Lupus and medication

Lupus (systemic lupus erythematosus or SLE) is a chronic condition that results from a malfunctioning immune system.

The immune system is designed to identify foreign bodies (such as bacteria and viruses) and attack them to keep you healthy. However, in the case of lupus, your immune system mistakenly attacks tissues such as the skin, joints, kidneys and lining of the heart and lungs, causing ongoing inflammation and pain.

Most people with lupus have a mild form of the disease, but experience occasional flares.

Flares are periods when your symptoms (such as rash, pain and fatigue) become more intense. They are unpredictable and can seem to come out of nowhere. They’re often triggered by stress and exposure to ultraviolet (UV) light.

Lupus most commonly appears in women of childbearing age. It is not known what causes lupus, however, it appears that your genes may play a role, as well as triggers such as an illness, injury or period of stress.

Medications for treating lupus

There is no cure for lupus, however there are different medications that can help to control it very effectively. If your condition is controlled early, the likelihood of later complications may be reduced. There are also many strategies you can use to manage your condition, including physical activity and lifestyle changes.

Medication can help manage your symptoms and assist in controlling your overactive immune system. Because people with lupus experience different symptoms, and to varying degrees, there is no ‘one size fits all’ treatment. You might need to take a combination of different medications that could include:

• pain relievers (analgesics)
• non-steroidal anti-inflammatory medications (NSAIDs)
• corticosteroids
• hydroxychloroquine (or anti-malarials)
• disease modifying anti-rheumatic drugs (DMARDs)
• immunosuppressants.

Non-steroidal anti-inflammatory medications (NSAIDs)

NSAIDs are used to reduce inflammation, pain and fever associated with lupus. They include over-the-counter medications such as ibuprofen (for example, Nurofen®), or prescription medications such as Voltaren® Celebrex® and Orudis®.

The main side effects of NSAIDs occur in the gastrointestinal tract, especially the stomach and oesophagus (food pipe), where they can cause indigestion, ulcers and even haemorrhages (bleeding inside your body). Sometimes people taking NSAIDs will also take stomach-protecting medications to protect against this.

More recent NSAIDs like Celebrex® or Arcoxia® may have a lower risk of gastrointestinal side effects. To minimise side effects, NSAIDs should be taken only as directed.
NSAIDs are also known to cause increased blood pressure and fluid retention and may impair kidney function in people with lupus. For this reason, they’re generally avoided in people who have kidney disease that has been caused by their lupus (lupus nephritis).There is some debate about the safety of NSAIDs for people at risk of heart disease, as some studies have reported an increase in the risk of heart attack and stroke. People with lupus are at higher risk of heart disease, so it’s important that you discuss the risks and benefits of using NSAIDs with your doctor.

Hydroxychloroquine

Medications such as hydroxychloroquine (Plaquenil®) are referred to as anti-malarials because they were originally used for the treatment of malaria. We now know that they’re very effective at controlling immune system activity in chronic conditions such as lupus. Usually taken as one or two tablets daily, hydroxychloroquine reduces the skin and joint problems associated with lupus. People who take hydroxychloroquine are less likely to have lupus flares, so most rheumatologists recommend that it be taken by all people with lupus for the long term.

Side effects of anti-malarial medications are uncommon. Occasionally, they can cause a rash or stomach upsets (including diarrhoea). If the dose is too high, they can cause eye damage, but this is extremely rare when the correct dose is used. However, annual eye checks are recommended.

Corticosteroids

Corticosteroids, also known as steroids, cortisone, prednisone and prednisolone, are synthetic hormones that mimic the action of cortisone, a naturally occurring hormone produced by the adrenal glands. These medications are usually taken in tablet form, but may be injected for a particularly severe lupus flare.

Dosage depends on the severity of symptoms and the person’s general state of health, including age and weight. The main function of steroids is to treat inflammation. They also help to reduce pain and fever.

Steroids also dampen the activity of the immune system, which will help to reduce the severity of your symptoms. It’s very important not to cut back on your dose without talking with your doctor.

The main problem with steroids is that they have significant side effects. All side effects are related to the dose you’re taking, so you and your doctor will often use other strategies to make sure that you take the lowest dose possible.

The potential side effects of corticosteroids include:

• mood changes
• skin thinning, resulting in easy bruising
• weight gain due to increased appetite and decreased metabolism
• osteoporosis – usually people with low bone density are given calcium and vitamin D supplements to counteract this
• risk of diabetes and high blood pressure
• unwanted hair growth
• increased risk of infections due to the suppression of your immune system
• cataracts (associated with long-term use only).

While these side effects sound bad, most people using steroids to manage lupus end up using very low doses with minimal side effects, even if their initial dose is high. The difference between well-controlled lupus and lupus that is affecting your health can be a few milligrams of steroids – so avoiding them at all costs is not recommended.

If you’re really concerned about taking corticosteroids, talk openly and honestly about your concerns with your doctor. Together you’ll be able to work out a solution that helps you manage your lupus, and ease your concerns.

Immunosuppressants

Lupus symptoms are triggered by the abnormal activity of the immune system, the specialised group of cells and chemicals that fight infection. Immunosuppressants such as azathioprine, cyclophosphamide and methotrexate reduce lupus symptoms by lowering immune system activity.

Azathioprine is used to treat lupus and is also used in the management of other immune diseases and organ transplantation. Methotrexate is a very commonly used medication in rheumatoid arthritis and is regarded as so safe that it is now the standard treatment. Mycophenolate is increasingly used, especially to treat lupus kidney disease.

Each of these medications has particular effects on lupus and particular side effects, so each should be used under close specialist supervision.

Precautions for taking lupus medications

Don’t change the doses, or stop taking any of your medications, without first talking with your doctor.

Some lupus medications can interact dangerously with other medications. Never take medications for unrelated conditions, unless they’re prescribed by the same doctor who treats your lupus. This includes over-the-counter medications and supplements that don’t require a doctor’s prescription.

Other medications and supplements may interfere with your lupus medication or cause you to experience side effects. Depending on the medications you are taking to treat your lupus, you may need to undergo routine tests (such as eye tests or blood tests) to ensure that your medications aren’t causing any side effects.

Managing lupus medications

It‘s important that you’re informed about what goes into your body, especially when it comes to medications. Studies suggest that people who are well-informed manage their condition better. Information sheets on the medications used in the management of lupus are available online or from your doctor or pharmacist.

Try to make sure you take your medications as prescribed, in the correct doses, and at the advised time of day. It‘s best to avoid making changes to your medications without talking with your healthcare team, including your doctor and specialists, especially if you’re considering stopping or increasing treatment.

Other treatment for lupus

As well as medication, other treatments that may help you manage your lupus include:

• limiting sun exposure
• applying sunscreen lotion
• regular exercise
• annual flu vaccinations
• regular medical check-ups
• eating a healthy, balanced diet
• managing your stress
• limiting alcohol.

Where to get help

• Your GP (doctor)
• Specialist (often a dermatologist, rheumatologist, nephrologist or immunologist)
• Musculoskeletal Australia National Help Line Tel. 1800 263 265
• Australian Rheumatology Association Tel. (02) 9252 2356