Jennifer M. Glunz
Dubuque, IA
Anti-inflammatory drugs fall into two categories: non-steroidal agents or corticosteroids. Among drugs of the non-steroidal class, salicylates (usually in the form of aspirin) are most commonly used. The aspirin is often enteric-coated or buffered with an antacid to reduce gastrointestinal symptoms. As an alternative to salicylates, a number of other non-steroidal drugs are available. Some of these drugs require a physician's prescription and others, such as ibuprofen, may be directly purchased without a prescription. For reasons that aren't known, people often respond better to one non-steroidal drug than another. Thus, it may be necessary to give brief courses of several different drugs to determine the most effective one.
The most common side effect associated with non-steroidal medications is irritation of the stomach or bowel causing abdominal pain. Infrequently, this may lead to serious complications such as an ulcer with bleeding. To reduce the chance of these problems, non-steroidal drugs are usually taken with meals or given along with other medications that protect the stomach and bowel.
Several very rare side effects of non-steroidal drugs may be mistaken for signs of lupus. The drugs may cause fever or skin rashes that can easily be confused with signs of active lupus. The drugs may produce changes in the kidney leading to edema or abnormalities on urinalysis or blood tests that resemble lupus nephritis. Similarly, non-steroidal drugs have been shown to cause fever and headache that can mimic a type of neurologic disease seen in lupus. Recognition of these side effects is important since the symptoms are promptly reversed simply by stopping the drug.
The decision to begin corticosteroids and the details as to what type and dose of corticosteroid to use is highly individualized and depends on the needs of the patient. Patients with symptoms such as fever, arthritis, or pleurisy that have not responded to non-steroidal drugs are generally treated with low doses of an oral corticosteroid such as Prednisone or methylprednisolone (Prednisolone). On the other hand, patients with more severe or serious manifestations of lupus, such as nephritis with massive proteinuria, anemia or low platelets (thrombocytopenia), or seizures may require high doses of corticosteroids. In most instances, the corticosteroid is given as a single dose in the morning. Other ways of giving corticosteroids include doses given several times each day, doses only on alternate days, or in high doses by intravenous infusion (bolus therapy). In general, once the symptoms of lupus have responded to treatment with corticosteroids, the dose is gradually reduced (tapered) while the patient is carefully watched for evidence of relapse of the disease. The longer a person has been on corticosteroids, the more difficult it becomes to lower the dose.
There are many complications of corticosteroid treatment. In general, the risks of these complications are increased when high doses of corticosteroids are required or when corticosteroids are used for an extended period. Corticosteroids may produce changes in physical appearance such as weight gain, puffiness of the cheeks, thinning of the skin and hair, and easy bruising. Stomach discomfort such as dyspepsia or heartburn are common and may be minimized by giving the drug with meals or along with medications that prevent stomach damage. Patients may note marked changes in mood while taking corticosteroids including both depression and emotional lability (mood swings). Corticosteroids may cause diabetes, increase the risk of infections, or when given for many months may cause cataracts. Corticosteroids may have an effect on the bones, producing joint damage of the hips, knees, or other joints (osteonecrosis). Corticosteroids may also produce osteoporosis (thinning of bone) when given over long periods. For many, calcium or other medications to prevent osteoporosis is given along with the corticosteroids.
The side effects of low-dose anti-malarial therapy include gastric symptoms (stomach pain or dyspepsia), rashes or darkening of the skin, and muscle weakness. Shortly after starting treatment, there may be a mild blurring of vision that entirely clears on its own.
In high doses such as those used in the treatment of malaria, anti-malarial drugs may damage the retina of the eye to produce visual disturbances, including blindness. The risk of this complication with the low doses of anti-malarials used in the treatment of lupus is extremely low. However, as a precaution, patients treated with anti-malarials generally have a thorough eye examination before treatment with the drug is initiated and then every 6 months during therapy. This allows for the detection of any damage to the retina very early so that, if needed, the drug can be stopped to prevent any further eye damage.
The possible toxicities of chemotherapies are considerable and patients treated with these drugs must be very carefully monitored. The drugs affect cells produced by the bone marrow including white blood cells, red blood cells, and platelets. Thus, patients treated with chemotherapies must have regular complete blood counts (CBCs) to make certain that levels of these cells in the blood do not become too low. In additon, chemotherapies reduce a person's ability to fight off infections. Patients who are receiving chemotherapy are more likely to contract viral infections such as shingles (herpes zoster), although other more serious infections may also develop.
There are other distinct toxicities that are unique to each chemotherapy drug. Cyclophosphamide, for instance, may cause nausea and vomiting, hair loss, bladder complications, and sterility. Azathioprine commonly causes gastrointestinal disturbances and has been associated with an allergic-type of hepatitis. Both drugs are thought to increase a person's risk for the development of cancer.
There is a need for people with lupus to know about the drugs used in the treatment of the disease. This pamphlet briefly reviews the major drugs used in treatment. If you have any questions about the information presented in this pamphlet, you should check with your physician, pharmacist, or the Lupus Foundation of America.