Heather DeGrendele, Ph.D.

Systemic Lupus Erythematosus (SLE) is a disease that, because of its complexity, poses major challenges for clinicians. The lupus patient will often find themselves with an arsenal of medications used to treat not only the underlying disease, but also the many symptoms and syndromes which accompany lupus. Because not all patients present with the same symptoms, associated syndromes, or disease severity, there is no set treatment regime. In this article, we will attempt to survey the common treatments available to combat the underlying autoimmune reactions of lupus. Due to the enormous number of drugs that could be used to treat the symptoms, these medications are not fully covered here. Please refer to the accompanying tables for more information. TABLE 1 summarizes commonly used treatments for SLE, TABLE 2 lists other medications mentioned in various articles in this issue, and TABLE 3 summarizes some of the new and experimental treatments for lupus. This article and the associated tables are for informational purposes only, and treatment with these medications should be on the advice of a physician.

Perhaps the most important treatments for the lupus patient do not involve drugs at all. These include lifestyle alterations such as avoiding direct sunlight and UV radiation, incorporating adequate sleep, and a healthy diet. Not all lupus patients find themselves severely affected by sunlight; however, the use of sunscreen can prevent even minor rashes and bouts of fatigue. Likewise, although there are currently no special dietary restrictions suggested for the lupus patient, a reasonable diet low in salt, sugar, and fat is advised. This is because some medications, including corticosteroids, can cause high blood pressure, increased blood sugar levels, and high serum cholesterol.

Among the common symptoms for SLE are joint and muscle pain and inflammation. Non-steroidal anti-inflammatory drugs (NSAIDs) are often used to treat these symptoms. The effect of an NSAID can be very individualized, and no two patients may experience the same benefits or side effects. The most common side effect associated with long term NSAID use is ulcers or gastrointestinal bleeding. Those medications with the lowest risk of this side effect include ibuprofen, naproxen, ketoprofen, nabumetone (Relafen), etodolac (Lodine), salsalate, and sulindac (Clinoril). A higher risk for bleeding is observed with flubiprofen (Ansaid), piroxicam (Feldene), fenoprofen, indomethacin (Indocin), meclofenamate (Meclomen), and oxaprozin (Daypro) (1). Drugs such as Prilosec and Arthrotec may help prevent ulcers and restore the stomach lining. Cox-2 inhibitors (Celebrex and Vioxx) act in a similar way as NSAIDs; however, they do not carry the same risk of gastrointestinal bleeding.

Anti-malarial drugs are also good anti-inflammatories. These medications are most commonly used for discoid lupus and cutaneous lupus. Although their exact mechanism of action is still unknown, these drugs can relieve fatigue, fever, pain and inflammation very effectively. In addition, hydroxychloroquine may help to reduce the risk of blood clots and increased serum cholesterol caused by corticosteroid treatments. It should be noted that these medications can require up to 4 to 6 months before an effect is seen (2). The most worrisome side effect of the anti-malarials is retinal damage; however, in the doses normally given for lupus treatments, the risk is low (2). To be proactive, patients should go for retinal monitoring regularly and report any visual disturbances to their doctor immediately.

For more severe and active forms of lupus, drugs that inhibit the immune response itself must be used. These include corticosteroids and immunosuppressants. Corticosterids have a very complex mechanism of action that involves the regulation of the expression of many different genes. The net result is a dramatic decrease in inflammation. These drugs can cause many side effects, but the benefits greatly outweigh these in some severe lupus cases. Patients with severe kidney or central nervous system involvement often require additional treatment with immunosuppressants. Immunosuppressants themselves can cause many side effects, but they also can decrease the patient's dependence on corticosteroids, reduce disease activity in the major organs, and, in some cases, lead to disease remission (2).

Today, new therapies are being developed for the treatment of SLE. These are fully covered in Table 3, and range from the use of chemotherapies already approved for the treatment of cancers, to novel therapies targeting the white blood cells (lymphocytes) that mediate lupus. Many of these therapies show the promise of being as helpful as the Immunosuppressants already in use, yet are so targeted that they exhibit far fewer side effects. These new treatments should improve the prognosis and quality of life of lupus patients as they become available.

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References.
Commonly used treatments for SLE.
Other medications mentioned in this issue
New and experimental treatments for SLE