Lupus treatment principals
The goal in lupus treatment is to reduce inflammation and pain and to prevent organ damage. Specific lupus treatment is dependent on the symptoms and severity of the disease. Often, a combination of general measures and medications is used by a rheumatologist in lupus treatment.
In most people, sun exposure can cause a flare or worsening of the disease. The recommendations are to stay out of the sun, and wear sunscreens with UV-A and UV-B protection and a high SPF.
Smoking can increase the risk of developing lupus and can exacerbate its flares. The most commonly used medication in lupus, Hydroxychloroquine (Plaquenil) is less effective in smokers.
Inactivity during a lupus flare can cause muscle atrophy and fatigue. It is important to stay in shape during remission and continue gentle exercises during a flare.
Maintain a healthy weight and a healthy diet. Many people with lupus are deficient in vitamin D (especially if avoiding the sun) and will need supplements). Vitamin supplements are ok, but be careful with herbal medications as some may interfere with your other medications.
Non-steroidal anti-inflammatory drugs (NSAIDs)
Examples: Advil, Ibuprofen, Motrin, Aleve, etc.
These are effective in mild disease and for tenderness in the joints and muscles, fevers, and headaches.
Examples: Hydroxychloroquine (Plaquenil), Quinacrine.
These are relatively mild medications with good efficacy and generally little side effects. These drugs are usually used long term and are thought to be effective at keeping the disease inactive. Plaquenil is the one used most commonly. Its most common side effects include nausea, diarrhea, and body aches. Yearly eye exams are required to screen for injury in the retina; an extremely rare side effect.
Examples: Prednisone (oral), solumedrol (IV)
Oral or IV steroids are used alone or in combination with other immunosuppressive drugs during flares of lupus or when the disease is severe. Varying doses are used depending on severity of the flare and organs that may be involved. For example, lower doses of prednisone (10-30mg per day) may be used when the flare involves the skin or joints, whereas doses as high as 1000mg may be used when the brain or kidneys are involved.
Disease Modifying AntiRheumatic Drugs (DMARDs)
Examples: Methotrexte, Azathioprine (Imuran), Mycophenolate mofetil (Cellcept), Cyclosporin, Cyclophosphamide (Cytoxan)
These medications are used in patients with moderate to severe lupus. They are usually used in combination with anti-malarials and/or corticosteroids.
Examples: Belimumab (Benlysta), Rituximab (Rituxan), TNF inhibitors
Belimumab is the newest FDA-approved medication for lupus. It is a monthly IV monoclonal antibody which was approved in March 2011 for lupus patients with a positive ANA without significant brain or kidney involvement. Rituximab is also a monoclonal antibody and like Belimumab affects the B-lymphocytes, although through a slightly different mechanism. Since B-lymphocytes are thought to be the major cells involved in lupus, suppressing the B-lymphocytes is a major target in treatment of lupus. TNF inhibitors (like Enbrel, Humira, etc), which have been revolutionary in treatment of rheumatoid arthritis, have been used in treatment of lupus with caution, as they can cause exacerbation of lupus in some patients.
Therapies for resistance disease
Severe-organ involvement in lupus can be life-threatening, especially when the conventional lupus treatment has been ineffective. These are some less commonly used and investigational treatment approaches.
Stem cell transplantation
A sample of the patient’s stem cells (from bone marrow) is taken out and stored. High dose chemotherapy is then used to wipe out the rest of the stem cells. This is followed by the transplantation of the stem cell sample back through an IV. It is thought that the new generation of the lymphocytes produced by the stem cells will not have anti-self activity. This approach has been reported to have an 84% survival rate at 5 years in one study, and 62% at 48 months in another study.
Other drugs targeting B-lymphocytes
Atacicept and Epratuzumab are other drugs in this family currently undergoing clinical trials
Drugs targeting B and T lymphocytes
Abatacept (orencia)- this drug has been successfully used in patients with rheumatoid arthritis. Its efficacy in treating lupus is currently being studied.
Most people with lupus can live normal lives. Successful therapies are available to us and can be tailored to address the disease in each individual person. Still, lupus is a complex disease. Frequent monitoring by a rheumatologist is usually needed to assess the disease activity and adjust the medications as needed to make sure lupus stays in remission!