Onome Whiteru, MDFellow, Division of RheumatologyAlbert Einstein College of MedicineGet into the Loop!New York City Hospital Tour 2013Annual Lupus Patient Education Series
You may have wondered: “Why am I taking all of these medications inthe first place.” You may have felt: “I am tired of taking all of these pills” You may been concerned about medicationside effects.
Because its your body! Lupus can affect your body in so many ways! We will talk about the ways lupus canpossibly affect your body. Then we will go over the medications forlupus and how they can help to protect yourbody.
Autoimmune disease: Caused by an over-active immune system Your immune system begins to attack your ownbody. Certain genes are more likely to occur in patientswith lupus Many of these genes involve parts of the immunesystem.
Female:Male ratio of 9:1 during childbearingyears Closer to 2:1 during childhood and aftermenopause, suggesting hormonal influence Disease in males can be more severe 70% of SLE: females between ages 15-45 10% present age >60
Highest occurrence is in Afro-Caribbeanfemales 1:250 African American to Caucasian ratio 3:1 Child of SLE mother - risk of SLE 7% 10-15% of SLE patients have 1st degreerelative with SLE
Lupus can be controlled with treatment and insome instances can go into remission. 90% survive 5 years, 80% 10 years Lupus kidney disease worsens prognosis African Americans have more aggressive andtreatment resistant disease 2 different causes of death: Early: disease activity and infections Late: due to long-term disease and treatment
Skin Brain and Nerves Heart Lungs GI system Kidneys Joints Blood
MALAR RASH: Fixed red, flat orraised, over the bridge ofthe nose and cheeks Tends to spare thenasolabial folds Discoid lupus: Red or dark patches ofinflammation and scarring Tends to occur on theface, ears, and scalp
Ulcers in theMouth and Nose: Usually painless Hair Thinning:
Mood Changes and Psychosis Trouble with memory Severe unending headache Strokes and Seizures Vasculitis-inflammation ofblood vessels of the brain Neuropathy-tingling, burningsensation on body Myelitis- inflammation of thespinal cord causing paralysis
Heart: Pericarditis- inflammation of thethin lining around the heart Pericardial effusion- fluid build uparound the heart Myocarditis- inflammation of theheart muscleUniversity of Michigan: www.uofmhealth.org/health Lungs: Pleuritis- inflammation of thelining around the lung Pleural effusions- fluid build uparound the lungCleveland Clinic: www.myclevelandclinic.org
GI System: Belly pain, nausea, vomiting,diarrhea Peritonitis-inflammation of thelining around the abdomen Intestinal vasculitis-inflammation of the bloodvessels with blockage of bloodflow to the intestines Joints: Found in 80% of patients Pain, warmth, swelling andstiffness of the joints. Usually non-erosive Can move deformed fingersback into position
Kidneys: Inflammation of the kidneys isknown as nephritis A serious complication of lupus A leading cause of death in lupusin the first 10 years of disease Patients can notice foamy/bubblyurine in the commode at home. People will usually have nosymptoms of lupus kidneydisease. Your doctor will run testson your urine. The blood: Anemia Low white blood cells Low plateletsKrames.sjmctx.com
Malar (Butterfly) Rash Discoid Rash Sensitivity rash to thesun (Photosensitivity) Ulcers in the nose andmouth Arthritis Fluid around theheart, lungs and inthe abdomen Lupus kidney disease Neurologic Disorders: Stroke, inflammation,depression, memorydysfunction, etc… Anemia, low plateletsand low white bloodcell count Abnormal bloodantibody levels ANA blood test
Affects of lupus are harmful to your body Some complications of lupus are lifethreatening This is why your medications for lupus are soimportant: Your medications protect your body from theharmful and even life threatening affects oflupus.
Active treatment Preventative Treatment Topical Steroids NSAIDs: Advil, Mobic, Naproxen Antimalarials: Plaquenil Steroids: Prednisone, Medrol Cytotoxics/Biologics: Cellcept, Cytoxan, Methotrexate, Imuran, Benlysta Sunscreen At least SPF 30 Calcium, VitaminD, Folate supplements To help prevent SE fromother medications Influenza Vaccine PneumococcalVaccine
Typically use both oral and IV steroid in lupusdepending on the severity of manifestation Oral: Prednisone Medrol IV: Solu-medrol
Very potent anti-inflammatory drugs. Not only anti-inflammatory but also suppressthe immune system. Work very quickly by blocking the formationof inflammatory proteins. Also promote action of anti-inflammatoryproteins.
Acute Lupus flare Active Lupus kidney disease Acute active Lupus of the nervous system Acute anemias Resistent fluid around the heart, lungs or inthe abdomen Inflammation of the blood vessels Severe fever, fatigue, weight loss, arthritis,etc.
Increased appetite Fluid retention Weight gain High Blood Pressure High cholesterol Diabetes Stomach ulcers Cataracts Osteoporosis Anxiety/Psychosis
Monitoring: Important to follow blood pressure andcholesterol Check bone density for bone loss Calcium and vitamin D May need alendronate Healthy diet to help weight gain and diabetes Medicines like omeprazole to help preventstomach ulcers Frequent eye exams
Also known as Plaquenil Old medication used to treat malaria Accumulates in the cell interfering with therecognition of self proteins Used as a preventative agent Decreases the risk of flare Lowers risk of permanent damage Also used for joint and skin manifestations
Typically a well tolerated medication Safe to use during pregnancy; probably helpswith disease activity Side effects include: Anemias Visual changes Retinal problems Certain rashes and skin discoloration
Monitoring: Most side effects are quite rare Recommend frequent eye exams
Other common names: Imuran and Azasan Decreases immune cells from proliferating bystop DNA production in the cells Typically used to treat moderate to severemanifestations of lupus: Maintenance of lupus kidney disease Anemias including low platelets and blood cellcounts Arthritis
Small studies show that the risk for fetalabnormalities is low when used in pregnancy Side effects: Anemias Infection Liver inflammation Pancreatitis Lymphoma
Monitoring: Before starting medication should check forinfections like hepatitis B/C and HIV, Requires frequent blood tests to monitor foranemias, and liver inflammation Vaccination to prevent common infections Typically do not screen for lymphoma unlessthere are concerning symptoms
Other common names: Rheumatrex, Trexall Used as a chemotherapy in much higher doses Inhibits folic acid metabolism in cells as well ascauses release of adenosine which is anti-inflammatory Typically used to treat the arthritis componentof lupus especially if presenting like rheumatoidarthritis Must take with folic acid to prevent side effects
Methotrexate cannot be taken duringpregnancy and can cause fetal abnormalitiesand miscarriage Must stop methotrexate and allow for washout before getting pregnant Side effects: Mouth ulcers Anemias Infections Liver inflammation Lung fibrosis Hair loss
Monitoring: Before starting medication should check forhepatitis, HIV, PPD Check baseline chest x-ray Frequent blood tests for anemia and liverinflammation
Other common name: Cellcept Mycophenolate mofetil: inhibits a moleculecalled inosine monophosphatedehydrogenase, inhibiting DNA and cellmultiplication Typically used for lupus kidney disease as well asrefractory cytopenias, vasculitis
Side effects: Nausea/vomiting Upset stomach Diarrhea Anemias Infections Lymphomas Mycophenolate is not safe during pregnancyand has been proven to cause birth defects Patients should be off of this medicationbefore getting pregnant
Monitoring: Frequent blood test to look anemias and any liveror kidney problems Work up any signs of infection Aggressive vaccinations to avoid commoninfections
Other common name: Cytoxan Cyclophosphamide works by causing changesto DNA so that inflammatory cells cannotmultiply Typically used for the most severemanifestations of Lupus: Lupus kidney disease Lupus of the nervous system Severe vasculitis Severe refractory anemias
Cyclophosphamide can be given either IV ororally but is a chemotherapeutic agent Side effects: Nausea/Vomiting Hair loss Anemias Infections Inflammation of the bladder Infertility Cyclophosphamide is not safe during pregnancy.Can cause birth defects and fetal loss. Must be off medication before getting pregnant
Monitoring: Aggressive hydration and the medication MESNAto help prevent bladder issues Anti-nausea medication Frequent blood tests especially to monitor foranemias Lupron monthly to help limit infertility Immunizations
Other common name: Benlysta Is given as monthly IV infusions In an antibody that inhibits the moleculeBAFF BAFF stimulates B cell production: the cells thatchurn out auto-antibodies in lupus that can causedamage Used to: Help get patients off of their steroids Particularly effective for the skin and arthritismanifestations of lupus
Side effects: Infection Allergy Infusion reaction It is unknown what the risk to the fetus isduring pregnancy Monitoring: Frequent labs Vaccines and avoidance of infection