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Systemic Lupus Erythematosus

Medical Treatment

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

SLE is a chronic inflammatory disease. The NSAIDs (see also FDA warnings about NSAIDS and CV and GI risks) relieve fever, pain muscle aches, malaise, inflammation, and serositis. Over 20 NSAIDS are available by prescription or over-the-counter. Vioxx® was prescribed by Dr. Smith. Vioxx®, one of the newer NSAIDs but later withdrawn by the manufacturer, is classified as a cyclooxygenase - 2 (COX-2) inhibitor. The COX-2s act with basically the same inflammation-fighting properties as traditional NSAIDs, but the COX-2s do not influence natural protective mechanisms of the stomach and are less likely to cause gastrointestinal distress and stomach ulcers.

Disease-Modifying Antirheumatic Drugs (DMARDs)

The DMARDs are used to alter the course of the destructive inflammatory process. We describe three categories of DMARDs for treating lupus: antimalarials, glucocorticoids, and immunosuppressives.

1. Antimalarials. Their value in rheumatic diseases was originally discovered following anecdotal reports from soldiers who took Atabrine during the war in the 1940s to prevent malaria. In addition to preventing malaria, Atabrine improved their rashes and joint symptoms. Atabrine was discontinued and has since been replaced with hydroxychloroquine (Plaquenil®).
   
   Antimalarials work by blocking ultraviolet light from damaging skin, lowering cholesterol levels, blocking cytokines that promote inflammation, and altering the acid-base balance of cells, thus limiting their ability to process antigens and lessening antibodies. Another important feature is that antimalarials do not lower blood counts or make patients more susceptible to infection. The onset of action is two to three months with benefits noted by patients in four to six months. Antimalarials are not used in the management of organ-threatening lupus.
   
   Report any medication side effects. Those most commonly noted include diarrhea, loss of appetite, nausea, rash and black spots in visual field. Eye exams are recommended before starting therapy and every year after.
   
   
2. Glucocorticoids. These hormones, which come in many forms, regulate many of the body's physiologic functions. When used for pharmacologic activities, they mainly stabilize the cells, making them less likely to engage in the inflammatory process. They also block numerous chemical pathways and decrease the number of circulating lymphocytes.
   
   The most commonly-prescribed glucocorticoid used in the treatment of lupus is prednisone. Prednisone is generally used for treating active, organ - threatening lupus. Patients with involvement of the heart, lungs, kidneys, liver, or blood are begun on higher doses than patients with severe flare-ups of non-organ threatening lupus or patients with chronic, mild, non-organ-threatening lupus. The last group of patients are on the lowest daily doses.
   
   Patients should take this medication as directed. When ordered once daily, it should be taken at breakfast with food. It may be ordered up to four times per day during acute inflammation as it is more quickly metabolized. Patients should not stop taking this medication abruptly as the adrenal gland has not been producing glucocorticoids and cannot respond to an abrupt removal of prednisone. The dosage of this medication is designed to be reduced gradually (tapered).
   
   Prednisone requires careful monitoring and can cause serious complications. In the beginning, side effects may include heartburn, palpitations, agitation, and difficulty sleeping. Additional side effects may occur over time. These include thin skin, bruises, hair loss (upper head and temples), increased facial hair, impaired wound healing, muscle weakness, loss of calcium in bones, cataracts, glaucoma, hypertension, increased appetite, elevated blood sugar, menstrual irregularity, weight gain (centrally - noted at the belly and buttocks), confusion, difficulty concentrating, fluid retention with bloating and puffiness (noted especially in face and ankles), decreased potassium levels, heartburn which can lead to ulcers, and a much greater risk of infection. Not all patients experience these side effects, but it is important to recognize the possibility and monitor for them carefully.
   
   One group of these side effects are known as Cushing's syndrome. Cushing's includes weight gain, moon-face appearance, thin skin, muscle weakness and brittle bones. If steroids are used, every effort is generally explored to reduce the dosage to its lowest possible effective level.
   
   
3. Immunosuppressives. Immunosuppressives are classified into chemotherapy agents and anti-rejection medications for transplant patients. They are also referred to as cytotoxic or "steroid sparing" medicines.
   
   These medications fall into different categories according to the actions they perform. In lupus, the most common chemotherapy agents include cyclophosphamide) and methotrexate (Rheumatrex®). Each one has specific uses in the treatment of lupus and side effects can be problematic. Azathioprine is an anti-rejection medication.

Patient's Medication

Mrs. Evan was placed on prednisone as she has beginning signs of kidney involvement based on her lab results and UA. She was given information about lupus and about her medications, and about community resources and how to contact the clinic. This information was reviewed with her. She was encouraged to call with questions and to report any possible side effects of the medication. She was given an appointment to follow-up in one month and lab work was ordered prior to that appointment.