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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.

Cyclosporine ophthalmic emulsion

Restasis is a medication used to treat eye symptoms related to Sjogren’s syndrome, a chronic autoimmune disorder in which the glands that produce tears and saliva do not function correctly. About 1 in every 10 people with lupus has Sjogren’s syndrome, but Sjogren’s can also affect people who do not have lupus. People with Sjogren’s often experience dryness of the eyes and mouth, and often they feel a gritty or sandy sensation in their eyes, especially in the morning. This dryness occurs because the immune system has begun to attack the moisture-producing glands of the eyes and mouth (the lacrimal and parotid glands, respectively), resulting in decreased tears and saliva.

Restasis is an immunosuppressive medication that works to reduce inflammation in the tear glands, helping to prevent further damage. Some people also report recovered tear production after using this medication for long periods of time. Yet, it is important to remember that it may take several weeks for your Restasis treatment to produce a therapeutic effect, and it may even take up to 6 months for you to feel the maximum benefit. Some people report that they stopped using their Restasis eye drops because they felt they were not working properly. However, remember that Restasis is used not to produce tears or wetness in your eyes, but rather to prevent further damage to your tear glands. Therefore, it is very important that you continue taking your Restasis eye drops as directed by your doctor, unless she/he decides they are ineffective. Your doctor may also prescribe lubricating eye drops (“artificial tears”) to help ease the every day discomfort of dry eyes. Restasis is generally safe and well-tolerated, but if you experience any serious discomfort (i.e., more than just a slight burning of the eyes), contact your doctor.

Restasis is not allowed in people with a history of serious eye infections. If you develop an eye infection, see your eye doctor immediately.

Other tests allow your physicians to monitor changes in lupus activity and the effectiveness of your medications.

• Erythrocyte Sedimentation Rate (ESR) The erythrocyte (or, red blood cell) sedimentation rate (ESR) is a test that measures the amount of inflammation in your body.
• 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.
• Creatine Phosphokinase (CPK) Creatine phosphokinase (a.k.a., creatine kinase, CPK, or CK) is an enzyme (a protein that helps to elicit chemical changes in your body) found in your heart, brain, and skeletal muscles. When muscle tissue is damaged, CPK leaks into your blood. Therefore, high levels of CPK usually indicate some sort of stress or injury to your heart or other muscles.
• Coombs’ Test The Coombs’ test is used to detect antibodies that act against the surface of your red blood cells. The presence of these antibodies indicates a condition known as hemolytic anemia, in which your blood does not contain enough red blood cells because they are destroyed prematurely. An acquired form, autoimmune hemolytic anemia (AIHA), is present in about 10% of people with lupus and results from an immune system attack on your red blood cells.

Antacids
Aluminum hydroxide, magnesium hydroxide (Mylanta, Maalox)
Calcium carbonate (Tums, Rolaids, Chooz)
Bismuth subsalicylate (Pepto-Bismol)
Sodium bicarbonate (Alka-Seltzer)

Proton Pump Inhibitors
Omeprazole (Prilosec)
Lansoprazole (Prevacid)
Rabeprazole (Aciphex)
Esomeprazole (Nexium)
Pantoprozole (Protonix)

Histamine2 Blockers
Cimetidine (Tagamet)
Ranitidine hydrochloride (Zantac)
Famotidine (Pepcid)
Nizatidine (Axid)

Promotility Agents
Metoclopramide (Reglan)

Many people with lupus suffer from gastrointestinal problems, especially heartburn caused by gastroesophageal reflux disease (GERD). Peptic ulcers can also occur, often due to certain medications used in lupus treatment, including NSAIDs and steroids. Occasional heartburn or acid indigestion can be treated with an over-the-counter antacid, such as Rolaids, Maalox, Mylanta, Tums, Pepto-Bismol, or Chooz. Your doctor may also include an antacid in your treatment regimen in addition to another form of GI medication. Antacids contain basic salts (ions), which interact with and neutralize the acid in your stomach on contact. Some antacids also contain simethicone, which helps relieve symptoms of gassy stomach. Antacids are effective when used to treat occasional symptoms, but you should try to avoid heartburn and acid indigestion altogether by eating smaller meals, remaining upright after eating, and cutting down on caffeine. If heartburn and acid reflux persist (e.g., for more than two weeks), you should speak with your doctor, because your heartburn symptoms could be part of a larger problem.

If you experience persistent heartburn, stomach acid, or ulcers, your doctor may prescribe a proton pump inhibitor (PPI), such as Nexium, Prevacid, Prilosec, Protonix, or Aciphex. These medications are used to treat people with heartburn, stomach or intestinal ulcers, or excess stomach acid. Proton pump inhibitors reduce acid by shutting down the tiny pumps within cells in your stomach that secrete it. Evidence also suggests that PPIs may inhibit Helicobacter pylori, a type of bacteria that can cause peptic ulcers, gastritis, and other gastrointestinal problems. Most PPIs come as over-the-counter or prescription tablets, but pantoprazole (Protonix) may also be given intravenously at the hospital for people who are admitted with a bleeding ulcer. Taking a PPI reduces the chance that an ulcer or gastrointestinal bleeding will occur again.

Your doctor may also prescribe histamine2 blockers (H2 blockers) for symptoms of GERD, esophagitis, or peptic ulcers. While both PPIs and H2 blockers suppress the production of acid in your stomach, they work in different ways and over different time periods. For example, H2 blockers work within an hour but last only about 12 hours, whereas PPIs need more time to take effect but last up to 24 hours. Also keep in mind that many PPIs and H2 blockers are available in both over-the-counter and prescription forms; while these medications vary in potency, over-the-counter forms may be more cost-effective. Talk to your doctor about these various options.

H2 blockers work to reduce the amount of acid that your stomach produces by blocking histamine2, a chemical in your body that signals the parietal cells of your stomach lining to make acid. In doing this, H2 blockers reduce the amount of acid made by your stomach. Different H2 blockers vary in potency. Over-the-counter forms are less potent, while prescription doses can be more potent.

In addition, your physician may prescribe a medication called a promotility agent if you experience GERD symptoms due to slow gastric emptying, or if H2 blockers and PPIs are not enough to control your GERD symptoms. Promotility agents help speed digestion by stimulating the movement of GI contents through your esophagus, stomach, and intestines. This helps to prevent acid from lingering in your stomach too long, thus reducing the amount of damage that acid can inflict on your GI tract and decreasing the occurrence of the acid reflux. Metoclopramide is the main promotility agent currently on the market. It works by increasing muscle contractions in the upper digestive tract, which in turn speeds the rate with which stomach contents move into the intestines.

While taking any GI medication, you should avoid drinking alcohol, since it can further upset your stomach and cause an increase in the side effects of certain medications. In addition, tell your doctor about any other medications you may be taking, since certain drugs can interact with your GI medications.

The following tests provide the starting point of any medical workup. By comparing your test results to the normal values for your age, sex, and personal circumstances (i.e., medications you may be taking, health conditions you might have, etc.), your doctor can monitor changes in your disease activity and overall health.

• Complete Blood Count (CBC) A complete blood count (CBC) is the most commonly performed lab test in the U.S. and is used to analyze red blood cells (RBCs), white blood cells (WBCs), and platelets. Many people with systemic lupus have abnormal CBCs.
• Blood Chemistry Panel A blood chemistry panel is a common test used to evaluate anywhere from 7-25 individual components of your blood. From these tests, doctors can glean information on the function of many vital organs and substances, including your kidneys, blood glucose, cholesterol, liver, thyroid.
• Urinalysis A complete urinalysis evaluates several different aspects of your urine through physical, chemical, and microscopic examination. In lupus treatment, a urinalysis is often used to monitor protein leakage (indicating kidney involvement) and identify and assess urinary tract infections (UTIs).

Why is aspirin used in lupus treatment?

Low doses of aspirin (81 milligrams, often called “baby aspirin”),* taken once a day may help to reduce the risk of blood clots and miscarriage in lupus patients who have antiphospholipid antibodies. Your doctor may recommend that you take one baby aspirin per day if you fit this category, since low doses of aspirin have been shown to lower the potential for clot-forming blood cells called platelets to stick together in narrow blood vessels. For this reason, low-dose aspirin is often grouped with the antiplatelet medications, sometimes called “platelet antagonists.” In addition, low dose aspirin may reduce the risk of heart attack and stroke.

How should I take aspirin, and what are the potential side effects?

Aspirin comes in tablets of different milligram doses. Your doctor will decide what dosage is right for you based on your symptoms of inflammation and the health of your kidneys and liver. If you take too much aspirin, you may experience an annoying ringing in your ears. In addition, if you experience stomach upset from taking aspirin or have an ulcer, you may have to stop the aspirin or take a protective medicine for your stomach such as famotidine (Pepcid).

Is there anything I should avoid while taking aspirin?

While taking aspirin, you should avoid taking ibuprofen (Advil, Motrin, Rufen), because studies have shown that this drug can counteract the benefits of aspirin therapy. If you need to take an over-the-counter medication for pain and stiffness, and your doctor has approved such a medication, you should try acetaminophen (Tylenol) or naproxen (Aleve, Naprosyn) instead.

Preparing for Surgery

Aspirin must be stopped one week before any surgery. Certain procedures, such as a colonoscopy, may also require that you stop aspirin therapy one week prior to the event. If you plan to have any surgeries or medical procedures, please discuss them with your doctor so that she/he may decide on the appropriate course of action.

∗ There is some debate as to which dose of aspirin is most effective in preventing blood clots. Usually, doctors recommend either 81 or 325 mg of aspirin daily. Go with whatever dosage your doctor recommends—both are beneficial.