How Lupus Is Treated

Lupus treatment plans are tailored to your individual needs and may change over time. The range and effectiveness of treatments for lupus have increased, giving doctors more choices in how to manage the disease upon diagnosis and thereafter. Prescription medications such as immunosuppressive and anti-inflammatory drugs, among other options, may be used. It's important that you work closely with your doctor and take an active role in managing your disease, reevaluating your treatment plan regularly to ensure it's as effective as possible.

Once lupus has been diagnosed, your doctor will develop a treatment plan for you based on your age, sex, health, symptoms, and lifestyle. In developing your treatment plan, your doctor has several goals:

• Reduce inflammation caused by the disease
• Suppress immune system abnormalities that are responsible for tissue inflammation
• Prevent flares and treat them when they do occur
• Control symptoms
• Minimize complications

Prescription medications are an important aspect of the management of many patients with systemic lupus erythematosus (SLE), the main type of lupus. An array of drug options are now available, which has increased the potential for effective treatment and excellent patient outcomes. 

Lupus treatment should include as few medications as possible for as short a time as possible. Some patients never require medications, and others take them only as needed or for short intervals, but many require constant therapy with variable doses. Despite their usefulness, no drugs are without risks. The medications most frequently used to control lupus symptoms are:

• Nonsteroidal anti-inflammatory drugs (NSAIDs)
• Antimalarials
• Corticosteroids
• Immunosuppressives/disease-modifying anti-rheumatic drugs (DMARDs)

If you have mild lupus symptoms, you will likely be treated with an antimalarial and potentially NSAIDs and/or a short-term dose of corticosteroids.

If you have moderate lupus symptoms, your treatment plan will likely include an antimalarial along with a short-term corticosteroid until the antimalarial takes effect. You may also benefit from an immunosuppressive.

For severe lupus symptoms that involve your organs, you'll likely need an intense dose of immunosuppressive therapy. You may also be treated with high doses of a corticosteroid for a brief period to reduce your inflammation. As with mild and moderate lupus, you will likely also benefit from an antimalarial.

The variety of available options and the complexity of treatment plans can be overwhelming and confusing. Once your doctor comes up with a medication plan, it's important that you thoroughly understand the reason for taking a drug, how it works, how much you're supposed to take, when you need to take it, and what the potential side effects can be. If you're unsure, be sure to ask.

Most patients do well on lupus medications and experience few side effects. If you do, try not to get discouraged, remembering that alternative drugs are usually available. Also, notify your doctor immediately. It can be dangerous to suddenly stop taking some medications, and you should never stop or change treatments without first talking with your doctor.

Antimalarials

Antimalarials were first developed during World War II because quinine, the standard treatment for malaria, was in short supply. Researchers found that antimalarials could also be used to treat the joint pain that occurs with rheumatoid arthritis. Subsequent use has shown that these drugs are effective in controlling these lupus-related conditions:

• Lupus arthritis
• Skin rashes
• Mouth ulcers
• Fatigue
• Fever
• Lung inflammation

Antimalarials, which are approved by the U.S. Food and Drug Administration (FDA) to treat lupus, are used to help prevent flares when they're taken continuously, but they're not used to manage more serious, systemic forms of lupus that affect the organs. It may be weeks or months before you notice that these drugs are controlling disease symptoms.

Types of antimalarials include:

• Plaquenil (hydroxychloroquine sulfate)
• Aralen (chloroquine)

Although chloroquine is still used, due to better safety, hydroxychloroquine sulfate is usually preferred. The anti-inflammatory action of these drugs is not well understood. Antimalarials also affect your platelets to reduce the risk of blood clots and lower plasma lipid levels.

Side effects of antimalarials can include:

• Stomach upset
• Damage to the retina of the eye (rare)

NSAIDs

Nonsteroidal anti-inflammatory drugs (NSAIDs) comprise a large and chemically diverse group of drugs that possess pain-relieving, anti-inflammatory, and fever-reducing properties. Pain and inflammation are common problems in patients with lupus, and NSAIDs are usually the drugs of choice for patients with mild lupus with little or no organ involvement, though they have not been officially approved by the FDA to treat lupus. Patients with serious organ involvement may require more potent anti-inflammatory and immunosuppressive drugs.

While some NSAIDs, such as ibuprofen and naproxen, are available over-the-counter, a doctor's prescription is needed for others. NSAIDs may be used alone or in combination with other types of drugs to control pain, swelling, and fever. It's important that you take these medications under your doctor's direction. An NSAID may be the only drug needed to treat a mild flare, but the more active disease may require additional medications.

 Common side effects of NSAIDs can include:

• Stomach upset
• Heartburn
• Diarrhea
• Fluid retention

Some people also develop liver, kidney, cardiovascular, or even neurological complications from using NSAIDs, making it especially important to stay in close contact with your doctor while taking these medications.

Although all NSAIDs appear to work in the same way, not all of them have the same effect on every person. In addition, patients may do well on one NSAID for a period of time and then for some unknown reason may begin to derive no benefit from it. Switching to a different NSAID may produce the desired effects. You should use only one NSAID at any given time.

Corticosteroids

Corticosteroids are hormones secreted by the cortex of the adrenal gland. Synthetic versions of these molecules are used therapeutically as potent anti-inflammatory drugs. The term "steroids" is often misunderstood and confusion can result when corticosteroids are mistaken for anabolic steroids.

Corticosteroids have been approved by the FDA for treating lupus and are usually administered orally. During periods of serious illness, they may be administered intravenously. But once you've been stabilized, the oral administration should be resumed. Because they are potent drugs, your doctor will seek the lowest dose with the greatest benefit.

Lupus patients with symptoms that don't improve or who are not expected to respond to NSAIDs or antimalarials may be given a corticosteroid. Although corticosteroids have potentially serious side effects, they are highly effective in reducing inflammation, relieving muscle and joint pain and fatigue, and suppressing the immune system. They are also useful in controlling major organ involvement associated with lupus.

Once your symptoms have responded to treatment, the dose is usually tapered until the lowest possible dose that controls disease activity is achieved. You need to be monitored carefully during this time for flares or recurrence of joint and muscle pain, fever, and fatigue that can result when the dosage is lowered.

Some patients may require corticosteroids only during active stages of the disease; those with severe disease or more serious organ involvement may need long-term treatment. Doctors sometimes give very large amounts of corticosteroid by vein over a brief period of time (days), called bolus therapy or pulse therapy.

After prolonged corticosteroid therapy, the drugs must not be stopped suddenly. Administration of corticosteroids causes your body’s own production of adrenal hormones to slow down or stop, and adrenal insufficiency or even adrenal crisis (a potentially life-threatening state) may result if the drug is stopped suddenly. Tapering the dose allows your body’s adrenal glands to recover and resume production of the natural hormones. The longer you've been on corticosteroids, the more difficult it is to lower the dose or discontinue their use.

Corticosteroids used to treat lupus include:

• Prednisone (Sterapred)—used most often to treat lupus; see more below
• Hydrocortisone (Cortef, Hydrocortone)
• Methylprednisolone (Medrol)
• Dexamethasone (Decadron)

Corticosteroids are available as:

• Topical creams or ointments (for skin rashes)
• Oral tablets
• Liquid solutions
• Steroid shots (intramuscular or intravenous injections)

Short-term side effects of corticosteroids can include:

• Increased pressure in the eyes (glaucoma)
• Swelling
• High blood pressure
• Increased appetite
• Weight gain

Long-term side effects of corticosteroids can include:

• Cataracts
• High blood sugar (diabetes)
• Infections
• Weakened or damaged bones (osteoporosis and osteonecrosis)
• Longer time for wounds to heal
• Thinner skin that's easier to bruise
• Stretch marks

Typically, the higher the dose and the longer they are taken, the greater the risk and severity of side effects. If you use corticosteroids, you should talk to your doctor about taking supplemental calcium and vitamin D or medications to reduce the risk of osteoporosis.

More on Prednisone

Prednisone is the typical corticosteroid that doctors prescribe, alone or in conjunction with other medications, but it's usually used as a short-term medication. It is extremely effective in treating active lupus and symptoms often rapidly dissipate. Those with mild cases of active lupus may not need the drug at all.

Contact your doctor if you develop any of the following symptoms that either don't go away or are severe while taking prednisone:

• Headaches
• Dizziness
• Difficulty falling asleep or staying asleep
• Inappropriate happiness
• Extreme changes in mood
• Changes in personality
• Bulging eyes
• Acne
• Thin, fragile skin
• Red or purple blotches or lines under the skin
• Slowed healing of cuts and bruises
• Increased hair growth
• Changes in the way fat is spread around the body
• Extreme tiredness
• Weak muscles
• Irregular or absent menstrual periods
• Decreased sexual desire
• Heartburn
• Increased sweating

Contact your doctor immediately if you experience any of the following symptoms while taking prednisone:

• Vision problems
• Eye pain, redness, or tearing
• Sore throat, fever, chills, cough, or other signs of infection
• Seizures
• Depression
• Loss of contact with reality
• Confusion
• Muscle twitching or tightening
• Shaking of the hands that you cannot control
• Numbness, burning or tingling in the face, arms, legs, feet, or hands
• Upset stomach
• Vomiting
• Lightheadedness
• Irregular heartbeat
• Sudden weight gain
• Swelling or pain in the stomach
• Difficulty breathing
• Rash
• Hives
• Itching

Immunosuppressives / DMARDs (Disease-Modifying Anti-Rheumatic Drugs)

Immunosuppressives and other disease-modifying anti-rheumatic drugs (DMARDs) are used "off-label" (meaning they haven't been approved by the FDA for treating lupus) for serious, systemic cases of lupus in which major organs such as the kidneys are affected or in which there is severe muscle inflammation or intractable arthritis. Immunosuppressives may also be used to reduce or sometimes eliminate the need for corticosteroids, thereby sparing you from undesirable side effects of long-term corticosteroid therapy. Immunosuppressives restrain your overactive immune system in a variety of ways.

Immunosuppressives and DMARDs can have serious side effects too. However, side effects are dependent on the dose you're taking and are generally reversible by reducing the dose or stopping the medication under a doctor's advisement. These drugs may be given by mouth or by infusion (dripping the drug into your vein through a small tube).

There are many serious risks associated with the use of immunosuppressives and DMARDs. These include:

• Immunosuppression
• Increased susceptibility to infection
• Bone marrow suppression
• Development of malignancies

A variety of immunosuppressive drugs and other disease-modifying anti-rheumatic drugs are available to treat lupus. All of these apply to a group of drugs essentially used as a second line of defense against lupus and other forms of arthritis. Although they have different mechanisms of action, each type functions to decrease or prevent an immune response.

Immunosuppressives and DMARDs used to treat lupus include:

• Cyclophosphamide (Cytoxan)
• Mycophenolate mofetil (CellCept): This medication is often used for lupus nephritis or treatment-resistant systemic lupus erythematosus, the main form of lupus, and helps reduce the dosage of steroids you might need.
• Azathioprine (Imuran, Azasan): Azathioprine works by inhibiting gene replication and subsequent T cell activation. Based on murine (mouse and rat) and human studies, azathioprine is considered a weak immunosuppressive agent. However, it's cheaper than other immunosuppressive agents and can be used instead of steroids. Specifically, azathioprine works well after initiation of treatment with cyclophosphamide or mycophenolate.
• Methotrexate (Rheumatrex)

Side effects of these medications may include:

• Nausea
• Vomiting
• Hair loss
• Bladder problems
• Decreased fertility
• Increased risk of cancer and infection

The risk for side effects increases with the length of treatment. As with other treatments for lupus, there is a risk of relapse after the immunosuppressives have been stopped.

Biologics

Benlysta (belimumab) is another FDA-approved drug for the treatment of active, autoantibody-positive lupus in patients who are receiving standard therapy including corticosteroids, antimalarials, immunosuppressives, and NSAIDs (nonsteroidal anti-inflammatory drugs). Benlysta is administered as an intravenous infusion and is the first drug to target B-lymphocyte stimulator (BLyS) protein, which should decrease the number of abnormal B cells—a problem in lupus.

If you've been diagnosed with discoid or subacute cutaneous lupus, conditions that are often separate from typical systemic lupus erythematosus (SLE), your plaques should first be treated topically with extra-strength corticosteroid creams or ointments. These creams can be applied to the lesions at night before you go to sleep; the treated skin should be covered with a plastic film or Cordran tape. If the plaques are left without such a cover, the corticosteroid ointments and gels should be applied twice a day.

Another way to locally treat the plaques caused by subacute and discoid cutaneous lupus is to use topical calcineurin inhibitors like pimecrolimus cream or tacrolimus ointment. If your lesions don't respond to either corticosteroids or calcineurin inhibitors, your doctor may try injecting a corticosteroid into your skin lesions.

If none of these treatments work, your doctor will likely try a systemic treatment. The first-line therapy includes antimalarials such as hydroxychloroquine sulfate, chloroquine, or quinacrine. These are effective for most people.

If antimalarials don't do the trick, your doctor may try one of these systemic treatments:

• An immunosuppressive, such as methotrexate or mycophenolate mofetil (MMF)
• A systemic retinoid, such as isotretinoin or acitretin
• Dapsone, a sulfonamide
• Thalidomide, an immunomodulatory agent

One possible adverse effect of antimalarial drugs is psoriasis, which is another type of skin disease that has similar symptoms to subacute and discoid cutaneous lupus. Isotretinoin and thalidomide are both teratogens, which means that these drugs can damage a fetus, so don't take these if you're pregnant or thinking about getting pregnant.

Because of the nature and cost of the drugs used to treat lupus and the potential for serious side effects, many patients seek alternative or complementary ways of treating the disease. Some alternative approaches include:

• Special Diets
• Herbal supplements
• Fish oil supplements
• Chiropractic care
• Homeopathy
• Acupuncture
• Tai Chi
• Massage therapy
• Biofeedback
• Meditation

Although these methods may not be harmful in and of themselves and may help with some of your symptoms when combined with your regular treatment plan, no research to date shows that they affect the disease process or prevent organ damage. In fact, herbal supplements may actually be harmful, potentially making your lupus symptoms worse and/or interfering with your prescription medications.

Always consult your doctor before you start any complementary or alternative treatment, and make sure you keep taking the medications you've been prescribed.

Sources:

Clarke J. Initial Management of Discoid Lupus and Subacute Cutaneous Lupus. UpToDate. Updated May 16, 2017.

Clarke J. Management of Refractory Discoid Lupus and Subacute Cutaneous Lupus. UpToDate. Updated January 11, 2017.

MedlinePlus. Prednisone. U.S. National Library of Medicine. Updated November 15, 2015.

Wallace DJ. Overview of the Management and Prognosis of Systemic Lupus Erythematosus in Adults. UpToDate. Updated January 24, 2018.