12-phase flow (12)

1. 1FRAME
   Confirmed SLE patient with acute flare. New diagnosis routes to rheum.sle.core.v1; APS / pure thrombosis to hem.aps.core.v1
   inputs: sle_diagnosis_confirmed
   advance: flare scope confirmed
2. 2ENTRY
   Recognise organ-specific or constitutional flare features
   inputs: organ_systems_involved
   advance: flare features documented
3. 3CONTEXT
   Current ISD, HCQ adherence, recent infections, vaccinations, pregnancy / lactation, comorbidities
   inputs: current_immunosuppression, pregnancy_status
   advance: baseline ISD and adherence captured
4. 4RED_FLAGS
   Severe flare — rapidly progressive GN, alveolar hemorrhage, NPSLE psychosis / seizure / myelitis, refractory thrombocytopenia, catastrophic APS → ICU + pulse methylpred
   inputs: cbc_with_diff, creatinine, esr_crp
   advance: red flags acted on; infection ruled out
5. 5INITIAL_WORKUP
   CBC + diff, creatinine, UA + UPCR, C3/C4, anti-dsDNA, ESR/CRP, LFT, AP panel, infection screen (cultures, CMV/HSV PCR if immunosuppressed)
   inputs: cbc_with_diff, creatinine, urinalysis_with_micro, upcr, complement_c3_c4, anti_dsdna, esr_crp
   actions: panel.cbc, panel.renal, panel.ua, panel.inflammation
   advance: workup sent + infection screen complete
6. 6BRANCHING_WORKUP
   Renal biopsy if proteinuria >0.5 / active sediment / unexplained AKI; brain MRI / LP for NPSLE; echo for myocarditis / pericardial effusion; CT chest for alveolar hemorrhage; APS panel if thrombosis
   inputs: anti_phospholipid_panel
   actions: workup.aki, workup.rpgn, workup.aps
   advance: organ-specific workup booked / completed
7. 7DIFFERENTIAL
   Distinguish flare from infection (CRP usually normal in pure flare), drug-induced lupus-like reaction, TMA / TTP / aHUS, MAS, malignancy
   inputs: esr_crp
   actions: tma_differential
   advance: mimics excluded or co-managed
8. 8RISK_STRATIFICATION
   Mild (mucocutaneous / mild arthritis), moderate (serositis, mild cytopenias), severe (renal class III/IV/V, NPSLE, AHA, severe thrombocytopenia, lupus pneumonitis, alveolar hemorrhage)
   inputs: organ_systems_involved
   advance: severity tier set
9. 9TREATMENT
   HCQ for ALL (5 mg/kg actual weight, 2023 EULAR). Mild: topical steroids + intra-articular + short-course low-dose prednisone. Moderate: prednisone 0.5 mg/kg/d + add MMF / AZA / methotrexate / belimumab / anifrolumab. Severe: pulse methylprednisolone 250-1000 mg × 3 d → prednisone 0.5-1 mg/kg/d + MMF (preferred) or Euro-Lupus CYC (low-dose IV) for class III/IV ± voclosporin add-on (AURORA-LN). Belimumab BLISS-LN for renal flare add-on. Anifrolumab TULIP for moderate-severe with skin / joint dominance. Rituximab refractory cytopenias. PJP prophylaxis if pred ≥20 mg ≥4 weeks or CYC. Avoid MMF / CYC / MTX in pregnancy — switch to AZA / HCQ-only / tacrolimus
   inputs: creatinine, pregnancy_status
   advance: induction regimen + steroid taper plan documented
10. 10DISPOSITION
    Severe flare → admit (often ICU for NPSLE / alveolar hemorrhage / refractory cytopenias); moderate → expedited rheum f/u; mild → outpatient
    advance: level of care set
11. 11MONITORING
    CBC, BMP, UA, UPCR weekly during induction; complement / dsDNA q4-6 wk; LFT for MMF / AZA; CYC cytopenia at nadir 7-14 d; voclosporin BP + creatinine + GFR q2 wk first 12 wk; HCQ retina screen baseline + annual after 5 y per AAO 2024; bone protection per dose / duration
    inputs: cbc_with_diff, creatinine, upcr
    actions: panel.renal, panel.cbc
    advance: response by 3-6 months (MMF) / 6-12 months (CYC)
12. 12FOLLOWUP
    Lifelong rheumatology continuity; SLE-PASS / SLEDAI-2K trend; minimise glucocorticoids; vaccinations (zoster, pneumococcal, HPV, COVID, influenza); CV risk modification; pregnancy planning when stable ≥6 months
    advance: long-term management plan documented