The good news is that with treatment of lupus the life expectancy will not be diminished for 95% of patients with systemic lupus. The 10 year survival from the time of diagnosis in Western countries is more than 95% (Ref. 2, p.428). However, it is important to diagnose lupus early so that therapy can be instituted and that the condition from then onward can be managed aggressively.
As lupus is relatively rare, it is wise to have a rheumatologist involved in the treatment who directs the therapy for the family doctor. From time to time a reassessment by the rheumatologist is recommended. Medication for lupus (mild disease with low ANA titers) can be managed with non steroid anti-inflammatories (NSAIDs) or COX-2 inhibitors. More severe lupus is managed with corticosteroids, hydroxychloroquine and immunosuppressive drugs as indicated in the table below.
If patients have hypertension, drugs such as beta-blockers and hydralazine should be avoided, because they, too, can cause drug induced lupus. Other drugs such as sulfonamides should be avoided as in lupus patients this can lead to a skin rash and a serious low white blood cell count (“neutropenia”).
For non specific symptoms such as headaches, joint pains and chest wall pains (different from heart attacks or angina pains) simple pain pills (analgesics) are used. Particular care must be taken to measure the blood pressure regularly, as lupus patients are very sensitive with their kidneys and kidney damage sets in much faster than if blood pressure is the only problem. Once high blood pressure is found, it has to be treated aggressively with medication.
The following summarizes some of the medications for lupus:
Common medications used to treat lupus
NSAIDs : helps with joint pains, but stomach irritation, bleeding ulcers and kidney damage are side effects.
COX-2 inhibitors : better tolerated than NSAIDs, but long term use also leads to some stomach irritation. Note the withdrawal of VIOXX because of side effects (heart attacks and strokes).
corticosteroids : so-called disease modifier; chronic use leads to infections, osteoporosis with fractures, possibly cardiovascular disease
hydroxychloroquine : an antimalarial drug, which stabilizes lupus; retinopathy with blindness much less common with this compared to chloroquine phosphate
immunosuppressive drugs : azathioprine, methotrexate or cyclophosphamide reserved for organ involvement such as kidneys, heart, lungs; immuno-suppressant, can cause fevers
anticoagulants : used in cases of lupus with antiphospholipid syndrome where clots are prominent
In an acute exacerbation of lupus your physician may decide to use prednisone, which is a corticosteroid. Although on the short term this is an impressive drug, the problem is that after about 2 to 3 weeks the initial beneficial effect is wearing off and side effects are more in the forefront. Ask your doctor about this.
Corticosteroids are inhibiting the immune system, which leads to potentially life threatening viral, bacterial or fungal infections. Acute gastric or duodenal ulcers are also a threat as this can lead to massive gastrointestinal bleeds. The more chronic effect is on the musculoskeletal system where osteoporosis or osteolytic hip bone lesions can all lead to fractures. Finally, there are negative cardiovascular effects with long-term use of prednisone as atherosclerosis is accelerated in the presence of corticosteroids.
Other medications that are used to stabilize lupus are the antimalarials (hydroxychloroquine) and the immunosuppressants. Each have their own worrisome side effects, which have to be monitored. It is best, if an experienced rheumatologist supervises the longterm treatment protocol.
There are newer treatment options at the horizon. For instance weak testosterone like agents and prolactin inhibitors exert an immunomodulatory function, which may be used as a treatment modality more frequently, once it is better understood (Ref. 4). Anti interleukin-10 antibodies or interleukin-10 decreasing agents may also have a much more prominent role in future therapy of lupus as it is much more specific against lupus than the conventional therapies. However, it should be the rheumatologist who decides which treatment modality is the best in a certain patient as the side effects of any of these treatments have to be carefully balanced against the advantage of such a treatment. This is also true for the use of hormones (Ref. 5), which were recommended to be used in the setting of postmenopausal women with lupus flare-ups. Estrogen in that setting appears to be a safe alternative, provided there were no antiphospholipid antibodies present in the blood and there was no active nephritis (kidney disease) present.
References:
1. ABC of rheumatology, second edition, edited by Michael L. Snaith , M.D., BMJ Books, 1999. Chapter 15.
2. The Merck Manual, 7th edition, by M. H. Beers et al., Whitehouse Station, N.J., 1999. Chapter 50.
3. BP Tsao et al. Curr Rheumatol Rep 2001 Jun;3(3):183-190.
4. D Alarcon-Segovia Isr Med Assoc J 2001 Feb;3(2):127-130.
5. CC Mok Semin Arthritis Rheum 2001 Jun;30(6):426-435.
6. Goldman: Cecil Textbook of Medicine, 21st ed.(©2000)W.B.Saunders
7. Ferri: Ferri’s Clinical Advisor: Instant Diagnosis and Treatment, 2004 ed., Copyright © 2004 Mosby, Inc.
8. Rakel: Conn’s Current Therapy 2004, 56th ed., Copyright © 2004 Elsevier
9. Suzanne Somers: “Breakthrough” Eight Steps to Wellness– Life-altering Secrets from Today’s Cutting-edge Doctors”, Crown Publishers, 2008
