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Treating Lupus with Immunosuppressive Medications

  • Azathioprine (Imuran)
  • Mycophenolate mofetil (Cellcept)
  • Cyclosporine (Neoral, Sandimmune, Gengraf)
  • Methotrexate (Rheumatrex)
  • Leflunomide (Arava)
  • Cyclophosphamide (Cytoxan)
  • Chlorambucil (Leukeran)
  • Nitrogen mustard (Mustargen)

What are immunosuppressive medications?

Immunosuppressives are medications that help suppress the immune system. Many were originally used in patients who received organ transplants to help prevent their bodies from rejecting the transplanted organ. However, these drugs are now also used for the treatment of certain autoimmune diseases, such as lupus and rheumatoid arthritis. In people with lupus, the immune system mistakenly attacks the body’s own tissues. Most immunosuppressives work to downregulate (suppress) this attack by interfering with the synthesis of DNA, the material in your cells that contains the blueprints for all of your genetic information. In doing this, these medications prevent the cells of your immune system from dividing. When cells cannot divide correctly, they will eventually die. The immunosuppressives prescribed most commonly for the treatment of lupus are azathioprine (Imuran), mycophenolate (Cellcept), and cyclosporine (Neoral, Sandimmune, Gengraf).

Immunosuppressive medications are used to control more serious lupus activity that affects major organs, including the kidney, brain, cardiovascular system, and lungs. Before prescribing an immunosuppressive medication, your doctor may perform a biopsy of the kidney or affected organ system to evaluate the most effective course of treatment. Sometimes immunosuppressive medications are given in addition to or instead of steroid therapy to lower the dose of steroids needed and thus spare some of the undesirable side effects of steroid therapy. For this reason, these drugs are sometimes called “steroid-sparing” medications or “adjuvant” (helping) drugs. Steroid-sparing drugs usually have a two-fold benefit, since they often reduce or eliminate the need for steroids while also improving lupus symptoms.

Because immunosuppressive drugs put down the immune system, people taking them are at an increased risk for infection. Try to stay away from people who have colds or other illnesses, and make sure to wash your hands regularly and maintain good personal hygiene. If you are also taking steroid medications, you may not realize that you are ill because the steroid may suppress your fever symptoms. Contact your doctor immediately at the first sign of any infection or illness.

In addition, immunosuppressive medications are known to increase the risk of cancer development later in life. However, lupus itself is also known to increase the risk of cancer, so by controlling your lupus now and preventing it from doing further damage to your body, immunosuppressive therapy may actually decrease your risk of developing cancer. Either way, it is very important to control your lupus activity now to prevent other potentially life-threatening complications.

Types of Immunosuppressive Medications

Azathioprine (Imuran)

Imuran is an anti-inflammatory immunosuppressive that can decrease joint damage and disability in people with lupus, rheumatoid arthritis, and other conditions. In addition, Imuran has proven to clearly improve lupus affecting the liver and kidneys. Imuran is “steroid-sparing,” which means that it may allow for a reduction of the amount of steroid being taken. Since the side effects of steroids generally increase with the dosage, this medication generally promotes a reduction in steroid side effects as well.

People with lupus have overactive immune systems. Imuran works by preventing some of the cells involved in this immune response (specifically, white blood cells [WBCs], or leukocytes) from spreading. Imuran is a “slow onset” drug, which means it may take 6-12 weeks for you to notice its effects. It usually comes in pill form and has fewer side effects than many other immunosuppressive medications. The most common and serious side effects involve the stomach and blood cells. Nausea and vomiting can occur, sometimes with stomach pain and diarrhea. Taking the medication with food may help to reduce these symptoms. Imuran can also decrease the number of certain cells in your blood. For this reason, blood tests should be done regularly to determine your white blood cell, platelet, and red blood cell count.

Less common side effects include liver test abnormalities, hepatitis (inflammation of the liver), pancreatitis (inflammation of the pancreas, a gland behind the stomach, that can cause abdominal pain), or an allergic reaction that can seem like the flu. During treatment, your doctor may perform tests for breakdown products (metabolites) of Imuran that can help monitor how your body is reacting to the drug.

Even though Imuran is effective in treating serious lupus symptoms, long term use of this medication does increase the risk of developing cancer. Your doctor can speak with you about this risk and any other concerns you may have. She/he will work with you to minimize the side effects of your medications while also maximizing the benefits.

In addition to having regular blood tests (CBCs), you should notify your doctor if you experience any of the following symptoms while taking Imuran: fever, a new rash, easy bruising or bleeding, or signs of infection. Be sure to speak with your doctor before taking getting any vaccines or having surgery. In addition, consult your doctor if you are pregnant, may become pregnant, or are breastfeeding, since Imuran can be harmful to your child.

Certain medications may interfere with Imuran, so be sure to notify your doctor of any other drugs you are taking. Medications that can interfere with Imuran include the gout medication allopurinol (Aloprim, Zyloprim), warfarin (Coumadin), some blood pressure medications including some ACE inhibitors (Accupril or Vasotec), olsalazine (Dipentum), mesalamine (Asacol, Pentasa), and sulfasalazine* (Azulfidine).

Mycophenolate mofetil (Cellcept)

Cellcept is an immunosuppressant used especially for lupus patients with signs of kidney disease. It works by targeting an enzyme in the body—a protein responsible for certain chemical reactions—that is important in the formation of DNA in your cells. In doing so, Cellcept impairs your immune system function as well. Usually Cellcept is given twice a day for a total dose of about 2000-3000 milligrams (mg) per day, but this dosage may be reduced. Like Imuran, Cellcept is steroid-sparing, so it may allow you and your doctor to reduce your dosage of steroid medications and thus also reduce their side effects.

Cellcept may cause some side effects. The most common effects include stomachache, nausea, vomiting, and/or diarrhea. Headache, dizziness, sleeplessness, and tremors (involuntary muscle movements) may also occur. Skin rashes can arise but are less common. Since lupus can also cause skin rashes, it may be difficult to determine whether a rash is from your medication or your lupus. You should speak with your doctor upon detecting any new rashes or symptoms.

Cellcept may also cause a reduction in the number of certain cells in your blood. A reduction in your white blood cell count could increase your chance of infection. As with other immunosuppressive medications, it is important that you try to avoid infection and notify your doctor at the first sign of illness. In addition, a reduction in red blood cells caused by Cellcept may lead to anemia, which could make you tired or lead to easy bruising. Cellcept can also reduce the number of platelets in your blood, which may also cause easy bruising or gastrointestinal bleeding (bleeding anywhere along the pathway that food travels in the body). Obtaining periodic blood tests while taking Cellcept can help you and your doctor to detect and correct these problems. Blood tests should be performed frequently during the first several months of taking this medication and less often as more time passes.

People over 65 and those that have experienced ulcers or other gastrointestinal disorders should speak to their doctors before taking Cellcept. People in these groups may experience an increased risk of side effects. In addition, there may be an increased risk of developing cancer such as lymphoma and skin cancer when taking immunosuppressives such as Cellcept. You should discuss this with your doctor before beginning this medication. It is important to realize, however, that Cellcept may be the best way to control the kidney disease associated with lupus, and that lupus too can cause cancer. Thus, prescribing Cellcept for your kidney involvement is not meant to introduce new risk factors, but rather to treat the seriousness of your condition at this moment in time.

In addition, be sure to wear sunscreen when going outside and avoid prolonged sun exposure—even if you are not taking immunosuppressive medications—since sunlight can also aggravate your lupus symptoms.

If you are pregnant, may become pregnant, or are breast-feeding, your doctor will strongly recommend that you stop taking Cellcept due to the risk of birth defects. In addition, even though it is not known whether Cellcept decreases the effectiveness of oral contraceptives, it may be able to reduce their concentration in the blood, so other forms of birth control are advised. Antacids can also interfere with your body’s absorption of Cellcept. If you need to take an antacid, do so at least one hour before or at least two hours after taking Cellcept. As with other immunosuppressive medications, you should speak to your doctor before getting any vaccines or having any sort of surgery.

Certain drugs may interact or interfere with the effectiveness of Cellcept. These medications include: cholestercholestyramine (Questran), acyclovir (Zovirax), gancyclovir (Cytovene), azathioprine (Imuran), antacids containing magnesium or aluminum hydroxide (such as Maalox, Rolaids, or Mylanta), oral contraceptives, trimethoprim/sulfamethoxazole (Bactrim),* theophylline (Theo-Dur), phenytoin (Dilantin), probenecid (Benemid), or aspirin and other salicylates.

Be sure to notify your doctor immediately if you experience easy bruising or bleeding, persistent or bloody diarrhea, trouble breathing, fever, or any sign of infection.

Recently, the FDA issued an alert regarding a possible relationship between Cellcept and a serious neurological disease called multifocal leukoencephalopathy (PML). A similar warning was issued regarding the drug rituximab (Rituxan) in late 2006. PML is an extremely rare but fatal disease, but it is important to understand that Cellcept and rituximab are not unique in their linkage to PML. PML is associated with conditions of severe immune deficiency, such as AIDS, cancer, lupus, and the immunosuppression that can be involved in the treatment of those conditions. Although immunosuppressive medications are effective in the treatment of lupus, your doctor can discuss with you the risk of this possible relationship and the use of the immunosuppressive medications involved in your advised treatment.

Cyclosporine (Neoral, Sandimmune, Gengraf)

Cyclosporine is a more potent immunosuppressive medication that works by blocking the function of cells in your immune system called T-lymphocytes, or “T-cells.” Like other immunosuppressives, it was originally used to prevent the immune systems of patients with transplanted kidneys from rejecting the transplanted organs. It is now also prescribed for people who suffer from inflammation of the kidney caused by lupus, otherwise known as lupus nephritis. However, cyclosporine can be toxic to the kidneys, so use of this medication is usually reserved for cases in which a person’s lupus does not respond to other immunosuppressive medications like Cellcept. Cyclosporine is also prescribed for people with severe psoriasis, a skin condition that can also cause pain and swelling of the joints, and it can be helpful in reducing some of the pain, swelling, and stiffness associated with lupus arthritis.

The starting dose of cyclosporine depends on your body weight (usually 2.5 milligrams [mg] per kilogram [kg] per day). The dose is then increased depending on how well the medication works for you and how well your body tolerates the drug. Cyclosporine comes in 25 and 100 mg tablets, and patients usually end up taking 75 or 100 mg per day. You may notice some reduction in pain and swelling after about a week of taking the medication, but its full effects are usually not felt for about 3 months.

Cyclosporine can cause some side effects. About 25% of people taking cyclosporine develop high blood pressure (hypertension). In addition, because cyclosporine can be tough on the kidneys, it can cause a substance called uric acid to build up in the blood (a state known as hyperuricemia). Sometimes this buildup of uric acid can cause gout, a condition that causes intense swelling in one of the joints, often the the big toe. If you already have gout, your condition may worsen while taking cyclosporine. Fortunately, many of these side effects go away as treatment with cyclosporine is reduced or stopped, so your doctor can work with you to adjust your dosage if you begin to experience these problems.

Other common side effects include headaches, stomach pain (including dyspepsia, a gnawing or burning pain in the pit of your stomach accompanied by bloating), vomiting, diarrhea, and swelling in your hands or feet. Less common side effects include tremors (unintentional muscle movements), increased hair growth, muscle cramps, and numbness or tingling in your hands and feet (a condition known as neuropathy). Some people may also experience swelling of the gums while taking cyclosporine. Be sure to brush and floss regularly; this routine may alleviate some of this swelling.

Cyclosporine may increase your risk of developing certain types of cancer, including skin cancer. For this reason, you should coordinate regular skin exams with your doctor. In addition, try to stay out of the sun and make sure to wear sunscreen when you do go outside.

Do not eat grapefruit or drink grapefruit juice while taking cyclosporine. Grapefruit increases the amount of cyclosporine that is absorbed by your body.

Like other immunosuppressive medications, cyclosporine increases your risk of infection, so make sure to wash your hands and stay away from people who may be sick. Notify your doctor at the first sign of any illness. In addition, tell your doctor if you plan to have any vaccines or surgeries, since both can pose risks for people taking immunosuppressive medications.

Cyclosporine can cause serious complications during pregnancy such premature labor and high blood pressure and fluid retention in your baby, so you should not take cyclosporine if you are pregnant or may become pregnant. Also, do not take cyclosporine while breast-feeding, since it can be passed to your baby through breast milk.

Cyclosporine interacts with certain drugs, so be sure to notify your doctor of any medications you may be taking, including prescription and over-the-counter drugs, supplements, and vitamins. Drugs that may interfere or interact with cyclosporine include:

  • Heart and blood pressure medications: diltiazem (Cardizem, Tiazac), nicardipine (Cardene), verapamil (Calan, Covera-HS, Isoptin, Verelan), “potassium sparing diuretics” amiloride (Midamor), spironolactone (Aldactone) and triamterene (Dyrenium)
  • Cholesterol lowering medications: lovastatin (Mevacor) and simvastatin (Zocor)
  • Antibiotics and antifungals: clarithromycin (Biaxin), erythromycin, naficillin, fluconazole (Diflucan), intraconazole (Sporanox), ketoconazole (Nizoral), and rifampin (Rifadin, Rimactane)
  • Anti-seizure (anti-epileptic) medications: carbamazepine (Tegretol), phenobarbital (Solfoton), and phenytoin (Dilantin)
  • Antidepressants: nefazadone (Serzone) and the selective serotonin reuptake inhibitors (SSRIs) such as paroxitine (Paxil), fluoxetine (Prozac), and sertraline (Zoloft)
  • Human immunodeficiency virus (HIV) protease inhibitors: indinivir (Crixivan), saquinavir (Fortovase, Invirase), ritonavir (Norvir), and nelfinavir (Viracept)
  • Others: allopurinol (Lopurin, Zyloprim), bromocryptine (Parlodel), androgens (male hormones), estrogens (female hormones), danazol (Danocrine), metoclopramide (Reglan), methylprednisolone, octreotide, ticlopidine (Ticlid), cimetidine (Tagamet), methoxsalen (Oxsoralen), coal tar (Balnetar, Zetar), trioxsalen (Trisoralen)

Be sure to tell your doctor if you are taking any of these medications.

Disease-Modifying Antirheumatic Drugs (DMARDs)

Methotrexate (Rheumatrex)
Leflunomide (Arava)

Disease-modifying antirheumatic drugs, better known as “DMARDs,” are immunosuppressive medications that are used to treat the pain and swelling of the arthritis that can accompany lupus. DMARDs not only reduce this pain and swelling, but they may also be able to decrease long term damage to your joints.

Methotrexate (Rheumatrex)

Methotrexate is one of the most commonly used drugs for the treatment of rheumatoid arthritis, and it is used in lupus patients to alleviate the joint pain and swelling of polyarthritis (arthritis involving multiple joints). It is only mildly effective for more severe lupus symptoms involving the kidneys and other organs and should be used carefully in people with these conditions. Historically, methotrexate has been used to treat cancer and psoriasis, a skin condition that can also affect the joints. However, in the late 1980s, the medication was approved by the FDA for the treatment of arthritis and has been used commonly for this ever since. Methotrexate works by interfering with the production of folic acid, which is a building block for growing cells in your body. As a result, methotrexate hinders the growth of certain cells, including those of the immune system. This medication is also steroid-sparing, meaning it can be used in conjunction with steroids to lower the dose of steroid therapy and thus also lower the associated side effects.

The medication is usually taken as a tablet in doses of 7.5 to 25 milligrams (mg) per week, but it can also be given as an injection. People taking methotrexate usually feel improvements in 3-6 weeks, but it can take up to 3 months to feel the full benefit of the drug. Be sure to take this medication as directed. If you miss a dose, you can usually take the medication up to 4 or 5 days after. However, if you miss this window, contact your doctor regarding how you should proceed.

Most people taking methotrexate do not experience side effects and many of the more minor side effects will decrease with time. However, the likelihood of these side effects does increase as your dosage goes up. Many of the side effects of methotrexate involve the fact that the medication works by interfering with the production of folic acid in your body. Therefore, your doctor will most likely recommend that you take folate supplements, which will prevent many of these side effects, including mouth sores (stomatitis). Other side effects may include nausea, vomiting, and an increased risk for abnormal liver function tests. Because of the danger to your liver, you should not drink alcohol while taking methotrexate; drinking while on this medication can cause irreversible damage to your liver. In addition, it is important that people taking methotrexate have normal liver function tests. Be sure to tell your doctor if you have a history of liver disease. In addition, lung problems, such as a continuing cough or shortness of breath, can occur while taking this medication but are more common in people with preexisting lung conditions. Talk to you doctor if you experience these symptoms.

Some patients experience gradual hair loss (alopecia), but hair usually grows back once you stop taking methotrexate. In addition, methotrexate can increase your sensitivity to sunlight. Since many lupus patients already experience sun sensitivity, try to limit sun exposure and be sure to wear sunscreen when going outdoors.

It is important to remember that sometimes the side effects of this medication can go unnoticed; sometimes people may have abnormal blood tests while feeling no side effects at all, so it is important to have blood tests (complete blood counts, or “CBCs”) performed every 2-3 months while taking methotrexate.

If you are pregnant, may become pregnant, or are breastfeeding, you should not take this medication because it can cause serious birth defects and complications during pregnancy. Women taking this medication should use an effective method of birth control. Speak to your doctor about any pregnancy plans or concerns.

As with other drugs that may suppress your immune system, talk to your doctor about any vaccines or surgeries you may have. In addition, be sure to notify him/her of any other medications, both prescription and over-the-counter, that you may be taking. Methotrexate can interact with certain drugs, including the antibiotic trimethoprim (Bactrim)* and NSAIDs such as ibuprofen (Advil, Motrin) and celecoxib (Celebrex). Do remember, though, that sometimes methotrexate may be used in combination with certain NSAIDs to treat lupus. Your doctor will work with you to determine which treatments will work best to treat your lupus symptoms with the fewest side effects.

Leflunomide (Arava)

Leflunomide is another DMARD used to treat the swelling, pain, and stiffness that many lupus patients feel due to arthritis. It can either be prescribed alone or in combination with other treatments, such as methotrexate; often leflunomide is prescribed for patients who do not respond well to methotrexate. Leflunomide works by blocking the formation of DNA in the cells of your body, including those of the immune system. In hindering the formation of DNA, leflunomide stops the body from producing the overactive immune cells that are responsible for the swelling, stiffness, and pain in your joints.

Leflunomide is usually taken in tablets of 10 or 20 milligrams (mg) once a day. 6-12 weeks may pass before you feel the full benefits of this medication, although your joint pain and stiffness will probably start to improve after just a few weeks. It takes some time for the medication to build up in your body, so some doctors may prescribe something called a “loading dose” when you first begin to take leflunomide. A loading dose is a large dose—about 100 mg—usually given once a week for three weeks in addition to your regular dose. Alternatively, some doctors may give this loading dose over the first three days. This technique, however, usually increases the chance that the person will develop side effects, including diarrhea. The good news is that the diarrhea usually goes away once the loading dose is stopped.

Leflunomide does have several side effects. The most common side effect is diarrhea, which affects about 1 in 5 people, but this symptom usually goes away with time. In addition, your doctor can talk with you about taking an anti-diarrheal medication to curb some of this discomfort. If the diarrhea persists, she/he may lower your dosage.

Other side effects include nausea, indigestion, rash, or hair loss (alopecia), but these effects are less common. In addition, about 1 in 10 patients taking leflunomide have abnormal liver function tests or decreased blood cell counts, so individuals taking this medication should have liver enzyme and blood count tests done regularly every 3-4 months. Because of this risk to your liver, you should not drink alcohol while taking leflunomide, and you should tell your doctor if you have had liver problems in the past.

Women who are pregnant, may become pregnant, or are breastfeeding should speak with their doctor before taking leflunomide, since this medication can cause serious birth defects and complications. In addition, women should use an effective method of birth control while taking leflunomide and continue to do so until two years after leflunomide is stopped, since the medication is known to remain in your body well after you actually stop taking it. Men who want to have children should also talk to their doctor about stopping the medication. Anyone who is on the medication and would like to have children should speak to their doctor about a medication called cholestyramine (Questran), which can help eliminate leflunomide from your body.

As with other drugs that suppress your immune system, speak with your doctor about any vaccinations or surgeries you plan to have and any other medications you may be taking, including prescription drugs, over-the-counter medications, vitamins, and supplements. Medications that can interact with leflunomide include cholestyramine (Questran), tolbutamide (Orinase), and rifampin (Rifadin, Rimactane), so be sure to tell your doctor if you are on these medications.

Cytotoxic Drugs

Cyclophosphamide (Cytoxan)
Chlorambucil (Leukeran)
Nitrogen mustard (Mustargen)

Cytotoxic medications are a class of immunosuppressives that were originally developed (and are still used) to treat certain types of cancer. The cytotoxic drugs usually prescribed to treat lupus symptoms are classified as alkylating agents and are reserved for patients with more serious forms of lupus that involve organs such as the kidneys, central nervous system, lungs, and blood vessels. Cytotoxic medications work against the cells of your immune system that make antibodies (immunoglobulins). Usually, these molecules help the body to ward of infections and other invaders. However, with lupus, these antibodies actually work against your own body and are produced at a rapid rate. Cytoxic drugs fight the rapidly dividing cells of the immune system, but in doing so, they also work against other rapidly dividing cells in your body, including blood cells, hair cells, and sex cells. As a result, cytotoxic medications can have serious long term side effects. Even though cytotoxics have proven to improve the symptoms of kidney, nervous system, lung, and blood vessel disease in lupus patients, it is important for you and your doctor to evaluate the costs and benefits of cytotoxic therapy before beginning this treatment.

Cytoxan (cyclophosphamide)

Cytoxan is a cytotoxic medication usually reserved for lupus patients with serious kidney problems who have not responded to other medications. The dosage of Cytoxan varies from person to person. It can be taken in tablet form, but more often it is given intravenously (IV) at the doctor’s office. The IV procedure usually take about 15 to 60 minutes, and a medication may be given before to reduce any nausea you may feel. Doctors usually give Cytoxan once a month for 6 months and then every 2 to 3 months for two years. It may take a few weeks or months for Cytoxan to improve your lupus symptoms.

The side effects of Cytoxan range from mild to severe and may be worse when the medication is taken in tablet form. Side effects include nausea and vomiting, which can sometimes be prevented with an anti-nausea medication such as ondansetron (Zofran). Hair loss (alopecia) can occur, but hair usually grows back when the medication is stopped. Skin rashes can also occur and be difficult to differentiate from lupus symptoms. Like other medications that suppress your immune system, Cytoxan can increase your risk of infections, especially shingles and certain “opportunistic infections,” infections that do not usually cause disease in healthy individuals. Therefore, it is important that you wash your hands regularly, maintain good personal hygiene, and notify your doctor at the first sign of any infection or fever. Also tell your doctor if you are to have any vaccines or surgeries, since your immune system will be suppressed by Cytoxan.

More serious side effects include a reduction in white blood cell count, which usually occurs about 8-12 days after starting treatment. Your doctor should perform blood tests at this time to determine whether your dosage should be altered. In addition, Cytoxan can cause infertility in both men and women when taken for long periods of time. However, an injection called leuprolide (Lupron) can be given to help protect your body against this sterility; you may want to discuss this issue with your doctor before starting the medication. In addition, women can stop having periods when on Cytoxan. However, you can still become pregnant, so it is recommended that you use a method of birth control, since taking this drug can cause serious harm to the fetus. Be sure to talk to your doctor before taking Cytoxan if you are pregnant, could become pregnant, or are breastfeeding.

Cytoxan can also cause certain bladder problems. In order to use this drug, your body must break it down into several byproducts, one of which can irritate your bladder and cause scarring or blood in your urine. This side effect is common, so you should drink plenty of fluids—at least 8 glasses of water—per day. If you are taking Cytoxan intravenously, you may be given mesna (Mesnex) to prevent these bladder issues.

Because Cytoxan targets normal cells within your body in addition to those of the immune system, it increases your risk of cancer. The more Cytoxan you take and the longer you take it, the greater your risk of developing cancer, even later in life. Leukemia and bladder cancer are the most common form of cancer developed in patients taking Cytoxan, so your doctor should perform urine tests regularly.
Cytoxan can interact with certain drugs, so be sure to tell your doctor about any medications you are taking, either prescription or over-the-counter. Also tell him/her about any dietary supplements (including herbal supplements) and/or vitamins that you may be taking. The following drugs can interact with Cytoxan: the gout medication allopurinol (Aloprim, Zyloprim), phenobarbital (Solfoton), warfarin (Coumadin), thiazide diuretics, such as hydrochlorothiazide, and some psychiatric medications. Be sure to notify your doctor if you are taking any of these medications.

Chlorambucil (Leukeran) and nitrogen mustard (Mustargen)

Chlorambucil (Leukeran) and nitrogen mustard (Mustargen) are cytotoxic medications similar to Cytoxan. They have been used in the past to treat lupus symptoms but are not used as commonly as Cytoxan at present. Leukeran is usually taken by mouth and is commonly used in Europe and developing countries. In the U.S., it is usually given to people who cannot tolerate Cytoxan or who have an allergy to the medication. The medication is usually tolerated better than Cytoxan tablets. However, it is more dangerous than IV Cytoxan because it must be taken for a longer period of time, which increases the risk of developing cancer. Therefore, if you take Leukeran tablets, you should do so only for a maximum of two years.

Nitrogen mustard was actually the first cytotoxic medication found to be effective in the treatment of lupus. However, it is seldom used today because it is trickier to administer and it must be given intravenously in the hospital. Your doctor will speak to you in more detail if this medication becomes involved in your treatment.

∗ People with lupus should not take Bactrim, sulfa antibiotics (e.g., Gantrisin, Septra), or sulfa diuretics (e.g., Aldactone), since these medications can cause lupus flares by increasing sun sensitivity and occasionally lowering blood counts. If you are prescribed one of these medications, talk to your doctor about possible alternatives.

C-reactive Protein (CRP)/Westergren Sedimentation Rate

Like the erythrocyte sedimentation rate, the C-reactive protein (CRP) test measures inflammation. However, CRP usually changes more rapidly than ESR because it is made by the liver and secreted hours after the beginning of infection or inflammation. CRP plays a part in your immune response by interacting with your body’s complement system. The CRP is non-specific, meaning it cannot give your doctor information about where inflammation is occurring in your body. However, the amount of CRP can give an idea as to the degree of inflammation your body is experiencing, and it is used by doctors in lupus treatment to monitor flares and to assess how well your medications are working. It is important to realize, though, that a low CRP value does not necessarily mean that an individual is experiencing no inflammation; a low CRP can be seen in lupus patients with active inflammation. An elevated CRP can also be seen after someone has a heart attack, surgical procedure, or infection.

High Sensitivity C-Reactive Protein (HS CRP)
In apparently healthy individuals, studies have shown that C-reactive protein (CRP) can be an indicator of the risk of cardiovascular disease (CVD), since certain types of CVD, namely atherosclerosis, are known to involve inflammation. A high sensitivity test (high sensitivity C-reactive protein, or HS CRP) is used to evaluate this risk, because the level of CRP in the blood is low. The high sensitivity CRP is important because studies have shown that lupus patients have higher levels of atherosclerosis than the general population. However, the HS CRP can reflect many things in lupus patients besides lupus activity and/or one’s risk of heart attack.

For the HS CRP test, blood is taken from a vein in your arm and mixed with a substance called an antiserum. The antiserum contains a specific substance that is able to detect the CRP. The American Heart Association and Centers for Disease Control and prevention maintain that a high-sensitivity CRP of less than 1.0 mg/L suggests a low risk for CVD, 1.0-3.0 mg/L suggests an average risk, and a CRP above 3.0 mg/L suggests a high risk.

Sources

  • “C-Reactive Protein.” Lab Tests Online. 29 April 2009. American Association for Clinical Chemistry. 12 July 2009 <http://labtestsonline.org/understanding/analytes/crp/test.html>.
  • “Inflammation, Heart Disease and Stroke: The Role of C-Reactive Protein.” American Heart Association. 12 July 2009. <http://www.americanheart.org/presenter.jhtml?identifier=4648>.
  • “Hs-CRP.” Lab Tests Online. 8 April 2009. American Association for Clinical Chemistry. 12 July 2009. <http://labtestsonline.org/understanding/analytes/hscrp/test.html>.

Nervous System

Lupus can affect both the central nervous system (the brain and spinal cord) and the peripheral nervous system. Lupus may attack the nervous system via antibodies that bind to nerve cells or the blood vessels that feed them, or by interrupting the blood flow to nerves.

Cognitive Dysfunction

The most common manifestation of neuro-lupus is cognitive dysfunction, which is characterized by clouded thinking, confusion, and impaired memory. Eighty percent of lupus patients who have had lupus for ten years or more will experience this condition. Single positron emission computed tomography (SPECT) scans of SLE patients with cognitive dysfunction show abnormalities in blood flow, indicating that the condition may be the result of decreased oxygen delivery to certain parts of the brain. Unfortunately, there is no real treatment for cognitive dysfunction. Normally, it does not get worse over time. However, some people find that counseling and other forms of cognitive therapy help them to cope with associated symptoms.

Headache

About 20% of patients with lupus have migraine-like headaches. These headaches are different from “lupus headaches,” which are due to active lupus and require a lumbar puncture (spinal tap) or blood vessel study (MRA or CT-angiogram) for diagnosis. A true lupus headache usually requires corticosteroids for treatment. Non-lupus migraine headaches should be treated with a migraine prevention diet. [A copy of this diet can be found in the article “Migraine Prevention Diet” under this heading.] However, when diet alone becomes insufficient, medications such as nortriptyline can be used to reduce headache frequency and severity.

Fibromyalgia

Fibromyalgia is a chronic pain sensitization disorder characterized by widespread tenderness, general fatigue, and non-restful sleep. Doctors do not currently know the cause of fibromyalgia, but it is believed to result from a rewiring of pain pathways that lead to the spinal cord and brain. As a result, the central nervous system experiences an increased sensitivity to pain signals. Many people with lupus have fibromyalgia; in fact, much of the pain that people with lupus feel is due to this condition. To check for fibromyalgia, your doctor may touch several points on the muscles of your body. People with fibromyalgia often feel pain when light pressure is applied to these areas, whereas people without the condition feel little discomfort.

Three drugs are currently approved by the FDA for the treatment of fibromyalgia: pregabalin (Lyrica), duloxetine (Cymbalta), and milnacipran HCl (Savella). While these drugs can help to reduce discomfort by about 25%, there are many things that you can do on your own to help ease and manage the symptoms of fibromyalgia. Some people believe that limiting their daily activities helps to reduce pain and fatigue. In fact, doctors recommend that people with fibromyalgia continue to engage in regular daily activities. Scheduling short daily rest times may help you to keep a normal schedule. However, spending too many hours resting may make your symptoms worse.

In addition, since responses to stress can cause physical symptoms such as headache, increased pain, and muscle tension, try to practice stress management skills. There are some stressors that you can control, and there are some that are simply out of your hands. Focus on what you can control, and direct your energy toward future growth.

Try to practice a healthy lifestyle. Research has shown that light stretching activities such as Tai Chi and yoga can help to relax muscles and improve some of the pain associated with fibromyalgia. In addition, molecules called endorphins that are released by your brain after exercise—usually about 30 minutes of moderate or intense activity—help you to achieve a ‘natural high,’ and many people report that exercise simply makes them feel better overall. Other lifestyle elements, such as a supportive social network and a healthy diet, can also help to ease feelings of emotional and physical discomfort and promote an overall sense of well-being. If you feel you need more help in managing your fibromyalgia, your doctor can assist you in devising coping strategies.

Organic Brain Syndrome

Organic brain syndrome is a general term referring to physical disorders that cause impaired brain function. Other names are cerebritis, encephalopathy, and acute confusional state. This condition is usually diagnosed through lumbar puncture (spinal tap) or EEG (the recording of brain waves), and before the diagnosis is made, the doctor will likely rule out certain causes, such as drug use, infection, cancer, or metabolic problems. If the condition is confirmed to be caused by lupus, high dose steroids will be used to combat its effects.

CNS Vasculitis

CNS vasculitis is a very rare SLE complication caused by inflammation of the blood vessels of the brain. It is diagnosed by a blood vessel study (brain MRA or CT-angiogram) and requires treatment with high dose steroids.

Sources

  • Wallace, Daniel J. “Heady Connections: The Nervous System and Behavioral Changes.” The Lupus Book: A Guide for Patients and Their Families. 1st ed. New York: Oxford University Press, 1995. 99-115.
  • “How Lupus Affects the Body: Nervous System.” Lupus Foundation of America. 1 July 2009. <http://www.lupus.org/webmodules/webarticlesnet/templates/new_aboutaffects.aspx?articleid=102&zoneid=17>.

Blood Chemistry Panel

A blood chemistry panel is another common test used to evaluate a variety of components. Usually, it consists of about 7-25 tests. The information below is meant to provide an overview of these tests. Your doctor will counsel you regarding the results of your personal blood work and laboratory tests.

Kidney Function Tests

The creatinine blood test and blood urea nitrogen (BUN) test are used to assess kidney function in people with lupus kidney disease (nephritis).

  • Creatinine: Creatinine is produced by your muscles as they breakdown creatine, a substance involved in muscle contraction. Creatinine is formed at a constant rate in the body and excreted by the kidneys, so by evaluating the amount of creatinine in your blood, your doctor can determine how efficiently your kidneys are working. Creatinine levels are measured by taking a sample of blood from your vein; then, the concentration of creatinine in your blood is compared to a standard amount for your age and sex. Increased blood creatinine levels may indicate an increase in lupus involvement of the kidney. Other conditions, such as high blood pressure or diabetes, can also cause elevated creatinine levels.
  • Sometimes individuals are asked to provide a 24-hour urine sample for further assessment. The combination of blood and urine samples can be used to evaluate a creatine clearance—how effectively your kidneys filter small molecules, such as creatinine, from your blood. In addition, since creatinine is usually removed from the blood at a constant rate, blood creatinine levels can be used as a standard by which doctors can compare other urine or blood tests. Your serum (blood) creatinine level can also be combined with your age, weight, and gender to evaluate your estimated glomerular filtration rate (eGFR). Glomeruli are tiny ball-shaped structures in your kidneys that help filter blood and prevent the loss of valuable substances, such as blood cells and proteins. The eGFR is an educated estimate of the amount of blood that is filtered per minute by your glomeruli and is often used to detect kidney damage.
  • Blood urea nitrogen (BUN): The BUN test measures the amount of urea nitrogen in your blood. The liver produces nitrogen in the form of ammonia (NH3) as it breaks down proteins into their constituent amino acids. From the liver, urea travels in your blood to the kidneys, which filter the urea and flush it from your body in the form of urine. To evaluate an individual’s BUN level, blood is drawn from the vein, and the concentration of urea nitrogen in the blood is evaluated and compared to a standard value for that person’s age range. Even though increased protein levels in a person’s diet can cause their blood urea nitrogen levels to increase, elevated BUN may suggest kidney involvement due to lupus or another condition such as dehydration that causes decreased blood flow to the kidneys. Low BUN levels are uncommon and are usually not as important; they can suggest certain conditions, such as malnutrition, over-hydration, or liver disease, but doctors usually use other tests to monitor these conditions.

Blood Glucose (Sugar) Test

Tests of blood glucose levels are performed to determine if an individual’s blood glucose is in normal range. This test helps to detect hyperglycemia (high blood sugar), hypoglycemia (low blood sugar), and diabetes (which can occur after long-term steroid therapy). Glucose is a simple sugar that your body gets from the food you eat. The cells of your body need glucose to obtain energy, and they cannot function without it. When we think of providing our bodies with energy, we usually think about movement and physical activity. However, glucose is also vital to the cells of your brain and central nervous system.

The amount of glucose in your blood is controlled by a feedback mechanism involving two hormones, insulin and glucagon. These hormones work to ensure that your blood contains the right amount of glucose so that your cells—including those in your brain and central nervous system—can function correctly. When your body takes in glucose after a meal, insulin is secreted by cells in your pancreas (beta cells) in order to lower your blood glucose to the appropriate level. When your blood sugar gets too low, glucagon is secreted by alpha cells of the pancreas in order to raise glucose levels. Disruptions in this feedback mechanism can be harmful to your body. In people with diabetes, the body either does not make enough insulin or does not use it properly. High or low blood sugar levels caused by diabetes or other conditions can be serious if not kept in check.
Blood glucose levels are usually evaluated when the patient is fasting, but they can also be taken at random, after a meal, or in a “challenge” test in which a person consumes a certain amount of glucose to challenge their system and track the way his/her body deals with glucose over time. Diabetics usually monitor their own blood glucose levels at home.

Fasting Lipid Profile

A lipid profile is a group of tests that includes measurements of total cholesterol, HDL-cholesterol (“good cholesterol”), LDL-cholesterol (“bad cholesterol”), and triglycerides (fats), all of which are risk factors for cardiovascular disease. It is important that your doctors perform fasting lipid profiles if your cholesterol has been elevated, because people with lupus are at an increased risk for heart disease. In fact, cardiovascular disease—not lupus itself—is the number one cause of death in people with lupus. Furthermore, medications used in lupus treatment, especially corticosteroids such as prednisone, can raise blood pressure, blood glucose, cholesterol, and triglyceride levels, exacerbating the risk factors for cardiovascular disease in people with lupus.

A fasting lipid profile is performed only when a patient is fasting (i.e., has not eaten since midnight of the previous night). Fasting ensures an accurate reading of your baseline total cholesterol, HDL, LDL, and triglyceride levels. However, please understand that it is alright to take your medications with water upon the day you are fasting—water does not affect the fasting lipid profile.

  • Total Cholesterol: Cholesterol is a fatty substance made in the body and absorbed from certain foods that is essential in your body’s normal processes. It plays an important role in the membranes of your cells, is used to make hormones, and helps form the bile acids needed for your body to obtain nutrients from food. Your total cholesterol is a measurement of both types of cholesterol—LDL and HDL—and should be below 200 mg/dL. Total cholesterol levels above 240 mg/dL are considered dangerously high, especially in people with additional risk factors for cardiovascular disease, such as smoking, obesity, or family history. If your total cholesterol level is above 200 mg/dL, your doctor will most likely recommend that you follow a diet low in saturated fats and cholesterol and begin a moderate exercise regimen. If diet and exercise alone are not enough to control your cholesterol, she/he may prescribe a medication called a statin to help lower your cholesterol levels.
  • Low Density Lipoproteins (LDL): Cholesterol circulates in the body in complex molecules called lipoproteins. Low density lipoproteins (LDL) are sometimes known as “bad cholesterol,” because they can deposit excess cholesterol in your arterial walls, restricting blood flow and causing a condition known as atherosclerosis. If arteries become blocked, a person can suffer heart attack, stroke, or other complications. LDL levels above 100 mg/dL are considered to be above the optimal range. If you have other risk factors for heart disease, such as a history of smoking, low HDL levels, high blood pressure, diabetes, or a personal or family history of cardiovascular disease, you should aim for lower LDL levels.
  • High Density Lipoproteins (HDL): High density lipoproteins (HDL) are known as “good cholesterol” because they help to move cholesterol out of the body by carrying it to the liver where it is processed for excretion. HDL levels less than 40mg/dL are associated with an increased risk of heart disease, but a good HDL level is above 60mg/dL.

Protein

A comprehensive metabolic panel will also check the levels of certain proteins in your blood. Specifically, the test checks for albumin levels and total protein levels.

  • Albumin: Albumin is a small protein made in the liver that constitutes the major protein in blood serum. Albumin performs many functions in your body, including nourishing tissues, transporting various substances through the body (hormones, vitamins, drugs, and ions), and preventing fluid from leaking out of your blood vessels. Albumin concentration will drop if a person suffers from liver damage, kidney disease, malnourishment, serious inflammation, or shock. Abumin levels allow your doctor to assess for or monitor liver or kidney disease due to lupus and other factors.
  • Total Protein: In addition to albumin, your blood serum also contains a protein called globulin. In fact, globulin is actually a class of proteins that includes enzymes, antibodies, and hundreds of other proteins. A total protein test measures the combined amount of these proteins in your blood. An albumin to globulin (A/G) ratio is also computed. A person’s total protein level gives information about kidney damage, liver damage, and nutritional health. If your total protein falls outside of the normal level, your doctor will most likely order other tests to assess for liver or kidney function.

Electrolytes

Electrolytes are ions (electrically charged chemicals) in the blood and other body fluids. The concentration of electrolytes in your body depends on adequate intake of nutrients, proper absorption of nutrients by the intestines, and proper kidney and lung function. Abnormal electrolyte concentrations can indicate abnormalities in certain organs and bodily processes. For example, retention of sodium, bicarbonate, or calcium can indicate problems with kidney function. Hormones also help to control electrolyte concentrations, so abnormal electrolyte levels can also reveal certain hormone deficiencies or problems with certain hormone-regulating glands or organs. Some of the electrolytes measured in a comprehensive metabolic panel are explained below.

  • Sodium (Na+): Sodium helps to regulate your body’s water balance and plays an important role in proper heart rhythm, blood pressure, blood volume, and brain and nerve function. Hypernatremia refers to having too much sodium in the blood; this can occur, for example, due to a high-salt diet. Too much sodium in your blood can cause high blood pressure, among other things. Hyponatremia refers to having too little sodium in the blood. Hyponatremia can cause confusion, restlessness, anxiety, weakness, and muscle cramps. Sodium levels in the blood are regulated by a hormone called aldosterone that is secreted by the adrenal glands. Aldosterone works to regulate sodium levels by increasing your kidneys’ reabsorption of sodium ions.
  • Potassium (K+): Potassium plays a role in regulating the acid-base chemistry and water balance in your blood and body tissues. It also helps your body to synthesize proteins and make use of carbohydrates for fuel. Potassium is essential for normal muscle growth and helps sodium and calcium to maintain normal hearth rhythm and regulate the body’s water balance. Potassium also helps your muscles to contract and your nerves to send impulses. Potassium levels may be low if an individual is on a diuretic (fluid pill) such as hydrochlorothiazide (HCTC) or furosemide (Lasix). Blood potassium levels that are too high or low may lead to muscle weakness and cramping; very low levels may cause irregularities in heartbeat. Like sodium levels, potassium levels in the blood are regulated by aldosterone, which promotes potassium loss from your kidneys.
  • Calcium (Ca2+): Most people recognize calcium as a part of bones and teeth, but calcium plays many other roles in the body, such as regulating heartbeat, transmitting nerve impulses, contracting muscles, and helping blood to clot properly. Blood calcium levels are regulated by parathyroid hormone, which is secreted by the parathyroid gland, and calcitonin, which is secreted by the thyroid gland. Since lupus causes an increased risk of osteoporosis and corticosteroid (e.g., prednisone) use can elevate this risk, most people with lupus should take calcium and vitamin D supplements to help maintain adequate bone density. Medications called bisphosponates may be added to help with bone integrity if osteoporosis is detected. However, it is important that you realize that a blood calcium test measures the amount of calcium in the blood, not the bones. For an adequate measurement of bone health, you will need to obtain a DEXA scan every 2 years.
  • Chloride (Cl-): Chloride ions help your body in maintaining proper pH and fluid balance. It also secreted by the stomach during digestion. Excessive sweating, vomiting, or diarrhea can cause chloride levels to drop. Low chloride levels may alter the pH of your blood, cause dehydration; they may also cause you to lose potassium.
  • Carbon dioxide (CO2): This test measures the amount of carbon dioxide (CO2) in the blood, which is present in the form of CO2, bicarbonate (HCO3-), and carbonic acid (H2CO3). These three forms are involved in the equilibrium that maintains the pH of your blood (7.35-7.45). Bicarbonate also works with other electrolytes to maintain a certain charge balance in your cells. The concentration of carbon dioxide in your blood is maintained by your lungs and kidneys. High or low levels of CO2 may prompt your doctor to order other tests to check your kidney and lung function, blood gases, or fluid retention.

Liver Tests

Lupus and some of the medications used to treat lupus can affect the liver. In addition, factors such as excessive alcohol intake or viral hepatitis can affect the liver in people with lupus, just as they can in the normal population. Certain tests can be performed as part of a comprehensive metabolic panel to give insight into the function of your liver. In addition, your doctor may order a test called a liver panel if she/he suspects that you have symptoms of a liver disorder. Usually these tests measure certain liver enzymes, namely alkaline phosphatase (ALP), alanine amino transferase (ALT), and aspartate amino transferase (AST). Bilirubin, a waste product of the liver that is stored in the gall bladder, is also measured. These values can be used by your doctor as a screening or monitoring tool for liver involvement. About 30-60% of lupus patients experience abnormal liver function tests; some have no symptoms of liver disorder. Generally, increased levels correlate with increased activity, but other factors can contribute to elevated levels of liver enzymes in the blood. For example, NSAIDs, acetaminophen (Tylenol), and aspirin can cause liver enzyme values to increase, especially in people with lupus. If your doctor notices abnormal liver enzyme levels, she/he may ask you to undergo additional tests for hepatitis.

The liver enzymes and substances detected in a comprehensive metabolic panel are explained in more detail below.

  • Alkaline phosphatase (ALP): Alkaline phosphatase (ALP) is an enzyme—a protein that helps to bring about chemical reactions in your body—found mainly in your liver and bones. High levels of ALP in the blood may indicate bone or liver abnormalities. If high ALP values are accompanied by high values of other liver enzymes and bilirubin, then the test suggests liver involvement. Certain ratios of liver enzymes can also indicate more specific conditions. Children usually have higher ALP levels than adults because their bones are still growing.
  • Alanine amino transferase (ALT): Alanine amino transferase (ALT) is another enzyme found mainly in the liver. Smaller quantities can also be found in your kidneys, heart, and muscles. Levels of this enzyme are usually assessed in conjunction with readings for other liver enzymes to determine or monitor liver involvement. Very high levels of ALT may indicate acute hepatitis.
  • Aspartate amino transferase (AST): Aspartame amino transferase (AST) is an enzyme found mainly in the liver, heart, and muscles. AST is released into the blood by injured liver or muscle cells but is used primarily to detect liver damage. [Another enzyme called creatine kinase (CK or CPK) is a better indicator of heart or muscle damage.]  Levels of AST are usually viewed alongside other liver enzymes to assess for liver damage. Like ALT, very high levels of AST may suggest acute hepatitis.
  • Bilirubin: Bilirubin is a yellow-brown substance formed when the liver breaks down old red blood cells. Too much bilirubin can be a sign that the liver cannot adequately remove bilirubin from the system due to blockage (e.g., gallstones, tumors), cirrhosis, or acute hepatitis. Elevated bilirubin can also indicate hemolytic anemia, a reduction in red blood cells due to abnormal breakdown of red blood cells (hemolysis). Hemolytic anemia can be inherited or acquired; about 10-15% of people with lupus develop autoimmune hemolytic anemia. Hemolytic anemia causes red blood cells to have a shortened lifespan in the blood, and since bilirubin is a product of old red blood cells, it accumulates in the body faster than it can be eliminated. [Other tests called the Coombs test, haptoglobin count, and reticulocyte count are better diagnostic tests for hemolytic anemia.] Several inherited conditions, such as Gilbert’s syndrome, can also cause a person to have too much bilirubin. These conditions may be serious or benign. Often a buildup of bilirbubin is accompanied by a yellowing of the skin called jaundice.

Thyroid Tests

The thyroid is a gland in your neck associated with your metabolism—the processes by which your body makes use of energy. Autoimmune thyroid disease can occur in people with lupus, as can other thyroid conditions. Usually, thyroid conditions cause the gland to release too much or too little hormone. Your doctor may order tests to detect the level of thyroid hormones in the blood, especially if you experience significant weight loss or gain, sweating, acute sensitivity to hot or cold, fatigue, or other symptoms. These tests can also help your doctor monitor the effectiveness of thyroid treatment. Tests for thyroid hormones are explained below in greater detail. Your doctor may request additional tests, such as tests for thyroid antibodies, to learn more about your condition.

  • Thyroid stimulating hormone (TSH): Thyroid stimulating hormone (TSH) is a hormone released by the pituitary gland that signals the thyroid to release its hormones (T3 and T4) when levels in the blood get low. Together, TSH, T3, and T4 are part of a negative feedback loop that keeps levels of thyroid hormones constant in the blood. Abnormal levels of TSH in the blood can suggest a problem with the pituitary gland, such as a tumor, but this is unlikely. More often, high or low TSH levels indicate problems with the thyroid gland. The thyroid may not be responding to stimulation by TSH, or it may be releasing too much T3 and T4. Underactive thyroid (hypothyroidism) is more common in lupus, but overactive thyroid (hyperthyroidism) can also occur. Both of these conditions can be dangerous if not properly treated.
  • T4 and T3: Thyroid hormone contains thyroxine (T4, 90%) and triidothyronine (T3, 10%). The primary role of these substances is to regulate your body’s metabolism. Abnormal levels of thyroid hormone can indicate hypo- or hyperthyroidism.

Sources

  • “Albumin.” Lab Tests Online. 8 April 2009. American Association for Clinical Chemistry. 12 July 2009 <http://labtestsonline.org/understanding/analytes/albumin/test.html>.
  • “BUN.” Lab Tests Online. 8 April 2009. American Association for Clinical Chemistry. 12 July 2009 <http://labtestsonline.org/understanding/analytes/bun/test.html>.
  • “Comprehensive Metabolic Panel.” Lab Tests Online. 8 April 2009. American Association for Clinical Chemistry. 12 July 2009 <http://labtestsonline.org/understanding/analytes/cmp/glance.html>.
  • “Creatinine.” Lab Tests Online. 8 April 2009. American Association for Clinical Chemistry. 12 July 2009 <http://labtestsonline.org/understanding/analytes/creatinine/test.html>.
  • “Electrolytes.” Lab Tests Online. 8 April 2009. American Association for Clinical Chemistry. 12 July 2009<http://labtestsonline.org/understanding/analytes/electrolytes/test.html>.
  • “Glucose.” Lab Tests Online. 8 April 2009. American Association for Clinical Chemistry. 12 July 2009 <http://labtestsonline.org/understanding/analytes/glucose/test.html>.
  • “Lipid Profile.” Lab Tests Online. 18 June 2009. American Association for Clinical Chemistry. 12 July 2009 <http://labtestsonline.org/understanding/analytes/lipid/glance.html>.
  • “Liver Panel.” Lab Tests Online. 8 April 2009. American Association for Clinical Chemistry. 12 July 2009 <http://labtestsonline.org/understanding/analytes/liver_panel/glance.html>.
  • Parker, Janet, ed. The Encyclopedic Atlas of the Human Body: A Visual Guide to the Human Body. Chicago: Global Book, 2007.
  • “Thyroid Panel.” Lab Tests Online. 8 April 2009. American Association for Clinical Chemistry. 12 July 2009 <http://labtestsonline.org/understanding/analytes/thyroid_panel/glance-2.html>.
  • “Total Protein and A/G Ratio.” Lab Tests Online. 16 May 2009. American Association for Clinical Chemistry. 12 July 2009 <http://labtestsonline.org/understanding/analytes/tp/test.html>.

Fibromyalgia Medications

Pregabalin (Lyrica)

Duloxetine (Cymbalta)

Milnacipran HCl (Savella)

Pregabalin (Lyrica), duloxetine (Cymbalta), and milnacipran HCl (Savella)are medications approved by the FDA for the treatment of fibromyalgia. Fibromyalgia is a chronic disorder characterized by widespread pain and tenderness, general fatigue, and non-restful sleep. Doctors do not currently know the cause of fibromyalgia, but it is believed that people with this condition have experienced a rewiring of pain pathways in the brain due to repeated nerve stimulation. As a result, the central nervous system (your brain and spinal cord) experiences an increased sensitivity to pain signals. Many people with lupus have fibromyalgia; in fact, much of the pain that people with lupus feel is due to this condition. Both pregabalin and duloxetine were originally developed to treat other conditions (epilepsy and depression, respectively), but they have also proven successful in reducing some of the physical and emotional symptoms of fibromyalgia.

Pregabalin helps fibromyalgia by reducing pain by up to 25% and improving sleep and fatigue. Many people also report that this medication helps to improve their overall vitality. It is not known exactly how pregabalin works to combat symptoms of fibromyalgia, but some believe that it binds to a protein in nerve cells that is responsible for heightened pain sensitivity. Like other medications, pregabalin can have some side effects, including dizziness, drowsiness, dry mouth, edema, blurred vision, weight gain, swelling of the hands and feet, constipation, exaggerated feelings of happiness/wellness, balance disorder, increased appetite, and difficulty concentrating.

Duloxetine also helps to improve pain and promote an overall feeling of improvement in patients with fibromyalgia. It is not known exactly how duloxetine works in the body against the symptoms of fibromyalgia, but it is known that this medication increases the activity of two neurotransmitters in the brain, serotonin and norepinephrine. These neurotransmitters are known to be linked to emotion and mood, but research also suggests that they are involved in the brain’s natural pain-suppressing system. Duloxetine can have some side effects, including nausea, dry mouth, constipation, decreased appetite, drowsiness, increased sweating, and agitation. More information on duloxetine can be found under the information sheet, “Antidepressants.”

Like duloxetine, milnacipran also increases the activity of the neurotransmitters serotonin and norepinephrine and was first used as an antidepressant. However, the drug has been shown to significantly improve pain and physical function in people with fibromyalgia and was approved this year by the FDA for the treatment of this condition. Like pregabalin and duloxetine, it is not known precisely how milnacipran works to combat fibromyalgia.

While pregabalin, duloxetine, and milnacipran can help reduce discomfort, there are many things that you can do on your own to help ease and manage the symptoms of fibromyalgia. Some people believe that limiting their daily activities helps to reduce pain and fatigue. However, doctors recommend that people with fibromyalgia continue to engage in their regular daily activities. Scheduling daily rest times may help you to keep a normal schedule; spending too many hours resting may make your symptoms worse and prevent you from adjusting to life with fibromyalgia.

In addition, since responses to stress can cause physical symptoms such as headache, increased pain, and muscle tension, try to practice stress management skills. There are some stressors that you can control, and there are some that are simply out of your hands. Focus on what you can control, and direct your energy toward future growth. Practice stress management by identifying stressors, focusing on what you can control, using coping techniques when a stressor is beyond your control, practicing relaxation techniques, and sometimes, simply letting go.

In addition, try to practice a healthy lifestyle. Research has shown that light stretching activities such as Tai chi and yoga can help to relax muscles and improve some of the pain associated with fibromyalgia. In addition, molecules released by your brain after exercise—usually about 30 minutes of moderate or intense activity—help you to achieve a ‘natural high,’ and many people report that exercise simply makes them feel better overall. Other lifestyle elements, such as a supportive social network and a healthy diet, can also help to ease feelings of emotional and physical discomfort and promote an overall sense of well being. Remember that you play the most important role in maintaining your own personal health. Your doctor can help you to devise strategies if you feel you need more help in managing your fibromyalgia.

Antiplatelet Medications (“Platelet Antagonists”)

Clopidogrel (Plavix, Clopilet)
Ticlopidine (Ticlid)

What are antiplatelet medications, and why are they used in the treatment of lupus?

Clopidogrel (Plavix, Clopilet) and ticlopidine (Ticlid) are antiplatelet medicines (a.k.a., “platelet antagonists”) that help to prevent blood clots (thromboses). By preventing these clots, platelet antagonists help to prevent heart attack, stroke, and other complications. Lupus patients are at an increased risk for blood clots due to the prevalence of a condition known as antiphospholipid antibody syndrome (APS).  There are different kind of antiphospholipid antibodies, namely lupus anticoagulant, anticardiolipin antibody, and an antibody called anti-beta2 glycoprotein I. APS is also sometimes called Hughes Syndrome after the British doctor who first described it in the 1980s. Virtually 50% of lupus patients have antiphospholipid antibodies, but only 10% experience complications associated with APS, including miscarriages, stroke, and deep vein thrombosis (DVT). People who do not have lupus can also have antiphospholipid syndrome, but lupus patients comprise about 50% of people who have the condition. Aspirin is usually used to prevent APS, but other antiplatelet medications may also be used.

How should I take my antiplatelet medication?

Antiplatelet medications come in tablet form. They should be taken with a full glass of water, with or without food. If you miss a dose, take that dose as soon as you remember. However, if it is closer to the time you will take your next scheduled dose, simply wait until that time and take your normal dose—do not take extra medicine to make up for the dose(s) you missed.

What are the side effects of antiplatelet medications?

Since antiplatelet medications work to prevent platelets from clumping together to cause a clot, they may cause easy bleeding, even with minor injuries. If you experience bleeding that will not stop, you should get medical attention immediately. In addition, let your doctor know of any surgeries—including dental surgeries—that you intend to have, since you will most likely need to stop this medication before the procedure to prevent excess bleeding. Antiplatelet medications can also cause bleeding in your stomach or intestines, so tell your doctor if you have black or bloody stools or vomit that looks like coffee grounds.

What should I remember while taking this medication?

Do not drink alcohol or smoke while taking this medication. In fact, people who have lupus should do neither of these things, because they will only aggravate your symptoms and cause further damage to your heart, lungs, liver, kidneys, and other organs. In addition, usually people who take antiplatelet medications should not take NSAIDs or aspirin. However, your doctor may prescribe aspirin along with a platelet antagonist to treat your risk or clotting because the benefits of taking the medications together may outweigh the risks. It is important that you stick to the medications prescribed by your doctor and take them only as directed.

You should not take antiplatelet medications if you have a stomach ulcer. Make sure you also discuss with your doctor any history of blood clots, stroke, liver disease, or kidney problems. Also talk to your doctor if you are pregnant, may become pregnant, or are breastfeeding. Platelet antagonists are not harmful to an unborn baby, but it is not known yet whether they can be passed into breastmilk.

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