Medications and Lupus

By Mr Patrick Keefe, Pharmacist
Mr Patrick Keefe spoke about medications and the importance of reading the information which comes with medication. He listed several of the medications for Lupus patients and what to expect if there are side ef- fects . “It is important that you understand the medications you are taking and the risks, benefits and restrictions associated with them” Mr Keefe stressed. Mr Keefe is the LGH pharmacist.

 

Some questions you might ask of your doctor or pharmacist:

 

  • Why is the doctor prescribing this medication?
  • What is the name of the medication, both brand and generic (e.g.Plaquenil/Hydroxychloroquine)?
  • What should the medication look like (pill, capsule, cream, liquid, injection etc.)?
  • Is it okay to substitute a generic version?
  • What is the best time of day to take the medication?
  • How should it be taken (with food, water, milk, on an empty stomach)?
  • What is the dosage being prescribed?
  • How often should it be taken (several times a day, once a day, weekly,)?
  • What are the side effects, both common and unusual?
  • When should the doctor be called about any side effects?
  • How long will it take for the medicine to work?

Mr Keefe advised to keep a daily journal where we can record our medication and any side effects we may experience He concluded that an expert patient is some one who:

  • Feels confident and in control of their life
  • Aims to manage their condition and its treatment in partnership with healthcare Professionals
  • Communicates effectively with professionals and is willing to share responsibility for treatment
  • Is realistic about how their condition affects them and their family
  • Uses their skills and knowledge to lead a full life

Outline of medications presently used

Anti-Inflammatories: reduce inflammations and pain, fever, arthritis or pleurisy.
Aspirin:
pain reducer with anti-inflammatory and anticoagulant (blood thinning) properties.
Paracetamol:
Treatment for pain Less stomach irritation than aspirin
Does not help inflammation and cannot treat lupus disease activity
Most people have no side effects when taking paracetamol, but in rare cases acute liver failure has occurred. Eight a day maximum.

Non-steroidal anti-inflammatory drugs ( NSAIDS):
Ibuprofen, naproxen indomethacin, and celecoxibInflammation - suppression, joint pain and stiffness
People often respond better to one particular NSAID then another
Stomach irritation, abnormal urine test results, occasionally may be mistaken for signs of active lupus.

Corticosteroids
Cortisol helps regulate blood pressure and the immune system and is the body‟s most potent anti-inflammatory hormone which works quickly to decrease swelling, warmth, tenderness and pain which are associated with inflammation. It also helps depress the immune system. Because of side effects use the lowest effective dose, however, taper the dose when it is no longer necessary, do not stop it instantly. The side effects are : weight gain, fluid retention and redistribution of fat, fragile skin that bruises easily, suppressed growth in children, irritability, agitation, excitability, insomnia or depression, increased risk of infection, osteoporosis, muscle weakness and cataracts may occur.

Antimalarials Hydroxychloriquine (plaquenil) and chloroquine
Most often prescribed for skin rashes, mouth ulcers and joint pain, also effective in mild forms of lupus where inflammation and blood clotting are a concern.
Plaquenil: Decrease autoantibody production, protects against the damaging effects of ultraviolet light. It may take months for improvement to be noted. Side effects are mild and may include stomach upset and changes in skin colour.

Immunosuppressives (Immune Modulators)
Immunosuppressive medications are prescription drugs used to control inflam- mation and the overactive immune system, especially when steroids have been unable to bring lupus systems under control, or when a person cannot tolerate high doses of steroids. Each immunosuppressive drug has its own unique side effects.

Cyclophosamide: originally developed as a chemotherapy drug to treat cancer but is used as an immunosuppressant to treat lupus.
Methotrexate: Originally developed as a chemotherapy drug but is used as an immuno-suppressant to treat lupus
Known as the “gold standard”- the best drug for the treatment of rheumatoid arthritis. Shown to be very effective in treating skin lesions, arthritis and pleuritis in people with lupus. Can cause sun sensitivity, liver damage, including cirrhosis and lung infections. Nausea, mouth sore and head aches are the most common side effects. If you are taking this drug you should not drink alcohol especially if you have a history of kidney disease. If you are on a high dose of methotrexate, you should not use NSAIDS, caution is also advised when taking aspirin. Once a week dosage.
Azathioprine: Developed to prevent rejection of kidney transplants, Helps to lower steroid dosage and improve liver and kidney function. Can cause pancreatitis and an allergic form of hepatitis, so liver function test and blood counts should be done regularly.
Anticoagulants: These drugs thin the blood to prevent it from clotting too easily. Anticoagulant medications include low-dose aspirin and prescription heparin and warfarin.

Monoclonal antibodies (mAbs)
Belimumab developed to disrupt activation of B lymphocytes by interfering with BLyS, a protein required for B cell activity. Belimumab is the first and only drug specifically developed for and approved to treat lupus. Belimumab represents a breakthrough in the treatment of lupus. It is the first drug approved to treat lupus in more than 50 years and is the first drug developed specifically for lupus since the disease was first discovered more than a century ago. Cost of this medication is $28000 a year. Belimumab targets specific immune cells, rather than the blanket ap- proach of other therapies which suppress the entire immune system. Currently approved medications for lupus are borrowed from other diseases and conditions; other treatments are used off-label, which means they were never approved by the TGA for lupus. Many of these treatments have serious and devastating side effects. The most commonly reported adverse reactions with Belimumab were nausea, diarrhoea, fever, inflammation of the nose and throat, bronchitis, insomnia, pain in the extremity, depression and migraine. 

Just a note, whenever possible, people with lupus should avoid taking sulfa-containing antibiotics (or sulphonamides) as these drugs can exacerbate lupus symptoms in some individuals. Herb and supplements such as alfalfa, melatonin, Echinacea should be avoided, as they can exacerbate the lupus condition or in some cases some herbs can thin the blood enhancing anticoagulants.

Conclusion: Some other drugs are currently in development and are being trialled, but there will be no new drugs without clinical trial volunteers. These are being trialled in America but there needs to be many questions and answers before they can reach the development stage for release.

Thank you to Mr Keefe for access to his notes and for the knowledge into these medications which many of us are taking.