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The Treatment of Lupus - Drugs

STEROIDS

For over half a century, steroids have formed the basis of treatment of the sick lupus patient. Steroids are either given as tablets ('Prednisolone' or 'Delta-cortril') or as injection (e.g. 'pulse' methyl prednisolone). Their effect is almost immediate and they can be life saving. They are used in many aspects of lupus e.g. low platelet counts, pleurisy, severe skin disease, arthritis and kidney disease.

One of the most important advances in lupus has been the more conservative uses of steroids - lower doses and for shorter periods of time. The other has been the consistent use of other drugs (such as plaquenil or azathioprine) as steroid 'sparing' drugs.

The down side of steroids is their long list of side effects. These are dose related: on small doses, side effects are few. The more well known are increased appetite (and weight gain), sleeplessness and sometimes more 'crotchety' behaviour.

The more serious side effects - associated with long term use, are cataracts, muscle weakness and bone osteoporosis


ANTIMALARIALS

These agents, notably hydroxychloroquine (Plaquenil) are used in lupus clinics throughout the world and are particularly useful for skin rashes, joint pains & fatigue. They are discussed in detail in a separate leaflet.


IMMUNOSUPPRESIVES

These are agents which suppress the over-active immune system in lupus. There are 4 main drugs currently in use - Azathioprine, Cyclophosphamide, Methotrexate and Mycophenolate.

Azathiaprine

This drug, in use for decades, has become the traditional 'first choice', particularly in combination with steroids, for kidney disease. Like all drugs in its class, it can lower the blood count and regular blood counts are necessary. Some patients are very intolerant of the drug with nausea and vomiting making a change of choice necessary.

Cyclophosphamide ('Cyclo')

This is a more toxic drug, kept for more severe cases, especially active disease. It is almost always given as a 'drip' or 'pulse'. At the lupus clinic at St. Thomas' we have pioneered a more conservative dose regime. This has not only resulted in fewer side effects, but has almost totally eradicated one of the most feared side effects - ovary failure and infertility.

Methotrexate

This drug, given weekly, is used worldwide in the treatment of rheumatoid & other chronic arthritis. In those patients with severe arthritis methotrexate does have a place in management. The two major side effects - low blood count & liver disturbance are monitored by regular (6 weekly) blood tests.

Mycophenolate

This relatively new (& expensive) drug is showing great promise, especially in the treatment of lupus kidney disease. At St. Thomas', we are increasingly using the drug, which promises to be a less toxic substitute for Cyclophosphamide in some patients.


OTHER DRUGS

There are a whole range of medical problems which can effect a lupus patient (as well as the rest of the population), but which are now increasingly effectively treated. These include thrombosis, arthritis, blood pressure, depression, osteoporosis, raised cholesterol & heart disease.

Thrombosis (blood clotting)

Those lupus patients with a clotting tendency usually require medication to keep the blood 'thinner'. The commonly used medicines are aspirin and in more severe cases, Heparin or Warfarin.

Arthritis

The commonly used drugs are known as 'non-steroidals' (non-steroidal, anti-inflammatory drugs). The older drugs such as ibuprofen and diclofenac are now being largely replaced by the new agents which are less irritant on the stomach. For more serious arthritis, stronger 'second line' drugs such as methotrexate are used.

Osteoporosis

Long term steroid treatment can lead to bone thinning. Nowadays, many patients on steroids are given supplementary calcium and Vitamin D. The good news is that there are a whole range of effective treatments now available, including alendronate (Fosamax) and in some patients, (including lupus patients), hormone replacement therapy (HRT).

Cholesterol

It is now recognised that coronary artery disease is a significant problem in some lupus patients. The causes for this tendency are unclear. However, one potential risk factor, raised cholesterol, can be treated very effectively indeed. A family of drugs called statins are used. There are over a dozen to choose between, the differences are very minor. Fortunately, they are generally well tolerated by lupus patients.

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