Treatment for lupus depends on your signs and symptoms. Determining whether your signs and symptoms should be treated and what medications to use requires a careful discussion of the benefits and risks with your doctor. As your signs and symptoms flare and subside, you and your doctor may find that you'll need to change medications or dosages.
Common medications used to treat lupus
Three types of drugs are commonly used to treat lupus when your signs and symptoms are mild or moderate. More aggressive lupus may require more aggressive drugs. In general, when first diagnosed with lupus, your doctor may discuss these medications:
• Nonsteroidal anti-inflammatory drugs. Aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs), such as naproxen sodium (Aleve) and ibuprofen (Advil, Motrin, others), may be used to treat a variety of signs and symptoms associated with lupus. NSAIDs are available over-the-counter, or stronger versions can be prescribed by your doctor. Check with your doctor before taking over-the-counter NSAIDs because some have been associated with serious side effects in people with lupus. Side effects of NSAIDs include stomach bleeding, kidney problems and an increased risk of heart problems.
• Antimalarial drugs. Although there's no known relationship between lupus and malaria, these medications have proved useful in treating signs and symptoms of lupus. Antimalarials may also prevent flares of the disease. Hydroxychloroquine (Plaquenil) is the most commonly prescribed antimalarial. Side effects of antimalarial drugs include vision problems and muscle weakness.
• Corticosteroids. These drugs counter the inflammation of lupus, but can have serious long-term side effects, including weight gain, easy bruising, thinning bones (osteoporosis), high blood pressure, diabetes and increased risk of infection. The risk of side effects increases with higher doses and longer term therapy. To help reduce these risks, your doctor will try to find the lowest dose that controls your symptoms and prescribe corticosteroids for the shortest possible time. Taking the drug every other day also can help reduce side effects. Corticosteroids are sometimes combined with another medication to help reduce the dose, and therefore the toxicity, of both drugs. Taking calcium and vitamin D supplements while using corticosteroids can reduce the risk of osteoporosis.
Treatment for specific signs and symptoms
What treatments you may consider depend on your signs and symptoms. Treatments for specific signs and symptoms include:
• Joint pain and swelling. Pain in your joints may be initially controlled with NSAIDs. If you experience more significant joint pain, you and your doctor may consider antimalarial drugs or corticosteroids.
• Skin rashes. Avoid skin rashes by staying out of the sun, wearing sunblock year-round and keeping your skin covered. Despite your best attempts to avoid the sun, even indoor fluorescent lighting can trigger skin rashes in people with lupus. Skin rashes are sometimes treated with topical corticosteroids. These creams are applied to the affected area to reduce the inflammation in your skin cells. Oral steroids or antimalarial drugs also can be used.
• Fatigue. Fatigue is treated by determining the underlying cause. Your fatigue may be caused by difficulty sleeping, depression or poorly controlled pain. In these cases, your doctor would treat the underlying cause. If you and your doctor can't determine a cause for your fatigue, you may consider medications, such as corticosteroids and antimalarial drugs.
• Swelling around the heart and lungs. Swelling around your heart and lungs that causes chest pain may be controlled by NSAIDs, antimalarial drugs or corticosteroids.
Treatment for aggressive lupus
Life-threatening cases of lupus — those including kidney problems, inflammation in the blood vessels, and central nervous system problems, such as seizures — may require more aggressive treatment. In these cases, you and your doctor may consider:
• High-dose corticosteroids. High-dose corticosteroids can be taken orally or administered through a vein in your arm (intravenously). A high-dose regimen of corticosteroids may help control dangerous signs and symptoms quickly but can also cause serious side effects, including infections, mood swings, high blood pressure and osteoporosis. To minimize side effects, your doctor will give you the lowest dose needed to control your signs and symptoms and then reduce the dosage over time.
• Immunosuppressive drugs. Drugs that suppress the immune system may be helpful in serious cases of lupus but can cause serious side effects. The most commonly used immunosuppressive drugs include cyclophosphamide (Cytoxan) and azathioprine (Imuran, Azasan). Less commonly, the immune protein gamma globulin and the disease-modifying anti-rheumatic drug methotrexate — normally used to treat rheumatic arthritis — may be used to control severe, treatment-resistant symptoms. The drug mycophenolate (CellCept), another immunosuppressant, can be used to treat lupus-related kidney problems. Depending on the drug, immunosuppressive medications may be taken orally or intravenously. Side effects include an increased risk of infection, liver damage, infertility and an increased risk of cancer.
High-dose corticosteroids can be combined with immunosuppressive drugs to reduce the dosage of each drug, which may reduce the risk of side effects. Sometimes, even with aggressive treatment, your kidneys may fail. In that case, you may need kidney dialysis or, if kidney failure is permanent, a kidney transplant.
Researchers are studying many new treatments for lupus in clinical trials. These studies give people with lupus the chance to try new treatments, but they don't guarantee a cure. If you're interested in a clinical trial, discuss the options with your doctor to determine the benefits and risks.
Treatments being studied in clinical trials include:
• Belimumab (Benlysta). Phase 3 clinical trial results released in July 2009 indicated that this drug, when added to a standard lupus treatment regimen, significantly improved symptoms in the majority of participants. Belimumab is a monoclonal antibody, a laboratory-produced molecule that mimics the disease-fighting properties of your body's natural, immune system antibodies. Results from another large, stage 3 clinical trial of this drug are expected in late 2009.
• Stem cell transplant. A stem cell transplant uses your own adult stem cells to rebuild your immune system. Doctors hope this treatment can help people with life-threatening cases of lupus. Before a stem cell transplant, you're given a drug that coaxes the adult stem cells out of your bone marrow and into your bloodstream. The stem cells are then filtered from your blood and frozen for later use. Strong immunosuppressive drugs are administered to wipe out your immune system. Then the adult stem cells are put back into your body where they can rebuild your immune system.
• Dehydroepiandrosterone (DHEA). Some clinical trials have shown that a synthetic form of the hormone DHEA may improve quality of life in people with lupus, though others haven't found this. Your body uses DHEA to make male and female sex hormones. Researchers are conducting further clinical trials to better understand whether DHEA may be useful for people with lupus.
• Rituximab (Rituxan). Rituximab decreases the number of B cells, a type of white blood cell, in your body and may benefit people who haven't responded to other immunosuppressants. However, study results have been inconsistent and more research is needed to understand whether this drug is useful in the treatment of lupus.