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• Highlights
• Introduction
• Causes
• Risk Factors
• Symptoms
• Complications
• Diagnosis
• Treatment
• Treatment for Cutaneous and Mild SLE
• Treatment for Severe SLE
• Lifestyle Changes
• Resources
• References

Systemic lupus erythematosus

Description

An in-depth report on the causes, diagnosis, treatment, and prevention of lupus.

Alternative Names

Lupus

Treatment for Cutaneous and Mild SLE

Creams. Steroid creams are often used for skin lesions. However, many patients with discoid lupus do not respond to steroids, particularly if they have eruptions that are caused by sun sensitivity. A cream derived from vitamin A (Tegison) may help some lesions that do not clear up with steroid creams.

Sun Protection. Sun protection is essential. Patients should always use sunblock creams (not just sunscreens) and always wear hats and clothing made of tightly woven fabrics.

Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

Common NSAIDs. NSAIDs block prostaglandins, the substances that dilate blood vessels and cause inflammation and pain. There are dozens of NSAIDs.

• Over-the-counter NSAIDs include aspirin, ibuprofen (Motrin IB, Advil, Nuprin, Rufen), naproxen (Aleve), ketoprofen (Actron, Orudis KT).
• Prescription NSAIDs include ibuprofen (Motrin), naproxen (Naprosyn, Anaprox), diclofenac (Voltaren), tolmetin (Tolectin), ketoprofen (Orudis, Oruvail), dexibuprofen (Seractil).

For people with lupus, NSAIDs may help relieve:

• Joint pain and swelling
• Muscle pain

Side Effects . Regular, long-term use of NSAIDs can cause ulcers and gastrointestinal bleeding, which can lead to anemia. To avoid these problems, it’s best to take NSAIDs with food or immediately after a meal. [See Box: NSAID-induced Ulcers and Gastrointestinal bleeding .] NSAIDs, (with the exception of aspirin), have also been associated with an increased risk for heart attacks and heart failure in high-risk patients.

Other NSAID side effects may include:

• Upset stomach
• Dyspepsia (burning, bloated feeling in pit of stomach)
• Drowsiness
• Skin bruising
• High blood pressure
• Fluid retention
• Headache
• Rash
• Reduced kidney function

Patients who have kidney problems associated with lupus (lupus nephritis) should be especially cautious about using NSAIDs. Experts recommend that patients with lupus who take NSAIDs on a regular basis should have their liver and kidney function tested every 3 - 4 months.

NSAID-Induced Ulcers and Gastrointestinal Bleeding Long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs) is the second most common cause of ulcers. Ulcers caused by nonsteroidal anti-inflammatory drugs (NSAIDs) are more likely to bleed than those caused by the bacteria Helicobacter pylori. NSAID-related bleeding and stomach problems may be responsible for 107,000 hospital admissions and 16,500 deaths each year. Those at high risk for bleeding include people over age 60, anyone with a history of ulcers of gastrointestinal bleeding, patients with serious heart conditions, people who abuse alcohol, and those who take medications such as anticoagulants (blood thinners) and corticosteroids. Proton-pump inhibitor (PPI) drugs may help prevent and heal ulcers caused by NSAIDs. PPIs include omeprazole (Prilosec), esomeprazole (Nexium), and lansoprazole (Prevacid).

Investigational Alternatives to NSAIDs

NO-NSAIDS. Experimental drugs are being developed that combine nitric oxide with NSAIDs (NO-NSAIDs). Nitric oxide increases blood flow in the mucous lining and secretions of mucus and bicarbonate.

Antimalarial Drugs

Antimalarial drugs may be prescribed for discoid lupus (skin sores) or for mild lupus when skin problems and joint pains are the predominant symptoms:

• Hydroxychloroquine (Plaquenil) is the most common antimalarial drug used for lupus. This drug is effective as maintenance therapy to reduce flares in patients with mild or inactive disease. Hydroxychloroquine may help protect against blood clots in people with antiphospholipid syndrome, high cholesterol levels, and bone loss.
• Other antimalarial drugs include chloroquine (Aralen) or quinacrine (Atabrine).

High doses may be prescribed initially in order to accumulate high levels of the drug in the blood stream. It is not known exactly why antimalarials work. Some researchers believe they inhibit the immune response, and others think they interfere specifically with inflammation.

A 2006 study suggested that anti-malarial drugs work best in patients who have genetic predispositions to certain types of immune-fighting proteins. The study found that patients who had genetic variations causing abnormally high levels of tumor necrosis alpha (TNF-alpha) and abnormally low levels of interleukin-10 (IL-10) responded best to these drugs.

Side Effects. Side effects of antimalarials may include:

• Skin rash
• Change in skin color (yellow in the case of quinacrine)
• Gastrointestinal problems
• Headache
• Hair loss
• Muscle aches
• Eye damage

The most serious is damage to the retina, although this is very uncommon when low doses are used. Eye damage after taking hydroxychloroquine is reversible when caught in time and treated, but it is not reversible if it develops after taking chloroquine. An eye exam is advisable about every 6 months.

Antimalarials may also be used in combination with other anti-SLE drugs, including immunosuppressants and corticosteroids. It should be noted that smoking significantly reduces the effectiveness of antimalarial drugs.

Thalidomide

Thalidomide inhibits a number of potent cytokines and reduces the formation of new blood vessels that allow the disease to progress. In low doses it has been found to be safe and effective for severe cutaneous lupus in many patients. It does not appear to have any benefits for systemic complications of lupus.

A major side effect of thalidomide is peripheral neuropathy, which can cause numbness, tingling, or other altered sensation in the nerves of limbs (feet, legs, hands, fingers). The drug should be taken for the shortest time possible. The drug is also notorious for producing very serious birth defects in children. Women who are in their reproductive years must be sure they are not pregnant before taking thalidomide and they must use very reliable birth control while taking it.

• Review Date: 1/2/2007
• Reviewed By: Harvey Simon, MD, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital.

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