From the Archives: Fall 2005 Lupus Now Magazine
Ask the Experts
Q: Are people with lupus more prone to infections even if they are not taking immunosuppressive drugs?
A: There is some evidence that people with lupus are more likely to get infections than completely healthy people, even when they are not taking corticosteroids (prednisone and similar medications). The most common infections are in the respiratory tract (colds, sore throats, sinusitis, bronchitis, and pneumonia), the urinary tract (bladder or kidney infections), and the skin (boils, cellulitis, and infected cuts).
If a person with lupus is taking corticosteroids every day, particularly more than 10 mg a day, the risk of infection goes up considerably. However, if a person can take corticosteroid doses once in the morning every other day-instead of every day-there is not much, if any, increase in the risk for infections. Of course, every-other-day treatment does not control active lupus as well as every day.
Other medications used for moderate to severe forms of lupus, such as azathioprine (Imuran), mycophenolate mofetil (CellCept), and cyclophosphamide (Cytoxan), increase infections even more than having the disease does. Herpes zoster outbreaks (shingles)-with painful blisters along the course of a nerve-are particularly increased by the immunosuppressive medications. In general, the more severe the lupus is, the higher the risk for infection, partly because of being sick and partly because of the treatments. In contrast, the antimalarials (hydroxychloroquine, Plaquenil, is the most commonly prescribed) do not increase infections.
There are excellent strategies to reduce your risk for infection. You should have your vaccinations up to date, including Pneumovax® to prevent pneumococcal pneumonia. You should take a flu shot every year. Most women can tell accurately that a bladder infection is present, and you should ask your doctor to prescribe medication for you as soon as symptoms begin. If you are taking high doses of immunosuppressive drugs and/or prednisone, ask your doctor about taking medications to prevent pneumocystis pneumonia. If you have frequent urinary tract infections, there are antibiotics taken once at bedtime and agents that change the acid in the urine that are effective at reducing urinary tract infection rates. If you suffer from outbreaks of herpes virus lesions/ulcers in your mouth, on your lips, or in genital areas, discuss preventive anti-viral treatment with your doctor. If you have been exposed to tuberculosis, you should have a PPD skin test (tuberculin) and consider taking six months of anti-tuberculosis antibiotics if the test is strongly positive. Finally, if it is possible to avoid people with bad colds or other communicable infections, you should do so. Of course, you cannot protect yourself from participating in life, so use your common sense.—Bevra H. Hahn, M.D.
Q: I have lupus and two of my daughters have it as well. What can be expected in the third generation?
A: This question is frequently on the minds of people with lupus. Although lupus appears to cluster in some families, as of yet there are no clear-cut rules to explain why some family members develop the disease and others remain healthy.
Lupus is a genetically complex disease, meaning that numerous genes can be involved in its development. Inheriting a gene associated with lupus is no guarantee that a person will develop the disease. This has been demonstrated by studies of identical twins: The rate at which both identical twins developed lupus varied from 15 percent to 69 percent. It should be noted that, while 69 percent is a high percentage, the rate at which both genetically identical twins developed lupus was not 100 percent. This information points out the role that environmental factors play in lupus disease onset.
According to the Lupus Foundation of America, only 10 percent of people with lupus will have a close relative (parent or sibling) who already has lupus or may develop lupus, and only about 5 percent of the children born to individuals with lupus will develop the illness. Other research has shown that the rate at which fraternal (or non-identical) twins will develop lupus varied from 2 percent to 5 percent. Additional research shows the occurrence of lupus in the offspring of women with lupus at about 10 percent of daughters and 2 percent of sons.
The bottom line is that, although the exact numbers are unknown, it is rare for additional family members to develop lupus, but having a family member with lupus increases your lupus risk factor. The best approach is to be aware of various family members' health and to pursue regular and consistent healthcare yourself. This helps establish your own individual health baseline that makes it more obvious if and when health problems occur.—John Harley, M.D., and the Lupus Genetic Studies Staff
Q: What is the best preventive treatment approach to protect the bones of children with lupus who have to take corticosteroids?
A: Bone health in children with lupus is very important. While physicians treating children with lupus have a high level of awareness about how the toxicities of the medications used to treat the disease affect the skeleton and how the disease itself affects bone health, we have not done enough studies to know how best to treat this problem. At this time, I am comfortable recommending adequate calcium and vitamin D supplementation.
In addition, an effort should be made, despite the disease, to have children do some kind of exercise four to five times a week for 30 minutes. Even with lupus, the combination of calcium, vitamin D, and exercise will work to lay down new and healthy bone. In addition, for children on high doses of glucocorticoids and/or immunosuppressive medications, cautious use of mild anti-resorptive agents like calcitonin could be considered. On the bright side, when lupus activity lessens, children often have catch-up bone growth.
For adults with lupus on glucocorticoids, there are a number of bone-active medications that we can use to prevent and treat bone loss. However, studies that carefully evaluate the benefits and risks associated with a growing skeleton in children with lupus have not been done. Therefore I am taking a conservative approach and waiting until such studies are done before prescribing bone-active medications to children.—Nancy Lane, M.D.
Bevra Hahn, M.D. is chief of Rheumatology at the University of California-Los Angeles School of Medicine, where she also sees patients, teaches, and conducts research.
John Harley, M.D., Ph.D. and the Lupus Genetic Studies Staff are at the Oklahoma Medical Research Foundation in Oklahoma City. Harley also sees patients at the University of Oklahoma Health Science Center.
Nancy Lane, M.D. conducts research and teaches at the Division of Medicine and Rheumatology at the University of California-Davis Medical School.