Medications to Treat Lupus Symptoms
Anti-inflammatory medications help to relieve many of the symptoms of lupus by reducing inflammation and pain. Anti-inflammatories are the most common drugs used to treat lupus, particularly symptoms such as fever, arthritis or pleurisy, which generally improve within several days of beginning treatment. For many people with lupus, an anti-inflammatory drug may be the only medication they need to control their lupus.
- Aspirin is inexpensive and available over the counter. It has pain-reducing, anti-inflammatory, and anticoagulant (blood-thinning) properties that can control some of the symptoms of lupus. However, aspirin can cause stomach irritation.
- Acetaminophen, known to most people as Tylenol®, is also used to reduce pain. Although it causes less stomach irritation than aspirin, acetaminophen does not help with inflammation and cannot control any of the disease activity of lupus. Most people have no side effects when taking Tylenol, but in rare cases acute liver failure has occurred.
- Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) suppress inflammation and are especially useful for joint pain and stiffness. Examples of NSAIDs are ibuprofen (Motrin®), naproxen (Naprosyn®), indomethacin (Indocin®), nabumetone (Relafen®), and celecoxib (Celebrex®). People often respond better to one particular NSAID than another, so you may need to try several different products to determine the most effective one for you.
Like aspirin, NSAIDs can cause stomach irritation. NSAIDs may also cause serious gastrointestinal (GI) complications, such as a bleeding ulcer. To reduce the chance of these problems, NSAIDs are usually taken with food, milk or antacids, or may be accompanied by other medications such as misoprostol (Cytotec®), omeprazole (Prilosec®), lanzoprazole (Prevacid®), and others.
Side effects of NSAIDS, such as abnormal urine test results, occasionally may be mistaken for signs of active lupus. Recognizing this possible complication of NSAID use is important, because the symptoms will go away when the drug is stopped. In general, you should always be cautious about taking too much of any NSAID, as excessive amounts can reduce the blood flow to your kidneys and may interfere with their ability to remove waste from your body.
Corticosteroids (also known as glucocorticoids, cortisone or steroids) are synthetic (man-made) drugs designed to work like the body’s naturally occurring hormones produced by the adrenal glands, in particular cortisol. Hormones are the body’s chemical messengers that regulate most of the body’s functions. Cortisol helps regulate blood pressure and the immune system, and it is the body’s most potent anti-inflammatory hormone. Corticosteroids prescribed for autoimmune diseases are different from the anabolic steroids that weightlifters and other athletes sometimes take to increase strength.
Steroid medications work quickly to decrease the swelling, warmth, tenderness, and pain that are associated with inflammation. They do this by lessening the immune system’s response. Prednisone is the most commonly prescribed steroid for lupus. Prednisolone and methyl-prednisolone (Medrol®) are similar to prednisone, and some physicians prefer to prescribe these if you have liver problems.
Most people take steroids in pill form, but topical creams or gels are often used for cutaneous (skin) lupus. Steroids in liquid form are sometimes injected into muscles or directly into joints, and in some cases into skin lesions. Pulse steroids are large liquid doses given intravenously (injected into a vein) over several hours; the beneficial effects can last for weeks so pulse steroids are sometimes prescribed to control a lupus flare, or for people who cannot tolerate steroids in pill form.
Your doctor will try to keep your steroid dosage at the lowest effective level. Once the symptoms of lupus have responded to treatment, the steroid dose is gradually reduced (tapered). As an alternative to tapering, or stepping down the steroid dose, your doctor may choose to have you take steroids on an every-other day basis -- one day on, one day off.
Steroids can produce a variety of side effects. The most common are changes in appearance (acne, a round or moon-shaped face, weight gain due to increased appetite, and hair growth). Steroids can cause fluid retention and a redistribution of fat, leading to a swollen face and abdomen, but thin arms and legs. Also, the skin becomes more fragile and bruises easily. Steroids can suppress growth in children. Steroids can also cause irritability, agitation, excitability, insomnia, or depression. These changes in appearance and mood are more apparent with high doses of steroids.
Side Effects of Long Term Steroid Use
- Increased risk of infections poses the most danger. If you are taking steroids you must take extra care to clean and protect any open wounds. Infections are one of the leading causes of death in people with lupus.
- Avascular necrosis of bone, which occurs most often in the hip, is the destruction of the bone itself and is quite painful. Relief from pain often requires total surgical joint replacement.
- Osteoporosis (bones become fragile and more likely to break) leads to bone fractures, especially compression fractures of the vertebrae with severe back pain.
- Muscle weakness
- Suppression of growth in children
Antimalarials are used in combination with steroids and other medications, in part to reduce the dose required of the other drugs. Antimalarials are most often prescribed for skin rashes, mouth ulcers, and joint pain, but also can be effective in mild forms of lupus where inflammation and blood clotting are a concern. Antimalarials improve lupus by decreasing autoantibody production, protecting against the damaging effects of ultraviolet light from the sun and other sources, and improving skin lesions.
The two types of antimalarials most often prescribed today for lupus are hydroxychloroquine (Plaquenil®) and chloroquine (Aralen®). Unlike the rapid response seen with steroids, it may take months before antimalarial drugs improve your lupus symptoms.
Side effects from antimalarials are rare and usually mild; they include upset stomach and changes in skin color. These side effects usually go away after the body adjusts to the medication. In high doses certain antimalarial drugs may damage the retina of the eye, causing vision problems. With the low doses of antimalarials used in the treatment of lupus, the risk of this complication is extremely low. However, as a precaution, people treated with antimalarials should see an eye doctor (ophthalmologist) regularly.
Women who are pregnant should continue to take their antimalarial medication as prescribed, in order to avoid a lupus flare. Although this medication can cross the placenta, the possibility of eye and ear toxicity in the infant is very low. In fact, recent studies suggest that the risk of flare for the mother is greater than the risk of fetal toxicity.
From Lupus Now Magazine: Drug Spotlight on Hydroxychloroquine
Immunosuppressives (Immune Modulators)
Immunosuppressive medications are used to control inflammation and the overactive immune system, especially when steroids have been unable to bring lupus symptoms under control, or when a person cannot tolerate high doses of steroids. However, there can be serious side effects from these drugs, so if you are being treated with immunosuppressives you should be carefully monitored by your physician. Immunosuppressive drugs reduce your body’s ability to fight off infections, and increase the chances that you could develop viral infections such as shingles (chicken pox, or herpes zoster). It is extremely important that you pay attention to even the smallest cut or wound, and let your doctor know if any sign of infection begins, such as redness, swelling, tenderness, or pain. These drugs may also increase your risk for developing cancer.
Each immunosuppressive drug has unique side effects. Therefore it is important that immunosuppressive drugs be given only by physicians who are experienced with the use of these medications.
Cyclophosphamide (Cytoxan®) was developed to fight cancer. Although in its early years of use it was taken in pill form, today Cytoxan is taken through the vein (intravenously, or IV). It has been shown to improve kidney and lung disease, but can affect a woman’s menstrual cycle and can cause bladder problems, hair loss, and sterility.
Methotrexate (Rheumatrex™), also developed to fight cancer, is known as the "gold standard" -- the best drug -- for the treatment of rheumatoid arthritis. It has also been shown to be very effective in treating skin lesions, arthritis, and pleuritis in people with lupus. However, the drug can cause sun-sensitivity, liver damage, including cirrhosis, and lung infections. If you are taking this drug you should not drink alcohol, especially if you have a history of kidney disease. If you are taking high-dose methotrexate you should not use NSAIDs; caution is also advised when taking aspirin. Nausea, mouth sores, and headaches are the most common side effects of methotrexate.
Azathioprine (Imuran®) was developed to prevent rejection of kidney transplants. It blocks inflammation pathways in lupus and helps to lower the steroid dosage and improve liver and kidney disease. However, it may cause pancreatitis and an allergic form of hepatitis, so liver function tests and blood counts should be done regularly.
Because blood clots can be a life-threatening symptom of lupus, these drugs are used to thin your blood to prevent it from clotting too easily. Anticoagulant medications include low-dose aspirin, heparin (Calciparine®, Liquaemin®) and warfarin (Coumadin®). In particular, if you are being treated with warfarin you must be monitored by your doctor to be sure your blood does not become too thin. Anticoagulant therapy may be lifelong in some people with lupus. Very recent research has shown that people’s genetic makeup may influence how they respond to warfarin; specifically, that people with variations in two genes may need lower warfarin doses due to differences in how the body breaks down (metabolizes) warfarin and regulates the ability of warfarin to prevent blood from clotting. Therefore the dosage and administration of warfarin must be individualized for each person.
Monoclonal antibodies (mAbs)
Benlysta® (formerly called LymphoStat-BT) was developed to disrupt activation of B lymphocytes by interfering with BLyS, a protein required for B cell activity. It is the first new medication approved for lupus in more than 50 years.
Frequently Asked Questions
I don't want to go on prednisone. Are there any other treatments available?
In addition to corticosteroids, lupus can be treated with non-steroidal anti-inflammatory drugs, anti-malarial medications, and chemotherapy drugs. There can be situations where steroids are the best choice of therapy and the other medications are not indicated or are ineffective.
What side effects can I expect from taking steroids?
Prednisone is a double-edged sword. It is a very effective anti-inflammatory agent in lupus, and it works fast. But over time, the side effects of higher doses of the medication can be significant. People taking steroids may have side effects that include weight gain (especially in the cheeks and over the back of the neck), acne, hair thinning on the scalp, new facial hair (on the chin or above the lips), mood swings and difficulty concentrating. Your doctor may also discover that your prednisone has caused higher blood pressure, higher glucose levels and higher cholesterol. Prednisone can also weaken bones and damage the blood supply to joints, which usually occurs first in the hips.
Does long-term prednisone use cause diabetes?
Cortisone and its analogues are "stress hormones" that prime the body for times of challenge. Thus, the rise in sugar in the body is a natural byproduct of a preparation for stress in tissues of the muscles, brain, and heart for example. This is why an increase in the stress hormone results in an increase of the body's stores of glucose. Long-term prednisone use can cause diabetes in someone who has a tendency to be diabetic. Moreover, the higher the dose of prednisone, the greater the likelihood that the blood glucose (sugar) level will rise. Obesity and a genetic background that includes diabetes also gives a person a greater chance of developing diabetes.