophosphamide, may be beneficial. Steroids themselves may induce psychosis; therefore it is important to serially monitor the patient with objective measures, including EEG, MRI, and some antibrain antibodies, as well as CSF protein. However, often one must rely on clinical judgment. Seizure disorders are treated with anticonvulsants (e.g., phenytoin, phenobarbital, carbamazepine); no evidence exists that these medications exacerbate SLE. Multiple small strokes may be due to antiphospholipid antibodies.

Treatment of the antiphospholipid antibody syndrome remains controversial. Low levels of this antibody rarely cause symptoms. Patients with high levels and no symptoms should be treated with low-dose aspirin (81 mg/day); with symptoms, chronic warfarin (Coumadin) therapy is used at a dosage to maintain an International Normalized Ratio between 3 and 4.

Patients started on prednisone therapy should receive high doses only until the inflammation has subsided--thus the patient should be assessed frequently regarding specific organ function, as well as immune status (complement, anti-DNA antibodies). For acute, severe lupus, split doses are recommended, then a switch to a daily morning dose. For long-term management, the benefit-risk issue needs to be discussed. The prednisone dosage should then be tapered, the rate depending on the severity of organ inflammation and damage, the maximum dose, and side effects from prednisone (i.e., psychological changes, insomnia, weight gain, hypertension, diabetes, peptic ulcer, infections such as acne, cushingoid features, adrenal