Treatment
Of Lupus The good news is that with lupus treatment 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
table summarizes some of the medications for lupus:
| Common medications
used to treat lupus | | Medication:
| Comments and
side effects: | | 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 | socalled
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. | |
