This handout is for adhf in sle myocarditis. Your care team identified this based on: new hf symptoms in patient with established sle or recently positive ana + dsdna + low complement.
Other reasons your team may use this plan: young woman (15-45) with new hf + pleuritic chest pain + arthritis + rash → sle myocarditis screen; ana ≥1:80 + low c3/c4 + elevated troponin without obstructive cad on cath; cardiac mri lake louise 2018 positive (t2 elevation + lge patchy mid-wall) + positive sle serology.
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| methylprednisolone | 1 g IV daily × 3-5 d (pulse), then transition to prednisone 1 mg/kg PO daily | IV | daily × 3-5 d pulse | EULAR 2023 SLE — pulse methylprednisolone for severe organ-threatening flare; AHA 2020 myocarditis statement (PMID 32200645) supports immunosuppression in autoimmune myocarditis |
| prednisone | 1 mg/kg PO daily after pulse, taper over 6-12 mo | PO | daily with slow taper | Standard EULAR 2023 SLE maintenance after pulse therapy |
| cyclophosphamide | 500-1000 mg/m² IV pulse monthly × 6 (NIH protocol) | IV | monthly × 6 pulses | NIH cyclophosphamide protocol for severe organ-threatening SLE; long track record in lupus nephritis + myocarditis case series |
| mycophenolate mofetil | 1 g PO BID, titrate to 1.5 g BID over 2 wk | PO | BID | ALMS PMID 19369404 — non-inferior to cyclophosphamide in lupus nephritis induction; preferred for women of reproductive age |
| rituximab | 1 g IV × 2 doses 2 wk apart (or 375 mg/m² weekly × 4) | IV | induction protocol | Off-label but supported in observational SLE refractory series; B-cell depletion attenuates autoantibody production |
| IVIG | 2 g/kg IV divided over 2-5 d | IV | induction or refractory bridge | Refractory autoimmune myocarditis salvage; bridge when infection complicates steroid escalation |
| hydroxychloroquine | 5 mg/kg PO daily (max 400 mg/d) | PO | daily lifelong | EULAR 2023 SLE — all SLE patients should receive HCQ for flare prevention; LUMINA cohort showed cardiac mortality reduction; baseline ophthalmology + annual screening for retinopathy |
| furosemide | 20-40 mg IV (diuretic-naive starting per DOSE PMID 21366472) | IV | q12h with reassessment | Standard ADHF diuretic; gentle if cardiogenic shock |
| warfarin | 5 mg PO daily, INR target 2-3 | PO | daily | APL syndrome anticoagulation + Libman-Sacks intracardiac thrombus → warfarin (DOACs inferior in APL per TRAPS PMID 30002145, RAPS) |
Plan: SLE myocarditis ADHF — immunosuppression phenotype (EULAR 2023 SLE + AHA 2020 myocarditis PMID 32200645)
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
Long-term rheumatology + cardiology co-management; SLE flare prevention with HCQ + DMARD; the four foundational heart-failure medications 4-pillar for residual HFrEF; ICD eval per HRS 2017 if EF <35 + sustained VT despite ≥3 mo the four foundational heart-failure medications + immunosuppression
Guideline: EULAR 2023 SLE recommendations + AHA 2020 myocarditis scientific statement (PMID 32200645) + ACR 2019 SLE classification (Aringer PMID 31385462) + ESC 2013 myocarditis (Caforio PMID 23824828)