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Lupus and Medication

 

The types of drugs used in lupus can be broadly divided into those that treat the disease itself (e.g. hydroxychloroquine and prednisolone) and those that are used for other problems sometimes associated with lupus (e.g. tablets for high blood pressure).

Non-steroidals

These are the standard drugs used for joint pains such as Ibuprofen (Nurofen). There are many types and they are designed to reduce pain due to inflammation. They are used most for arthritis and pleurisy. Unfortunately, they are prone to cause indigestion. They may cause peptic ulcers and bleeding from the gut and may increase the risk of heart attacks and stroke if taken regularly for long periods of time (e.g. years).

Anti-malarials

The most commonly used drug in this group is hydroxychloroquine (Plaquenil). It has a number of properties which make it useful in treating lupus, for example disease modifying properties resulting in reduction in fatigue, sun-induced flares and flares of arthritis, pleurisy, fever and it is safe in pregnancy and breast-feeding. There is some evidence that it may reduce blood clotting (sticky blood) and it improves the outcome for mother and baby if taken in pregnancy. The older drug chloroquine was associated with a higher risk of eye (retinal) damage so it is avoided now. Recent studies with hydroxychloroquine, at recommended doses based on body weight, show that the risk of retinal disease is minimal. Unfortunately, hydroxychloroquine may take 3-6 months to exert its full effect and it is not sufficient for treating severe lupus manifestations such as kidney disease and nervous system involvement.

Corticosteroids (prednisolone)

These are life-saving for moderate and severe lupus (e.g. kidney, lung, heart, gut and nervous system) and have totally changed the outcome of the disease. Modern treatment is geared to reduce the dose as soon as possible, and it is now known that the majority of lupus patients can be maintained either on a low dose or be weaned off steroids altogether. The side-effects of high dose steroids long term are well known and include weight gain and "moon" face, diabetes, infections, raised cholesterol, muscle weakness and bone softening or osteoporosis. The risks are highest with higher doses for longer periods of time. Injections intramuscularly or intravenously may provide an alternative to high dose daily steroids to treat severe manifestations of lupus quickly with the least risk of
side-effects.

Immunosupressives

These drugs are used to reduce the need for steroids to control moderate and severe lupus. Azathioprine is a milder immunosuppressive and is safe in pregnancy after appropriate counselling. It is used when it is difficult to reduce the steroid dosage. Methotrexate is an alternative but it is not suitable for patients with kidney disease or those wanting to become pregnant. Cyclophosphamide is given as an injection or "pulse" and is widely used for severe kidney disease and severe neuropsychiatric disease. It is a very effective drug and the newer regimes using lower doses by injection have a much higher safety profile than the older higher dose regimes. Possible side-effects of cyclophosphamide are a reduction in white cell count with risk of infections and with the use of higher doses, failure of the ovaries or sperm-producing cells, making the patient infertile (unable to have children). It must not be given to women who are or might be pregnant in the next 3 months as it can cause congenital abnormalities in children.

Cyclophosphamide is increasingly being replaced by mycophenolate mofetil for treating kidney and some other severe manifestations of lupus that cannot be controlled with low dose steroids, hydroxychloroquine and azathioprine. Mycophenolate mofetil does not cause infertility but it can cause congenital abnormalities so it should not be given to lupus patients that are or might become pregnant in the next 3 months.

Other drugs

Other drugs that are less frequently used in lupus include intravenous immunoglobulin (often used when the platelets are low) and ciclosporin A, a drug widely used in transplantation medicine to suppress rejection that is useful for patients with low white cells or platelets due to lupus. For very severe skin disease in patients where pregnancy is not a consideration, thalidomide may be considered.

Non-lupus drugs

Various medications have helped improve the long term outcome in lupus, such as tablets to control blood pressure, anticoagulants (aspirin or warfarin) in those patients with an increased tendency to clotting, and anti-epileptic medication. Skin creams that may be used include corticosteroid and sun-protection creams. Patients who have received long-term steroids are at increased risk from osteroporosis, so calcium and vitamin D3 preparations are often recommended. Other drugs for the prevention and treatment of osteoporotic fractures may be advised in those not planning pregnancy (e.g. bisphosphonates).

Finally HRT (hormone replacement therapy) and the Pill.

It is now recognised that those women with antiphospholipid antibodies are at increased risk of thrombosis or migraine when taking contraception containing oestrogen, so progesterone only contraception may be advised. Hormone replacement therapy containing oestrogen used to be given to treat osteoporosis in post menopausal lupus patients, but it is no longer recommended for use long term due to increased risk of heart attacks.

Taking your Medication

In order for a medicine to be effective it must reach a particular concentration in the blood and/or tissues, e.g. skin, joints, kidneys, etc. and therefore it is important to take a medicine regularly at the prescribed dose and frequency in order to attain and maintain this "effective concentration". Moreover, as different medicines exert their effects in different ways in the body, the time taken to achieve a notable benefit will vary – from days to several months! For people with chronic diseases, such as lupus, it is tempting to give up on medicine if the hoped for benefits are not seen quickly, but it is best to be patient and to persevere according to the prescriber's advice. Drugs should not be stopped just because you feel better either, as many drugs are used to help prevent problems in the future, as well as to treat current symptoms. It can be hard to distinguish side effects of the disease from side-effects of the drug, so always reduce drugs as recommended by your doctor or nurse and discuss any concerns that you might have before changing your treatment.

Anyone unclear or dissatisfied with any aspect of their medication, or concerned about meeting the cost of drugs prescribed for them, should discuss this with their doctor, nurse or pharmacist.

 

 
 

 

 
 

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