Living with Lupus : Treatment, Sun and Stress

by Food and Drug Administration (FDA)

(Page 2 of 3)

"It should be stressed that because patients with other diseases may also have immune complexes and low serum complement, the diagnosis of [lupus] can only be made by examining all the features of the person's illness and by excluding a number of other illnesses that [lupus] may mimic," writes Ronald I. Carr, M.D., in the Lupus Foundation of America's lupus handbook.

The interpretation of the results of these tests is made even more difficult by the unpredictability of the disease. A test may be positive one time and negative the next, depending, in part, on whether the disease is active or in remission.

Kidney and skin biopsies can also help with diagnosis. A kidney biopsy may show deposits of antibodies and immune complexes, and a sample of skin tissue may reveal deposits of antibodies and complement proteins.

Treatment

Treatment for lupus is as varied as the symptoms and depends greatly on how sick the patient is. The drugs used run the gamut from aspirin and other anti-inflammatory drugs to powerful anti-cancer drugs that suppress the immune system. However, no matter how successful the treatment is at alleviating the symptoms, nothing, as yet, actually cures the disease.

According to Phoebe Kray, M.D., director of rheumatology at the New Jersey Medical School, if the patient has a mild disease, involving only the skin and joints, and perhaps even mild kidney disease, the first choice for treatment is nonsteroidal anti-inflammatory drugs. Aspirin is the most familiar in this group of drugs.

For some patients, however, nonsteroidal anti-inflammatories aren't enough. Corticosteroids, which are also anti-inflammatory drugs, are the most common drugs used to treat lupus, especially in patients with advanced kidney disease and any of several different abnormal blood conditions.

"We usually have very clear indications for using corticosteroids," says Kray. "If the patient has thrombocytopenia [a decrease in the number of blood platelets] or hemolytic anemia [a below normal number of red blood cells] we always treat with prednisone." (Prednisone is the most frequently used corticosteroid.) In addition, central nervous system involvement such as headaches and seizures require corticosteroids, Kray says.

However, Kray cautions that steroids aren't always necessary. "Occasionally we get patients referred to us from family physicians — they just simply hear the word lupus and they immediately think that prednisone is indicated," says Kray. But because steroids have many unwanted side effects, Kray says they shouldn't be used automatically.

The most familiar side effect from steroids is a round, puffy "moon" face, but "the side effect we fear the most is necrosis of the bone," says Kray. This damage to the bones — the steroids cause the bone cells to die — especially affects the hips and shoulders, and, for some patients, makes artificial hip replacements necessary.

Lupus treatment may also include antimalarial drugs. While it isn't clear why the antimalarials work against lupus, they can relieve symptoms such as skin lesions and joint swelling. In addition, pleuritis (inflammation of the membranes of the lungs and thoracic cavity) and mild pericarditis (inflammation of the tissue that surrounds the heart) may respond to antimalarials.

Patients with advanced kidney or neurologic disease may also be treated with cytotoxic drugs, which were originally developed to treat cancer. Studies at the National Institutes of Health have demonstrated that the use of cytotoxic drugs like cyclophosphamide have the capacity to prevent kidney failure, according to NIH's Klippel. The usefulness of these drugs, however, is limited. They suppress patients' immune systems, and serious infections such as herpes zoster have occurred in patients taking them. "Obviously it requires a good deal of judgment as to whether or not the benefits of the drug outweigh the toxicities for any individual patient," says Klippel.

Cytotoxic drugs are not the only ones that cause side effects. The antimalarials can cause irreversible retinal damage that can lead to blindness, dizziness, irritability, and nausea.

Even when the disease is in remission some drugs may have to be continued. "I almost never take patients off prednisone," says Kray, "because my indications [for starting the steroids] are so strict." Kray explains that even if the patient has no outward signs or symptoms, they usually will have some laboratory manifestations of lupus.

Sun and Stress

How did Angela Richardson get lupus in the first place? She has an aunt who also has lupus, so it's possible members of her family have some genetic susceptibility to the disease.

"This appears to be, in some patients, a disease that is inherited," says NIH's Klippel. This inheritance is not absolute, however. It can skip multiple generations, and so even if a parent has the disease, there's no guarantee that any of the offspring will. Only about 4 percent of patients' children, in fact, develop full-blown lupus. Consequently, says Klippel, "trying to understand why certain people have the tendency to get this disease through genetic factors is an active part of NIH research."

Other possible factors that can contribute to the onset of lupus include unidentified viruses and drugs such as birth control pills, sulfa, penicillin, and barbiturates. While drug-induced cases often clear up when the medication is discontinued, it may not be clear whether a flare-up is caused by the medicine itself, or by the virus or infection it is trying to wipe out.

For those who are predisposed to developing lupus, exposure to certain external factors may also trigger an attack. One of the most common is sunlight. Because ultraviolet radiation is thought to increase the response of the immune system, exposure to too much ultraviolet light can precipitate or aggravate a flare-up.

Kray tells all her patients to use a sunblock with a protection factor of at least 15. But she says it isn't necessary to live in fear of the sun. "I don't forbid my patients anything," she says. "You don't want to cut them off from a normal life and the normal pleasures. I tell them not to go to the beach and stay in the sun — that's idiotic. But they can go into a pool — just stay in the shade when not swimming."

Physical and emotional stress can also trigger an attack. And the stress doesn't have to be something upsetting or unhappy. The stress of good times like Richardson's wedding and the birth of Tavel's baby may bring on the disease, too.

About the Author

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