LUPUS AND YOU:YOUR BODY

YOUR MEDICATIONS

Onome Whiteru, MDFellow, Division of Rheumatology

Albert Einstein College of Medicine

Get into the Loop! New York City Hospital Tour 2013 Annual Lupus Patient Education Series

PILLS, PILLS AND MORE PILLS! You may have wondered: “Why am I taking all of these

medications in the first place.”

You may have felt: “I am tired of taking all of these pills”

You may been concerned about medication side effects.

THIS IS FOR YOU! Because its your body!

Lupus can affect your body in so many ways!

We will talk about the ways lupus can possibly affect your body.

Then we will go over the medications for lupus and how they can help to protect your body.

WHAT IS LUPUS? Autoimmune disease:

Caused by an over-active immune system Your immune system begins to attack your

own body. Certain genes are more likely to occur in

patients with lupus Many of these genes involve parts of the

immune system.

WHO GETS LUPUS? Female:Male ratio of 9:1 during

childbearing years Closer to 2:1 during childhood and after

menopause, suggesting hormonal influence

Disease in males can be more severe

70% of SLE: females between ages 15-45

10% present age >60

WHO GETS LUPUS? Highest occurrence is in Afro-Caribbean

females 1:250

African American to Caucasian ratio 3:1

Child of SLE mother - risk of SLE 7%

10-15% of SLE patients have 1st degree relative with SLE

MORTALITY Lupus can be controlled with treatment and

in some instances can go into remission.

90% survive 5 years, 80% 10 years

Lupus kidney disease worsens prognosis

African Americans have more aggressive and treatment resistant disease

2 different causes of death:Early: disease activity and infectionsLate: due to long-term disease and

treatment

LUPUS CAN AFFECT YOUR BODY FROM HEAD TO TOE Skin Brain and Nerves Heart Lungs GI system Kidneys Joints Blood

SKIN MALAR RASH: Fixed red, flat or raised,

over the bridge of the nose and cheeks

Tends to spare the nasolabial folds

Discoid lupus: Red or dark patches of

inflammation and scarring

Tends to occur on the face, ears, and scalp

SKIN Ulcers in the

Mouth and Nose:

Usually painless

Hair Thinning:

BRAIN AND NERVES Mood Changes and

Psychosis

Trouble with memory

Severe unending headache

Strokes and Seizures

Vasculitis-inflammation of blood vessels of the brain

Neuropathy-tingling, burning sensation on body

Myelitis- inflammation of the spinal cord causing paralysis

HEART AND LUNGS Heart: Pericarditis- inflammation of

the thin lining around the heart

Pericardial effusion- fluid build up around the heart

Myocarditis- inflammation of the heart muscle

University of Michigan: www.uofmhealth.org/health

Lungs: Pleuritis- inflammation of the

lining around the lung

Pleural effusions- fluid build up around the lung

Cleveland Clinic: www.myclevelandclinic.org

GI SYSTEM AND THE JOINTS

GI System: Belly pain, nausea, vomiting,

diarrhea

Peritonitis-inflammation of the lining around the abdomen

Intestinal vasculitis- inflammation of the blood vessels with blockage of blood flow to the intestines

Joints: Found in 80% of patients

Pain, warmth, swelling and stiffness of the joints.

Usually non-erosive

Can move deformed fingers back into position

KIDNEYS AND THE BLOOD Kidneys: Inflammation of the kidneys is

known as nephritis

A serious complication of lupus

A leading cause of death in lupus in the first 10 years of disease

Patients can notice foamy/bubbly urine in the commode at home.

People will usually have no symptoms of lupus kidney disease. Your doctor will run tests on your urine.

The blood: Anemia

Low white blood cells

Low platelets

Krames.sjmctx.com

CRITERIA FOR THE DIAGNOSIS OF SLE

Malar (Butterfly) Rash

Discoid Rash Sensitivity rash to

the sun (Photosensitivity)

Ulcers in the nose and mouth

Arthritis Fluid around the

heart, lungs and in the abdomen

Lupus kidney disease Neurologic Disorders:

Stroke, inflammation, depression, memory dysfunction, etc…

Anemia, low platelets and low white blood cell count

Abnormal blood antibody levels

ANA blood test

LUPUS CAN AFFECT YOUR BODY IN MANY WAYS!

Affects of lupus are harmful to your body

Some complications of lupus are life threatening

This is why your medications for lupus are so important:

Your medications protect your body from the harmful and even life threatening affects of lupus.

TREATMENT OF SLE

Active treatment Preventative Treatment

Topical Steroids NSAIDs:

Advil, Mobic, Naproxen Antimalarials:

Plaquenil Steroids:

Prednisone, Medrol Cytotoxics/Biologics:

Cellcept, Cytoxan, Methotrexate, Imuran, Benlysta

Sunscreen At least SPF 30

Calcium, Vitamin D, Folate supplements To help prevent SE

from other medications

Influenza Vaccine Pneumococcal

Vaccine

STEROID THERAPY Typically use both oral and IV steroid in

lupus depending on the severity of manifestation

Oral:PrednisoneMedrol

IV:Solu-medrol

STEROID THERAPY Very potent anti-inflammatory drugs.

Not only anti-inflammatory but also suppress the immune system.

Work very quickly by blocking the formation of inflammatory proteins.

Also promote action of anti-inflammatory proteins.

STEROID THERAPY Acute Lupus flare Active Lupus kidney disease Acute active Lupus of the nervous

system Acute anemias Resistent fluid around the heart, lungs

or in the abdomen Inflammation of the blood vessels Severe fever, fatigue, weight loss,

arthritis, etc.

SIDE EFFECT OF STEROIDS Increased appetite Fluid retention Weight gain High Blood Pressure High cholesterol Diabetes Stomach ulcers Cataracts Osteoporosis Anxiety/Psychosis

STEROID THERAPY Monitoring:

Important to follow blood pressure and cholesterol

Check bone density for bone loss Calcium and vitamin D May need alendronate

Healthy diet to help weight gain and diabetes

Medicines like omeprazole to help prevent stomach ulcers

Frequent eye exams

HYDROXYCHLOROQUINE

HYDROXYCHLOROQUINE Also known as Plaquenil Old medication used to treat malaria Accumulates in the cell interfering with

the recognition of self proteins Used as a preventative agent

Decreases the risk of flare Lowers risk of permanent damage

Also used for joint and skin manifestations

HYDROXYCHLOROQUINE Typically a well tolerated medication Safe to use during pregnancy; probably

helps with disease activity Side effects include:

AnemiasVisual changesRetinal problemsCertain rashes and skin discoloration

HYDROXYCHLOROQUINE Monitoring:

Most side effects are quite rareRecommend frequent eye exams

AZATHIOPRINE

AZATHIOPRINE Other common names: Imuran and

Azasan Decreases immune cells from

proliferating by stop DNA production in the cells

Typically used to treat moderate to severe manifestations of lupus:Maintenance of lupus kidney diseaseAnemias including low platelets and blood

cell countsArthritis

AZATHIOPRINE Small studies show that the risk for fetal

abnormalities is low when used in pregnancy

Side effects:Anemias InfectionLiver inflammationPancreatitisLymphoma

AZATHIOPRINE Monitoring:

Before starting medication should check for infections like hepatitis B/C and HIV,

Requires frequent blood tests to monitor for anemias, and liver inflammation

Vaccination to prevent common infectionsTypically do not screen for lymphoma unless

there are concerning symptoms

METHOTREXATE

METHOTREXATE Other common names: Rheumatrex, Trexall Used as a chemotherapy in much higher doses Inhibits folic acid metabolism in cells as well

as causes release of adenosine which is anti-inflammatory

Typically used to treat the arthritis component of lupus especially if presenting like rheumatoid arthritis

Must take with folic acid to prevent side effects

METHOTREXATE Methotrexate cannot be taken during

pregnancy and can cause fetal abnormalities and miscarriage

Must stop methotrexate and allow for wash out before getting pregnant

Side effects:Mouth ulcersAnemias InfectionsLiver inflammationLung fibrosisHair loss

METHOTREXATE Monitoring:

Before starting medication should check for hepatitis, HIV, PPD

Check baseline chest x-rayFrequent blood tests for anemia and liver

inflammation

MYCOPHENOLATE MOFETIL

MYCOPHENOLATE MOFETIL Other common name: Cellcept Mycophenolate mofetil: inhibits a

molecule called inosine monophosphate dehydrogenase, inhibiting DNA and cell multiplication

Typically used for lupus kidney disease as well as refractory cytopenias, vasculitis

MYCOPHENOLATE MOFETIL Side effects:

Nausea/vomitingUpset stomachDiarrheaAnemias InfectionsLymphomas

Mycophenolate is not safe during pregnancy and has been proven to cause birth defects

Patients should be off of this medication before getting pregnant

MYCOPHENOLATE MOFETIL Monitoring:

Frequent blood test to look anemias and any liver or kidney problems

Work up any signs of infectionAggressive vaccinations to avoid common

infections

CYCLOPHOSPHAMIDE

CYCLOPHOSPHAMIDE Other common name: Cytoxan Cyclophosphamide works by causing

changes to DNA so that inflammatory cells cannot multiply

Typically used for the most severe manifestations of Lupus:Lupus kidney diseaseLupus of the nervous systemSevere vasculitisSevere refractory anemias

CYCLOPHOSPHAMIDE Cyclophosphamide can be given either IV or

orally but is a chemotherapeutic agent Side effects:

Nausea/Vomiting Hair loss Anemias Infections Inflammation of the bladder Infertility

Cyclophosphamide is not safe during pregnancy. Can cause birth defects and fetal loss.

Must be off medication before getting pregnant

CYCLOPHOSPHAMIDE Monitoring:

Aggressive hydration and the medication MESNA to help prevent bladder issues

Anti-nausea medicationFrequent blood tests especially to monitor

for anemiasLupron monthly to help limit infertility Immunizations

BELIMUMAB

BELIMUMAB Other common name: Benlysta Is given as monthly IV infusions In an antibody that inhibits the molecule

BAFF BAFF stimulates B cell production: the cells

that churn out auto-antibodies in lupus that can cause damage

Used to:Help get patients off of their steroids Particularly effective for the skin and

arthritis manifestations of lupus

BELIMUMAB Side effects:

InfectionAllergy Infusion reaction

It is unknown what the risk to the fetus is during pregnancy

Monitoring:Frequent labsVaccines and avoidance of infection

THANK YOU! Irene Blanco, MD Yasmin Santiago Our Audience!