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).
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).
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
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
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 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.
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
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.