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No overarching diet exists for people with lupus. However, lupus is a systemic disease, so maintaining good nutritional habits will help your body remain as healthy as possible. Generally, doctors recommend a diet composed of about 50% carbohydrates, 15% protein, and 30% fat. However, since people with lupus often experience symptoms like weight loss or gain, inflammation, osteoporosis, kidney disease, high blood pressure, and atherosclerosis, certain specific nutritional concerns may also need to be taken into consideration. If you need help managing your weight or making healthy food choices, please speak with your doctor. S/he can give you more specific information and refer you to a registered dietitian if needed.

Foods to avoid

Certain foods, including garlic and alfalfa sprouts, should be avoided by people with lupus. [For a more complete list of items to be avoided, please see the article “Things to Avoided” in the Lupus 101 section.] Recently controversy has also arisen over whether aspartame induces lupus. However, scientists have concluded that there is no evidence to suggest that aspartame causes lupus.

Weight changes, high blood pressure, and kidney disease

Often, people with lupus experience weight loss or gain due to loss of appetite, unhealthy dietary habits, or decreased energy and mobility. If you experience weight loss or loss of appetite, talk to your doctor. S/he can help you determine the cause of the problem and take strides to correct it. Weight gain can be caused by many factors, including reduced activity levels and overeating due to steroid use or increased stress. However, remember that women with lupus between the ages of 35 and 44 experience a risk of heart attack that is 50x that of the normal population. Therefore, it is very important that you try to stick to a diet that is low in cholesterol and saturated fats. A low-sodium diet is also essential for people suffering from high blood pressure (above 120/80 mmHg for people with lupus) and kidney disease.

Steroid medications such as prednisone can also cause significant weight gain and redistribution of fat stores in the body. While taking steroids, your cholesterol, triglyceride, and blood sugar (glucose) levels may increase. For these reasons, it is absolutely essential that you follow a low-fat, low-cholesterol diet. You do not need to cut out all of the foods you love, but concentrate on eating whole grain breads and cereals and lean sources of protein such as chicken and fish. When you need a snack, look to raw vegetables—they are low in sugar and calories and provide the perfect food for “grazing.” Try to eat them without Ranch dressing or vegetable dip, because these items carry lots of fat and calories. If you need something to accompany your vegetables, try lighter dips like hummus. It is also important that you minimize alcohol intake ,because combining alcohol with corticosteroids, Tylenol, warfarin, and other lupus medications could be very harmful to your liver and stomach. For those taking methotrexate, alcohol is never allowed.

Inflammation

A diet high in omega-3 fatty acids may help to mitigate inflammation. Although omega-3s have not been adequately studied in lupus, studies of the general population suggest that these essential fatty acids may also boost mood and improve cardiovascular health. Fish, nuts, and flax are excellent sources of omega-3s and can be easily incorporated into everyday meals. Try to avoid saturated fats, such as those in beef and fried snack foods, since these fats are known to increase the risk of cardiovascular disease and may actually stimulate the immune system.

Osteoporosis / Osteopenia

If you have osteoporosis or osteopenia, your doctor will most likely recommend that you take calcium and vitamin D supplements in addition to your regular bone medications, since vitamin D helps your body to absorb calcium. It is important that you also try to eat foods rich in calcium, such as milk, light ice cream/frozen yogurt, cottage cheese, pudding, almonds, broccoli, fortified cereal, oranges, yogurt, hard cheese, soybeans and soymilk, navy beans, oysters, sardines, and spinach. These foods will help to keep your bones as healthy and strong as possible.

Other medications

Certain medications require the observance of strict dietary controls. Your doctor and pharmacist will most likely update you on these regulations, but more information on the dietary restrictions and considerations that accompany certain medications can also be found in the “Lupus Treatment” section.

Sources

• FAQ: Causes of Lupus.” Lupus Foundation of America. 26 June 2009 <http://www.lupus.org/webmodules/webarticlesnet/templates/new_aboutfaq.aspx?articleid=379&zoneid=19>.
• Wallace, Daniel J. The Lupus Book: A Guide for Patients and Their Families. 1st ed. New York: Oxford University Press, 1995.

About 20% of patients with lupus have migraine-like headaches. The following list outlines a program designed to mitigate such headaches. This list is taken directly from a handout prepared by Dr. David Buchholz, MD.

Foods to Avoid:

• Caffeine: Coffee, tea (hot or iced), cola; even decaf coffee and tea may be a problem; try caffeine-free herbal tea
• Chocolate
• Cheese: Avoid all cheeses except American, cream, and cottage cheese. Avoid cheese-containing foods such as pizza and macaroni-and-cheese.
• Monosodium glutamate (MSG): Chinese restaurant food, many snack foods and prepared foods, Accent and other seasoning products; MSG may be labeled as hydrolyzed vegetable/soy/plant protein, natural flavorings, yeast extract, Kombu, “broth,” “stock,” and others; read labels – note: “hydrogenated” is OK)
• Certain Dairy Products: Yogurt, sour cream, and buttermilk.
• Nuts: All, including nut butters (e.g., peanut butter)
• Processed meats: Those that are aged, canned, cured, marinated, tenderized, or contain nitrates or nitrites; includes hot dogs, sausage, bacon, salami, bologna
• Alcohol and vinegar: Especially red wine, champagne, and dark/heavy drinks; vodka is best tolerated; white vinegar is OK
• Citrus fruits and juices: No oranges, grapefruits, lemons, limes, pineapples, or juices from these fruits. Vitamin C and citric acid are OK
• Certain other fruits: Avoid bananas, raisins, red plums, canned figs, and avocados.
• Certain vegetables: Avoid lima, fava, and navy beans, and pea pods, sauerkraut, and onions.
• Certain bread products: No yeast-risen bread products less than one day old – such as those from bakery, doughnut shop, or home
• Aspartame (Nutrasweet)

Over-the-counter Medications to Avoid

• Caffeine-containing medications: Excedrin, Anacin, etc.
• “Sinus”/decongestant medications: Actifed, Sudafed, Dimetapp, Sine-Aid, Dristan, and all other “sinus” and cold products that contain decongestants; plain antihistamines without decongestants are OK

Notes

• The migraine prevention program may not be maximally effective until you have been on it for at least 1 month. Caffeine withdrawal may be associated with temporarily increasing headaches.
• In some cases, this dietary program alone may not adequately control migraine symptoms. In such cases, avoidance of certain other medications (e.g., birth control pills) and addition of migraine-preventive medication may be advisable.
• Even if you take migraine medication, you should follow this program. Without this program, migraine-preventive medication may not work to its full potential.
• You should strictly follow this program until your migraine symptoms are adequately controlled. Then, you may wish to ‘experiment’ with an item you have been avoiding, one item at a time, so that you can assess its individual effect on your symptoms. If eating or drinking an item is associated with recurrent symptoms, you should continue avoiding that item. Dietary triggers can act 1-2 days after consumption.
• Take a high-potency multivitamin daily.

Source

David Buchholz, MD. “Migraine (Headache) Prevention Program.” 2001.

Although lupus manifests in different ways in different people, the articles below provide information on diet and lifestyle considerations common to most lupus patients.

• Things to Avoid If you have lupus or a condition that predisposes you to lupus, such as undifferentiated connective tissue disease (UCTD), there are certain foods and medications that you should avoid. The substances listed in this article have shown to induce lupus signs and flares and should be avoided by people with lupus or autoimmune diseases suggesting “pre-lupus.”
• Lupus and Cancer Systemic lupus erythematosus (“lupus” or “SLE”) and other autoimmune diseases are linked to an increased risk of certain types of cancer. Specifically, lupus patients may experience an elevated risk of lymphoma and other cancers, such as cancer of the cervix. This article provides more information on the link between lupus and cancer.
• Diet No overarching diet exists for people with lupus. However, this article provides more information on overall healthy dietary choices and foods that may be helpful or harmful to people with certain conditions that commonly occur with lupus.
• Lupus and Pregnancy An article written by Dr. Petri on lupus and pregnancy, including the risks of miscarriage and preterm birth, maternal risks, management, and monitoring.

• Prednisone
• Prednisolone
• Hydrocortisone
• Methylprednisolone (Medrol)
• Dexamethasone (Decadron)
• Triamcinolone IM
• IV methylprednisolone (Solu-Medrol)
• Topical Steroids

What are steroids, and why are they used to treat lupus?

Steroids are a group of chemicals that make up a large portion of the hormones in your body. One of these steroids, cortisone, is a close relative of cortisol, which the adrenal glands in your body make as a natural anti-inflammatory hormone. Synthetic cortisone medications are some of the most effective treatments for reducing the swelling, warmth, pain, and tenderness associated with the inflammation of lupus. Cortisone usually works quickly to relieve these symptoms. However, cortisone can also cause many unwelcome side effects, so it is usually prescribed only when other medications—specifically NSAIDs and anti-malarials—are not sufficient enough to control lupus.

The word “steroid” often sounds frightening because of the media attention given to the anabolic steroids that some athletes use to put on muscle. However, it is important to remember that steroids make up a large group of molecules with different functions, and the steroids given to treat lupus—specifically, corticosteroids—are different than those you may hear about on the news.

How do corticosteroids work to reduce inflammation in the body?

Inflammation is the body’s natural response to events such as injury, infection, and the presence of foreign substances—things your body doesn’t recognize as a part of itself. Sometimes, however, as with lupus, your body’s immune system does not function properly, and the inflammatory response works to damage your own tissues, causing stiffness, swelling, warmth, pain, and tenderness in different parts of the body. Corticosteroids help to slow and stop the processes in your body that make the molecules involved in your inflammatory response. These steroids also reduce the activity of your immune system by affecting the function of cells in your blood called white blood cells. In reducing inflammation and immune response, corticosteroids help to prevent damage to the tissues in your body.

What steroid medications are commonly prescribed for lupus?

Prednisone is the steroid most commonly prescribed for lupus. It is usually given as tablets that come in 1, 5, 10, or 20 milligram (mg) doses. Pills may be taken as often as 4 times a day or as infrequently as once every other day. Usually, a low dose of prednisone is about 7.5 mg per day or less, a medium dose is between 7.5 and 30 mg per day, and a dose of more than 30 mg qualifies as a high dose. Your doctor may also prescribe a similar drug called prednisolone, especially if you have had any liver problems. Prednisolone and prednisone are very similar. In fact, the liver must convert prednisone to prednisolone before the body can use it.

Sometimes lupus flares can be treated with an intra-muscular (IM) injection of a drug called Triamcinolone. These injections are usually given at your doctor’s office, and they often reduce flares without some of the side-effects that would accompany an increase in the dosage of an oral steroid like prednisone. Usually, the only noticeable side effect of these injections is a dimple or loss of pigmentation at the injection sight.

Steroids can also be given intravenously (IV) in the form of methylprednisolone (Solu-Medrol), and your doctor may prescribe higher doses of methylprednisolone (1000 mg) given over 3-5-day period. These treatments are often referred to as “pulse steroids.” Other forms of steroid medications commonly given for lupus are hydrocortisone, methylprednisolone (Medrol) dose packs, and dexamethasone (Decadron) tablets. These medications vary in potency. For example, hydrocortisone is weaker than prednisone, methylprednisolone is stronger, and dexamethasone is very potent. Ointments containing corticosteroids are also commonly prescribed for lupus rashes.

What are the side effects of steroid medications?

Steroid medications can have serious long-term side effects, and the risk of these side effects increases with higher doses and longer term therapy. For this reason, steroid medications are usually prescribed only after other less potent drugs have proven insufficient in controlling your lupus. Your doctor will work with you to determine the lowest dose of steroids necessary to control your lupus symptoms and will prescribe steroids for the shortest possible amount of time. Steroids are sometimes combined with other drugs to help reduce some of these side effects.

Possible side effects of taking these steroid medications are:

• Changes in appearance
  • Acne
  • Development of round/moon-shaped face (sometimes called “Cushing’s syndrome” after the physician who first described it)
  • Weight gain due to increased appetite
  • Redistribution of fat, leading to swollen face and abdomen, but thin arms and legs
  • Increased skin fragility, leading to easy bruising
  • Hair growth on the face
• Psychological problems
  • Irritability
  • Agitation, psychosis
  • Euphoria/depression (mood swings)
  • Insomnia
• Increased susceptibility to infections
• Stomach irritation, peptic ulceration
• Irregular menses (periods)
• Potassium deficiency
• Aggravation of the following preexisting conditions:
  • Diabetes
  • Glaucoma
  • High blood pressure
• Increase in:
  • Cholesterol
  • Triglycerides
• May suppress growth in children
• Long term side effects:
  • Avascular necrosis of bone (death of bone tissue due to lack of blood supply):
    • Usually associated with high doses of prednisone taken over long periods of time.
    • Produces pain, including night pain. Pain relief usually requires either a core bone biopsy or total surgical joint replacement.
    • Occurs most often in hip, but can also affect shoulders, knees, and other joints.
  • Osteoporosis
    • Thinning of the bones.
    • Can lead to bone fractures, especially compression fractures of vertebrae with severe back pain.
  • Cataracts
  • Glaucoma
  • Muscle weakness
  • Premature atherosclerosis – narrowing of the blood vessels by cholesterol (fat) deposits.
  • Pregnancy complications –Doses of 20mg or more have shown to increase pregnancy and birth complications, such as preeclampsia.

What can I do to stay as healthy as possible while taking my steroid medications?

While taking steroid medications such as prednisone, it may seem that your body’s reactions to the things you do and the food you eat are out of your hands. If you feel overwhelmed or frustrated with some of the outward effects of your medications, your doctor can help you to come up with some strategies to minimize side-effects. However, it is important to realize that you play the most important role in helping yourself to stay as healthy as possible. There are many things you can do on a daily basis to help minimize the side effects of both steroid medications and your lupus symptoms.

Diet

A healthy diet is important for everyone, but it is especially important for people with lupus and those taking steroid medications. While taking steroids, your cholesterol, triglyceride, and blood sugar levels may increase. For these reasons, it is absolutely essential that you not increase your calorie intake and follow a low sodium, low-fat, and low-carbohydrate diet. You do not need to cut out all of the foods you love, but concentrate on eating whole grain breads and cereals and lean sources of protein such as chicken and fish.* When you need a snack, look to vegetables—they are low in sugar and calories and provide the perfect food for “grazing.” Try to eat them without Ranch dressing or vegetable dip, because these items carry lots of fat and calories. If you need something to accompany your vegetables, try lighter dips like hummus. It is also important that you minimize alcohol intake when taking steroid medications, since steroids may already irritate your stomach. In fact, it is best not to drink alcohol at all, because combining alcohol with certain lupus medications can be very harmful to your liver.

Steroids may deplete certain vitamins in your body, such as vitamins C, D, and potassium. Your doctor may recommend for you to take supplemental vitamins or increase your intake of certain foods in order to make up for these deficiencies. Usually it is beneficial to take a multivitamin every day, but speak with your doctor to see which one is right for you, since some vitamins can adversely affect certain conditions. For example, people with antiphospholipid antibodies, especially those taking anticoagulants such as warfarin (Coumadin), should avoid vitamin K because it can increase the risk of blood clots.

Osteoporosis

Steroids can also contribute to a thinning of the bones known as osteoporosis, which may put you at an increased risk for bone fractures. Your doctor may prescribe a drug for osteoporosis or advise you to take a calcium or hormone supplement. Bisphosphonates such as Actonel, Fosamax, and Boniva are commonly prescribed, as are parathyroid hormone (Forteo) and other medications. To help keep your bones as strong as possible, try to increase your intake of calcium and vitamin D. Calcium helps to keep bones strong and vitamin D helps your body make use of calcium. Foods high in calcium include milk and milk products, tofu, cheese, broccoli, chard, all greens, okra, kale, spinach, sourkraut, cabbage, soy beans, rutabaga, salmon, and dry beans.

Staying Active

In addition to increasing your risk of osteoporosis, steroid medications can weaken your muscles. Staying as active as possible will help you to maintain strong muscles and bones. Weight-bearing activities such as walking, dancing, and running will help your muscles stay strong and healthy. Many people report that these activities make them feel better mentally as well. In fact, there are actually chemicals in your brain triggered by significant exercise (usually about 30 minutes per day) that help you to attain a “natural high.” Your doctor can help you to assess your personal condition and decide on an exercise routine that is best for you. However, you should never put yourself through more than reasonable discomfort when exercising.

Smoking

People with lupus should never smoke due to their increased risk of cardiovascular disease. Steroid medications increase this risk by upping blood pressure, triglycerides, and cholesterol. Smoking, steroids, and lupus make a very bad combination.

Infection

Steroid medications can also increase the risk of infection; this risk increases if you are also taking immunosuppressive drugs. For this reason, it is important that you try to avoid colds and other infections. Washing your hands regularly is perhaps the best way to keep germs at bay. More serious infections can lead to serious—even fatal—illness. The infections that most worry doctors are kidney infection, a type of skin infection called cellulitis, urinary tract infections, and pneumonia. It is important to be on the lookout for any changes in your health, because people taking steroids may not run a fever even though they are very ill. If these infections go untreated, they could enter the bloodstream and pose an even bigger threat, so it is important that you notify your doctor at the first signs of an infection or illness. In addition, live virus vaccines, such as FluMist, the small pox vaccine, and the shingles vaccine (Zostavax) should be avoided because they may cause disease in individuals taking steroid medications.

Eye Exams

Finally, since medications can increase your risk of cataracts and aggravate glaucoma, try to get an eye exam twice a year. Notify your doctor of any major changes in your vision.

Do not abruptly stop taking steroids

You should not stop taking steroids abruptly if you have been taking them for more than 4 weeks. Once your body has adjusted to taking steroids, your adrenal glands may shrink and produce less natural cortisone. Therefore, it is important to slowly reduce the dosage of steroids to allow the adrenal glands to gradually regain their ability to produce cortisone on their own.

Are there other drugs that I might take while taking steroids?

Steroids are often given in high doses, which may increase the risk of side effects. Medications called “immunosuppressive” drugs are sometimes prescribed in addition to steroids to help spare some of these undesirable side effects. However, as their name suggests, immunosuppressive work to suppress the immune system, so when taking these drugs, it is important to watch out for infection and notify your doctor at any sign of illness. If you do acquire an infection, you may be prescribed an antibiotic or other medication, but be sure to stay away from Bactrim, since this medication can cause flares in some people with lupus.

Because of the risk of osteoporosis, your doctor may also prescribe a bisphosphonate such as Actonel, Fosamax, or Boniva. She/he may also recommend taking calcium or vitamin D supplements to reduce bone thinning. Your doctor may also prescribe a diuretic to deal with bloating, fluid retention, and hypertension (high blood pressure).

In addition, since cortisone can cause elevated cholesterol, your doctor may prescribe statins such as Lipitor, Crestor, Vytorin, or Caduet. These medications work to lower cholesterol.

∗ The omega 3 fatty acids in fish and fish oil also have anti-inflammatory properties, which may help to reduce some of the discomfort in your joints and muscles.

What are antidepressants and why are they involved in lupus treatment?

Anti-depressant medications are used to treat clinical depression or pain. Depression and anxiety are present in almost half of all people who have lupus and can be caused by the disease itself, by medications used to treat the disease, or by inadequate coping mechanisms. Clinical depression is different than the passing pangs of sadness that can haunt all of us from time to time. Rather, clinical depression is a prolonged, unpleasant, and disabling condition. The hallmark characteristics of depression are feelings of helplessness, hopelessness, general sadness, and a loss of interest in daily activities. Depression also often involves crying spells, changes in appetite, nonrestful sleep, loss of self-esteem, inability to concentrate, decreased interest in the outside world, memory problems, and indecision. In addition, people who are depressed may suffer from certain physiologic signs, such as headache, palpitations, loss of sexual drive, indigestion, and cramping. Patients are considered to be clinically depressed when they experience symptoms that last for several weeks and are enough to disrupt their daily lives. Lupus patients suffering from depression also often experience a general slowing and clouding of mental functions, such as memory, concentration, and problem-solving abilities; this phenomenon is sometimes described as a “fog.”

Some people think that people with chronic illnesses like lupus feel sad or depressed because they are sick. This notion can cause physicians and loved ones to dismiss or overlook clinical depression in people with lupus. While clinical depression can be caused by the emotional drain of coping with a chronic medical condition and the sacrifices and adjustments that are required of the disease, it can also be induced by steroid medications (e.g., prednisone), lupus involvement of certain organs such as the brain, heart, and kidneys, and other physiological factors. It is important that you speak with your doctor if you feel you are experiencing clinical depression, because many people who are physically ill respond well to anti-depressant medications. In addition, your doctor may treat your depression in different ways depending on the cause.

How do antidepressants work?

Most antidepressants work by slowing the removal of certain chemicals—neurotransmitters—from the brain. Neurotransmitters are chemicals that carry messages between neurons (nerve cells in the brain) and are important in the normal functioning of your brain. However, an imbalance in the amount of a certain neurotransmitter can cause a slowing of communication between neurons, and your normal feelings, emotions, or thoughts may become impaired. Antidepressants help people by making certain neurotransmitters associated with depression (specifically, dopamine, norepinephrine/noradrenaline, and/or serotonin) more available to the brain. The availability of more of a certain neurotransmitter means that more of this chemical will reach is target neuron, increasing communication and connectivity (neurotransmission) between the nerve cells in your brain and thus reducing certain symptoms of depression.

What kinds of medications are categorized as antidepressants?

Anti-depressant medications include four main kinds of drugs—tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), selective serotonin and norepinephrine reuptake inhibitors (SNRIs), and lithium. Other types of medications are also used, including venlafaxine (Effexor), bupropion (Wellbutrin, Zyban), mirtazapine (Remeron), and trazodone (Desyrel). Anti-anxiety medications and/or hypnotics (for insomnia) may be recommended in addition to antidepressants to help combat certain symptoms, and several combination therapies are also available.

How well do antidepressants work?

Six out of 10 people will feel better with the first antidepressant they try; however, the other 4 people will need to try another antidepressant until they find the one that is right for them. In addition, most people will need to take an antidepressant regularly for at least 6 weeks until they feel the full effect. You may also need to keep taking them for longer periods of time, even for the rest of your life.

What should I keep in mind while taking antidepressants?

Antidepressants can cause side effects that may mimic or intensify certain lupus symptoms. For example, antidepressants may cause an increase in the drying of mucous membranes, which could further aggravate symptoms in people with Sjogren’s syndrome (dry eye/dry mouth syndrome). In addition, antidepressants have been associated in rare cases among the general population (both non-lupus and lupus patients) with worsening of feelings of depression and suicidal thoughts. This side effect is especially prevalent early in treatment, during an alteration of dosage, or in people under 25. If you feel you are experiencing this effect, contact your doctor. You may need to stop the medication if symptoms worsen. However, you should not stop taking your medication without first speaking with your doctor. While most antidepressants are considered to be nonaddictive, suddenly stopping your treatment or missing doses can cause feelings of withdrawal, a phenomenon called discontinuation syndrome. Symptoms of this condition include nausea, headache, dizziness, lethargy, and flu-like symptoms. If you feel you should stop taking antidepressants, work with your doctor to slowly decrease your dose before you stop.

Types of Antidepressants

Tricyclic antidepressants (TCAs)

Amitriptyline (Elavil, Endep)
Amoxapine (Asendin, Defanyl, Demolox, Moxadil)
Clomipramine (Anafranil)
Desipramine (Norpramin)
Doxepin (Adapin, Sinequan)
Imipramine (Tofranil, Janimine)
Iprindole
Maprotiline (Ludiomil)
Nortriptyline (Aventyl, Pamelor)
Protriptyline (Vivactil)
Trimipramine (Surmontil)

Tricyclic antidepressants (TCAs) have been on the market since the 1960s. These drugs were the most commonly prescribed antidepressants until the late-1980s, when selective serotonin reuptake inhibitors (SSRIs) were introduced. TCAs work by inhibiting the reabsorption (or, reuptake) of three neurotransmitters in the brain that can affect mood and behavior, namely serotonin, norepinephrine, and, to a lesser extent, dopamine. Tricyclic antidepressants are named for their chemical structure, which contains three rings of atoms.

Nowadays, TCAs are used mainly in very low doses at night to help with pain and to restore natural sleep patterns. TCAs work as an analgesic (pain reliever) for many neuropathic pain syndromes (pain resulting from disturbances in your nervous system). They can also help people with problems sleeping—including those with fibromyalgia, a syndrome that causes fatigue, generalized weakness, and pain amplification—to regain normal sleep regimens.

TCAs are less selective than other antidepressant medications in the cells that they affect. For example, TCAs also block certain cell receptors in your brain, which can cause certain side effects. The potential side effects of TCAs include drowsiness, dry mouth, changes in appetite, impaired thinking or confusion, blurred vision, constipation, water retention, dizziness, impaired sexual function, increased heart rate, headache, low blood pressure, sensitivity to sunlight, weight gain, nausea, and weakness.

People with narrow-angle glaucoma or an enlarged prostate should avoid TCAs, and those with a history of seizures or thyroid problems should use them with caution. Speak to your doctor if you experience any of these conditions; only she/he can decide whether TCAs are the right choice for you.

If you are pregnant, may become pregnant, or are breast-feeding, speak to your doctor about whether continuing therapy with TCAs is right for you.

Selective serotonin reuptake inhibitors (SSRIs)

Citalopram (Celexa)
Escitalopram oxalate (Lexapro)
Fluoxetine (Prozac, Sarafem, Symbyax)
Fluvoxamine (Luvox, Fevarin, Dumyrox)
Paroxetine (Paxil, Pexeva)
Sertraline (Zoloft)

Selective serotonin reuptake inhibitors (SSRIs) are usually preferred over other antidepressants because they are associated with fewer side effects. These medications are particularly helpful in the early stages of depression, and some studies suggest that SSRIs are most useful for people with more minor forms of depression. SSRIs work by preventing the reuptake (reabsorption) of serotonin by nerve cells (neurons) in the brain. In doing this, SSRIs cause more serotonin to be available in the brain for the sending of nerve impulses (neurotransmission), improving mood. The term “selective” stems from the fact that these medications work only to affect serotonin and not other neurotransmitters.

SSRIs generally come in tablet form. Some are available as extended- or controlled-release tablets, usually labeled XR or CR. In addition to causing fewer side effects than other antidepressants, SSRIs are generally less likely to interact with other medications, and they are less harmful in the event of an overdose. Most SSRIs share the same side effects and mechanism of action, but some do have different chemical characteristics, meaning your body may respond differently to different SSRIs. For this reason, it may be beneficial to try a different SSRI if one causes certain side effects or does not work particularly well for you.

Side effects of SSRIs include nausea, impaired sexual function or desire, headache, diarrhea, nervousness, rash, agitation, restlessness, increased sweating, weight loss or gain, drowsiness, or insomnia. If you experience nausea from your medication, you may benefit from trying a controlled-release tablet instead. In addition, be sure to speak to your doctor about any other medications you may be taking, especially other medications that may affect serotonin levels such as St. John’s wort. Very high levels of serotonin in the brain, which can occur when SSRIs interact with other antidepressants, can cause something called “serotonin syndrome.” Signs of serotonin syndrome include confusion, restlessness, hallucinations, extreme agitation, fluctuations in blood pressure, increased heart rate, nausea, vomiting, fever, seizures, and coma. This rare but serious side effect requires immediate medical attention. For this reason, you should not take any other form of antidepressants while taking SSRIs or within two weeks of each other, without the knowledge and permission of your doctor.

In addition, be sure to speak with your doctor if you are pregnant or may become pregnant. Certain SSRIs, namely Paxil, have been associated with birth defects. In 2006, the FDA issued a warning that women taking SSRIs during pregnancy—especially after the first 20 weeks—were at a risk for persistent pulmonary hypertension, a condition that makes it difficult for your newborn baby to breath outside the womb.

Serotonin and norepinephrine reuptake inhibitors (SNRIs)

Duloxetine (Cymbalta)
Venlafaxine (Effexor)
Desvenlafaxine (Pristiq)

Serotonin and norepinephrine reuptake inhibitors (SNRIs) are a class of antidepressants that are used to treat depression and certain anxiety disorders. They work by inhibiting the reabsorption (reuptake) of certain neurotransmitters associated depression, namely serotonin and norepinephrine. In doing this, SNRIs increase neurotransmission (communication) between the nerve cells in your brain and thus help to elevate mood. SNRIs are generally believed to cause fewer side effects than older antidepressant medications such as tricyclic antidepressants. However, SNRIs do have some potential side effects, including nausea, vomiting, dizziness, insomnia, drowsiness, trouble sleeping, abnormal dreams, impaired sexual function and desire, headache, constipation, excessive sweating, dry mouth, tremor, gas, anxiety, agitation, and abnormal vision.

Like SSRIs, SNRIs can also cause “serotonin syndrome” if taken in conjunction with or within two weeks of other medications that increase serotonin in the brain, including St. John’s wort. Serotonin syndrome requires immediate medical attention and can cause confusion, restlessness, hallucinations, severe agitation, fluctuations in blood pressure, increased heart rate, nausea, vomiting, fever, seizures, and coma.

In addition, you should not take venlafaxine (Effexor) if you have uncontrolled high blood pressure or high cholesterol, since this medication is known to raise blood pressure and cholesterol levels, even in healthy individuals. Your doctor may recommend that you get additional blood pressure and cholesterol checks, even if you experience normal levels. In addition, people who have narrow-angle glaucoma or raised intraocular pressure should also avoid all SNRIs.

If you are pregnant or may become pregnant, you should talk to your doctor about whether SNRIs are right for you. These medications have been deemed category C drugs by the FDA, meaning they have shown side effects to the fetus in animal studies but have not been adequately studied in pregnant women. You and your doctor should decide together upon the appropriate course of treatment during pregnancy. SNRIs should be avoided during the third trimester to avoid certain complications in your baby. Evidence suggests that SNRIs taken after the twentieth week of pregnancy increase the risk of persistent pulmonary hypertension, a condition that makes it more difficult for your newborn baby to breath outside the womb.

Lithium (Eskalith, Lithobid)

Lithium (Eskalith, Lithobid) is used to treat manic depression, a condition characterized by severe mood changes, ranging from a state of excitement and elation to feelings of severe sadness and depression. Lithium works to reduce the frequency and severity of manic-depressive states, but it is not yet known exactly how lithium works to help stabilize a person’s moods. However, it is known that lithium alters the flow of sodium through nerve and muscle cells in the body, interferes with the production and uptake of certain neurotransmitters, affects the concentrations of tryptophan and serotonin in the brain, and interrupts the signaling of dopamine receptors in the brain. Lithium has been used to treat manic depression since the 1950s, and the most common preparation, lithium carbonate, was approved by the FDA in the 1970s. The effects of the medication are usually felt after about 1 week of treatment, but it can take up to 3 weeks to feel the full benefits.

Before starting treatment with lithium, be sure to tell your doctor if you are on a low-sodium diet, since lithium interferes with the regulation of sodium and water levels in the body. Be sure to drink plenty of water throughout the day. In addition, you should always take lithium with food (to prevent stomach upset) and at the same time(s) every day to keep the amount of drug in your body at a constant level.

Lithium can cause certain side effects. The most common side effects include hand tremor, dry mouth, altered taste, weight gain, increased thirst, increased frequency of urination, impotence, decreased sexual desire, and kidney abnormalities. Nausea, vomiting, and diarrhea can also occur but usually disappear as therapy continues. Taking the medication with food can help to alleviate some of these gastrointestinal side effects. Lithium can also cause low blood pressure and decreased heart rate. Approximately 1 in 25 people taking lithium develops an enlarged thyroid gland (goiter); low thyroid levels (hypothyroidism) have also been reported. Signs of this condition include dry skin, hair loss, hoarseness, increased sensitivity to cold, and swelling of the feet, lower legs, or neck.

Once you start treatment, your doctor should work with you to monitor the amount of lithium in your blood. If lithium blood levels get too high, your dosage should be reduced. Certain signs of high blood lithium levels include loss of appetite, vision problems, exhaustion, muscle weakness, muscle twitches, tremor, unsteady walking, confusion, seizure, arrhythmias, slurred speech, and coma. Once your lithium dosage is stable, you should get blood tests every month, kidney function tests every 3-6 months, and thyroid function tests every year.

Lithium can interact with many medications, including some commonly prescribed in lupus treatment. These medications include most blood pressure medications, NSAIDs, and some other medications (e.g., antidepressants). For this reason, be sure to tell your doctor of any medications you may be taking before starting treatment with lithium.

If you are pregnant or may become pregnant, you should not take lithium, since studies in pregnant women have shown a serious risk to the fetus. In addition, since lithium is secreted into the breast milk, women who are breast feeding should be very careful when taking lithium. Your doctor can advise you on the best course of treatment if you are pregnant, may become pregnant, or are breastfeeding.

Bupropion (Wellbutrin, Zyban)

Bupropion (Wellbutrin, Zyban) is another type of antidepressant classified as a norepinephrine and dopamine reuptake inhibitor (NDRI). NDRIs work by preventing the reuptake of these neurotransmitters in the brain, which in turn elevates mood. Bupropion is used to treat clinical depression and seasonal affective disorder (SAD) and is sometimes implemented in smoking cessation. It can be prescribed either alone or in combination with other antidepressant therapies, such as SSRIs. The exact mechanism of action of bupropion in the brain is not known, but it is thought to work differently than other antidepressant medications.

Side effects of bupropion are generally similar to SSRIs and SNRIs and can include agitation, dry mouth, insomnia, headache, nausea, constipation, and tremor. 4 out of every 1,000 people taking bupropion in doses of less than 450 mg/day experience seizures, and this risk increases by ten times in doses exceeding this amount. Bupropion can also increase blood pressure, so be sure to speak with your doctor if you have hypertension. In addition, be sure your doctor knows about other medications that you may be taking, especially other antidepressants.

If you are pregnant or may become pregnant, talk to your doctor about whether you may take bupropion. One study has suggested a small link between bupropion use in the first trimester and the risk of congenital abnormalities, but other studies must be performed to accurately evaluate this risk. Nursing mothers should avoid bupropion because it is secreted into breast milk.

Other Antidepressants
Mirtazapine (Remeron)
Trazodone (Desyrel)