ANIFROLUMAB IN THE MANAGEMENT OF LUPUS HEADACHES: A CASE REPORT

PV305 / #413 Case Report Poster Topic: AS24 - SLE-Treatment Introduction We present a 52-year-old woman with a 10-year history of systemic lupus erythematosus (SLE) characterized by systemic, articular, cutaneous, and neurological involvement (lupus headache). Her condition was refractory to treatment with glucocorticoids, hydroxychloroquine, and belimumab. Despite treatment, her headaches remained resistant to nonsteroidal antiinflammatory drugs (NSAIDs), triptans, and amitriptyline. After initiating treatment with anifrolumab 300 mg monthly for 5 months, she experienced significant symptom resolution, including improvement of her lupus headaches. Case Presentation With Investigation The patient was diagnosed with SLE in 2014 after presenting with pericarditis, polyarthritis, photosensitive skin lesions, recurrent oral aphthae, and positive ANA, with no anti-dsDNA elevation or complement consumption. She also had secondary Sjögren’s syndrome (anti-Ro >320 U) and Raynaud’s phenomenon. Initial treatment included glucocorticoids and hydroxychloroquine (200 mg/day). Methotrexate was trialed in 2019 but was stopped due to ineffectiveness. In 2018, belimumab was added for persistent polyarthritis. In 2022, she developed persistent unilateral headaches resistant to migraine therapies (NSAIDs, triptans, amitriptyline, and flunarizine). By April 2024, her systemic symptoms worsened with chronic fatigue, polyarticular pain, and photosensitive rash, requiring glucocorticoids. Neurologically, she had refractory headaches and depressive symptoms (normal MRI (Image 1); SLEDAI-2k 14, SLE-DAS 31.04). Belimumab was stopped, and anifrolumab 300 mg IV monthly was started. Image 1. MRI scans with T1 and T2 sequences showed no abnormalities. After 1 month of anifrolumab, she had fewer, less intense headaches and improved cutaneous and articular symptoms. By 5 months, systemic symptoms resolved, and headaches diminished. Laboratory tests showed normalized lymphopenia, stable hemoglobin, and normal CRP, with no anti-dsDNA elevation or complement consumption (SLEDAI-2k 0, SLE-DAS 0.37). Literature Review Anifrolumab, a human monoclonal antibody targeting type I interferon receptor subunit 1, was approved in March 2022 for SLE treatment. It is included in the updated 2023 EULAR recommendations for managing SLE, particularly for patients not responding to hydroxychloroquine or those unable to reduce glucocorticoids to acceptable doses. Phase 3 trials (TULIP 1 and TULIP 2) demonstrated that Anifrolumab leads to rapid and sustained reductions in global and organ-specific disease activity, facilitating glucocorticoid tapering. Recently, new real-world data have been published demonstrating the activity of Anifrolumab and observed rapid effectiveness in severe and refractory patients, particularly in those with cutaneous, joint, and hematological involvement. Additionally, other manifestations, including renal or neuropsychiatric symptoms, are also studied also responded to treatment. Neurological manifestations in systemic lupus erythematosus (SLE) encompass a wide range of neurologic and psychiatric symptoms with varying severity, often complicating the differentiation from unrelated conditions. Lupus headache is a term used to describe a severe headache that is directly attributed to SLE with no secondary cause, and the pathogenic mechanism is unclear. The prevalence of headache in SLE varies from 24 to 72% with no clear association with disease activity, and the management typically involves a combination of treatments targeting both the neurological complications and the underlying SLE. However, the efficacy of these treatment protocols has not been rigorously studied, highlighting the need for further investigation. Discussion Anifrolumab may prove beneficial for SLE patients with neurological or neuropsychiatric involvement, including lupus headaches, showing a positive response and sustained improvement from the first month of treatment.