Medications used to treat lupus

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A detailed guide to the types, uses and potential side effects of the main medications used by people with lupus.

Anti-inflammatories and over-the-counter pain relievers

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 symptoms like fever, arthritis or pleurisy. These symptoms often 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 lupus.

Aspirin

• Pain-reducer with anti-inflammatory and anticoagulant (blood-thinning) properties.
• Can control some lupus symptoms.
• Can irritate the stomach.

Acetaminophen (Tylenol®)

• Treatment for pain.
• Less stomach irritation than aspirin.
• Does not help with inflammation and cannot control lupus disease activity.
• Most people have no side effects when taking Tylenol. But, in rare cases liver problems have occurred.

Non-Steroidal Anti-Inflammatories (NSAIDs): Ibuprofen (Motrin®), naproxen (Naprosyn®), indomethacin (Indocin®), nabumetone (Relafen®), and celecoxib (Celebrex®).

• Reduces inflammation.
• Especially useful for joint pain and stiffness.
• People often do better with one particular NSAID than another. So, you may need to try several different ones to determine the best one for you.
• Like aspirin, NSAIDs can irritate the stomach. 
• NSAIDs may also cause serious gastrointestinal (GI) problems, such as a bleeding ulcer. To reduce the chance of these problems, NSAIDs are usually taken with food, milk or antacids. They also may be accompanied by other medications such as misoprostol (Cytotec®), omeprazole (Prilosec®), lanzoprazole (Prevacid®) and others. You may need a prescription for these medications.
• Side effects of NSAIDS, such as urine test results that are not normal, may be mistaken for signs of active lupus. Recognizing these possible side effects are important because the symptoms will go away when the drug is stopped. 
• In general, you should always be careful about taking too much of any NSAID. This can reduce the blood flow to your kidneys and may interfere with their ability to remove waste from your body.
• NSAIDs are available over the counter and by prescription (for higher dosages).

Corticosteroids

Corticosteroids (also known as glucocorticoids, cortisone or steroids) are man-made prescription drugs. They are designed to work like cortisol, a naturally occurring hormones produced by the adrenal glands. Hormones are the body’s chemical messengers that regulate most of the body’s functions. Cortisol helps regulate blood pressure and the immune system. It is also the body’s most powerful anti-inflammatory hormone. Corticosteroids prescribed for autoimmune diseases are different from anabolic steroids. Anabolic steroids are sometimes used by weightlifters and other athletes to increase strength.

Steroid medications work quickly to decrease the swelling, warmth, tenderness and pain that are related to inflammation. They do this by lessening the immune system’s response. Prednisone is the most commonly prescribed steroid for lupus. Prednisolone and methylprednisolone (Medrol®) are similar to prednisone. Some physicians prefer to prescribe these if you have liver problems.

Most people take steroids in pill form. But, creams or gels applied to the skin are often used for cutaneous (skin) lupus. Steroids in liquid form are at times 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 side effects can last for weeks, so pulse steroids are sometimes prescribed to control a lupus flare or for people who cannot take steroids in pill form.

Your doctor will try to keep your steroid dosage at the lowest level possible. Once lupus symptoms respond to treatment, the dose is gradually reduced (tapered). As an alternative to lowering the steroid dose, your doctor may ask  you to take steroids on an every-other day basis -- one day on, one day off.

Steroids can produce a variety of side effects, including:

• Acne
• A round or moon-shaped face, weight gain or hair growth
• Fluid retention and a redistribution of fat, leading to a swollen face and abdomen but thin arms and legs
• Fragile skin that bruises easily.
• Lower than normal growth in children.
• Irritability, agitation, excitability, insomnia or depression.

Changes in appearance and mood are more apparent with high doses of steroids.

Long-term steroid use can produce additional side effects, including:

• Increased risk of infections. Long-term steroid use can increase your risk of infection. 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. This occurs most often in the hip—it is the destruction of the bone itself and is quite painful. Relief from pain often requires total joint replacement.
• Osteoporosis (bones become fragile and more likely to break). This leads to bone fractures, especially compression fractures of the vertebrae with severe back pain.
• Muscle weakness and cataracts also can occur.

Antimalarials

Antimalarials are prescription drugs used along with steroids and other medications. They are used in part to reduce the dose required of the other drugs. Antimalarials are most often prescribed for skin rashes, mouth ulcers and joint pain. They also can be effective in mild forms of lupus where inflammation and blood clotting are a concern. 

Antimalarials improve lupus by decreasing autoantibody production. This protects 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. Side effects usually go away after the body adjusts to the medication. 

In high doses and over time, certain antimalarial drugs may damage the retina of the eye (retinal toxicity), causing vision problems. If low doses of antimalarials are used in the treatment of lupus, the risk of this complication is low. However, as a precaution, people treated with antimalarials should get an eye exam before or soon after starting the drug. They should also visit an eye doctor (ophthalmologist) annually. 

Long term plaquenil users on high doses will need to get check-ups for eye health regularly to prevent retinal toxicity from long-term use. 

Pregnant women should continue to take their antimalarial medication as prescribed 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 higher than the risk of harming the fetus. 

Immunosuppressives (Immune Modulators)

Immunosuppressive medications are prescription drugs used to control inflammation and the overactive immune system. They are especially used when steroids have been unable to bring lupus symptoms under control, or when a person cannot take high doses of steroids. However, there can be serious side effects from these drugs. 

If you are being treated with immunosuppressives, your physician should carefully monitor you. Immunosuppressive drugs reduce your body’s ability to fight off infections. Therefore, they increase the chances that you could get 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 certain types of cancer.

Each immunosuppressive drug has unique side effects. So, it is important that only physicians who are experienced with these medications prescribe them.

Voclosporin (Lupkynis™)

• Developed to treat lupus nephritis
• One of only two drugs specifically approved for lupus nephritis (along with Benlysta)
• Works by preventing an autoimmune response to reduce inflammation and damage to the kidneys
• Most common serious side effect is infection
• Taken as a pill

What you need to know about Lupkynis (voclosporin)

Cyclophosphamide (Cytoxan®)

• Originally developed as a chemotherapy drug (to treat cancer) and used as an immunosuppressant (to treat lupus).
• Taken in pill form previously. Today, Cytoxan is taken through the vein (intravenously, or IV).
• Shown to improve kidney and lung disease.
• Can affect a woman’s menstrual cycle.
• Can cause bladder problems, hair loss and sterility.

Methotrexate (Rheumatrex™)

• Originally developed as a chemotherapy drug (to treat cancer) and used as an immunosuppressant (to treat lupus).
• Known as the "gold standard" -- the best drug -- for the treatment of rheumatoid arthritis.
• Shown to be very effective in treating skin lesions, arthritis and pleuritis in people with lupus.
• Can cause sun-sensitivity, lung infections and liver damage, including cirrhosis.
• Nausea, mouth sores and headaches are the most common side effects.
• 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-doses of methotrexate, you should not use NSAIDs. Caution is also advised when taking aspirin.

Azathioprine (Imuran®)

• Developed to prevent rejection of kidney transplants.
• Blocks inflammation pathways in lupus.
• Helps to lower steroid dosage and improve liver and kidney disease.
• Can cause pancreatitis and an allergic form of hepatitis. For this reason, liver function tests and blood counts should be done regularly.

Anticoagulants

Blood clots can be a life-threatening symptom of lupus. Anticoagulants thin the blood to prevent it from clotting too easily. Anticoagulant medications include low-dose aspirin and prescription heparin (Calciparine®, Liquaemin®) and warfarin (Coumadin®). If you are being treated with warfarin, you must be regularly checked on 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 shows that people’s genetic makeup may influence how they respond to warfarin. Specifically, 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. For this reason, the dosage and administration of warfarin must be individualized for each person.

Monoclonal antibodies (mAbs)

A monoclonal antibody is a type of protein made in the laboratory that is developed to find and attach to only one type of substance in the body.

Benlysta® (belimumab, formerly called LymphoStat-B™) is a human monoclonal antibody. It was developed to disrupt activation of B lymphocytes by interfering with BLyS, a protein required for B cell activity. Benlysta is the first and only drug specifically developed for lupus. It is approved to treat lupus and lupus nephritis. Studies have shown that Benlysta can reduce autoantibody levels and help control disease activity.

Repository Corticotropin Injection (H.P. Acthar Gel)

Acthar® contains a naturally occurring, highly purified hormone called ACTH. ACTH stands for adrenocorticotropic (a-DRE-no-cor-ti-co-TRO-pic) hormone. Acthar is thought to work by helping your body produce its own natural steroid hormones, such as cortisol. These hormones may assist your immune system by helping your body defend itself against inflammation.