Treatment for Cutaneous and Mild SLE
Creams. Steroid creams are often used for skin lesions, although many patients with discoid lupus do not respond to steroids, particularly eruptions that are caused by sun sensitivity. A cream derived from vitamin A (Tegison) has been beneficial for some lesions that do not clear up with steroid creams.
Sun Protection. Sun protection is essential. Patients should always use sunblock creams (not just sunscreens) and always wear hats and clothing made of tightly woven fabrics. [For detailed information on sun protection see the Well-Connected Report #20 Aging Skin: Blemishes and Nonmelanoma Skin Cancers.]
Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
Common NSAIDs. NSAIDs block prostaglandins, the substances that dilate blood vessels and cause inflammation and pain. There are dozens of NSAIDs.
- Over-the-counter NSAIDs include aspirin, ibuprofen (Motrin IB, Advil, Nuprin, Rufen), naproxen (Aleve), ketoprofen (Actron, Orudis KT). One study suggested that ibuprofen or naproxen is more effective than aspirin or acetaminophen for acute tension-type headache.
- Prescription NSAIDs include ibuprofen (Motrin), naproxen (Naprosyn, Anaprox), diclofenac (Voltaren), tolmetin (Tolectin), ketoprofen (Orudis, Oruvail), dexibuprofen (Seractil).
Regular use of even over-the-counter NSAIDs may be hazardous for anyone and has been associated with the following side effects:
- Ulcers and gastrointestinal bleeding. This is the major danger with long-term use of NSAIDs.
- Increased blood pressure. Most NSAIDs appear to pose this risk, with higher risks observed with piroxicam (Feldene), naproxen (Aleve), and indomethacin (Indocin). (Sulindac has the smallest effect and aspirin as no risk.) People with hypertension, severe vascular disease, kidney, or liver problems and those taking diuretics must be closely monitored if they need to take NSAIDs.
- May delay the emptying of the stomach, which could interfere with the actions of other drugs. The elderly are at special risk.
- Dizziness.
- Tinnitus (ringing in the ear)
- Headache.
- Skin rash.
- Depression has also been noted.
- Confusion or bizarre sensation (in some higher-potency NSAIDs, such as indomethacin).
- As with acetaminophen, high daily doses of aspirin have been associated with an increased risk of kidney failure, although the risk remains low in those with healthy kidney function. Kidney abnormalities have been reported in people taking other NSAIDs as well, which resolve when the drugs are withdrawn. Any sudden weight gain or swelling should be reported to a physician. Anyone with kidney disease should avoid these drugs.
- Diabetics taking oral hypoglycemics may need to adjust the dosage if they also need to take NSAIDs because of possible harmful interactions between the drugs.
Note: Some studies have reported that ibuprofen (but not other NSAIDs) may blunt the heart-protective effects of low-dose aspirin, Additional research is needed to confirm these findings.
NSAID-Induced Ulcers and Gastrointestinal Bleeding
Long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs) is the second most common cause of ulcers and the rate of NSAID-caused ulcers in increasing. Ulcers caused by nonsteroidal anti-inflammatory drugs (NSAIDs) are more likely to bleed than those caused by the bacteria H. pylori. NSAID-related bleeding and stomach problems may be responsible for 107,000 hospital admissions and 16,500 deaths each year. Because there are usually no gastrointestinal symptoms from NSAIDs until bleeding begins, physicians cannot predict which patients taking these drugs will develop bleeding. Among the groups at high risk for bleeding are elderly people, anyone with a history of ulcers of GI bleeding, patients with serious heart conditions, alcohol abusers, and those on certain medications, such anticoagulants ("blood thinners"), corticosteroids, or bisphosphonates (drugs used for osteoporosis).
Ulcer Risk for Specific NSAIDs. One study ranked the sixteen most commonly used NSAIDs according to risk for ulcers and bleeding.
- Lowest Risk: nabumetone (Relafen), etodolac (Lodine), salsalate, and sulindac (Clinoril).
- Medium Risk: diclofenac (Voltaren), ibuprofen (Motrin, Advil, Nuprin, Rufen), aspirin, naproxen (Aleve, Naprosyn, Naprelan, Anaprox), and tolmetin (Tolectin). (Drugs within this group vary in risk. Studies show, for example, that short-term use of naproxen is twice as likely as ibuprofen to be associated with hospitalization from GI bleeding. Although ketoprofen (Actron, Orudis KT) was considered a medium-risk drug, another study reported that even one week of taking the drug at low doses causes significant GI injury.
- Highest Risk: flurbiprofen (Ansaid), piroxicam (Feldene), fenoprofen, indomethacin (Indocin), meclofenamate (Meclomen), and oxaprozin.
Drugs for Prevention NSAID-Induced Ulcers. If NSAID-induced ulcers are identified, the following steps have been suggested:
- Switching to alternative pain relievers is the first step in preventing or healing ulcers caused by NSAIDs. If people cannot change drugs, then they should used the lowest NSAID dose possible. For example, Arthrotec is a combination of an ulcer protective agent called misoprostol and the NSAID diclofenac that may reduce the risk for gastrointestinal bleeding. One study found that patients taking Arthrotec had 65% to 80% fewer ulcers than those who took NSAIDs alone.
- In addition, agents are available that may help prevent ulcers in people who need to take NSAIDs. For example, proton-pump inhibitors (PPIs) are the first choice for preventing ulcers in high-risk individuals and have been demonstrated to reduce NSAID-ulcer rates by as much as 80% compared with no treatment. Brands include omeprazole (Prilosec), esomeprazole (Nexium), lansoprazole (Prevacid), rabeprazole (Aciphex), and pantoprozole (Protonix). Prevacid is the first proton-pump inhibitor to be specifically indicated for protecting against ulcers in chronic NSAID users.
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An ulcer is a crater-like lesion on the skin or mucous membrane caused by an inflammatory, infectious, or malignant condition. To avoid irritating an ulcer a person can try eliminating certain substances from their diet such as caffeine, alcohol, aspirin, and avoid smoking. Patients can take certain medicines to suppress the acid in the stomach causing the the erosion of the stomach lining. Endoscopic therapy can be used to stop bleeding from the ulcer. |
COX-2 Inhibitors (Coxibs). Celecoxib (Celebrex), rofecoxib (Vioxx), and valdecoxib (Bextra) are known as COX-2 (cyclooxygenase-2) inhibitors, or coxibs. They inhibit an inflammation-promoting enzyme called COX-2. Meloxicam (Mobicox) is a related drug known as a COX-2 preferential.
Most studies have found coxibs to be about equally effective to each other (and to NSAIDs) for allaying arthritic pain of osteoarthritis. Furthermore, evidence is increasing that both coxibs are significantly less harmful to the GI tract than standard NSAIDs. Celebrex may be superior to Vioxx in this regard, although more studies are needed to confirm this. Some early evidence also suggests that, like NSAIDs, they may be partially protective against colon cancer and possibly even Alzheimer's disease.
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Click the icon to see an image of colon cancer. |
In spite of their potential promise, some researchers theorize that inhibiting COX-2 may have some negative side effects over the long term. The effects of these drugs on the heart particularly require clarification. The following are possible adverse effects or complications:
- Some studies have reported twice the incidence of heart attacks in patients taking Vioxx compared to those taking standard NSAIDs. There were limitations to these studies, however, and 2003 study found no higher risk. Some (but not all evidence) suggests that the COX-2 inhibitors may increase the risk for blood clots. On the other hand some studies have suggested that the anti-inflammatory effects, at least in Celebrex and meloxicam (Movicox) may have beneficial effects on blood vessels, which would be heart protective.
- In one study, people who took Celebrex or Vioxx experienced an increase in blood pressure, with Vioxx having the greater effect.
- A few cases of neurologic side effects (hallucinations) have been observed with higher doses of Celebrex or Vioxx. There have also been reports of meningitis with Vioxx, which is reversible when the drug is stopped.
- Coxibs may have some adverse effects on kidney function, particularly in elderly people, which is similar to the effects of standard NSAIDs. Liver abnormalities, which are side effects of many drugs, have also been reported with coxibs and need further follow-up.
- They may have negative effects on pregnancy and fertility.
- Some severe allergic reactions have been reported in patients taking valdecoxib (Bextra). Anyone who develops a rash after taking these agents should stop taking them immediately.
- Patients who are sensitive to aspirin should discuss coxibs with their physician. Some may be safer for these individuals than others.
- Coxibs can interfere with other drugs taken concurrently. Patients taking anticoagulant drugs such as warfarin may experience a higher risk for bleeding with the use of these agents. The use of coxibs can interfere with many other drugs taken concurrently, including lithium, methotrexate, and many others taken for heart disease, high blood pressure, or epilepsy. Patients should discuss all other medications with their physician. Patients should discuss all other medications with their physician.
COX-2 inhibitors are also currently more expensive than traditional NSAIDs, however, costing about $80 per month, compared to about $15 for an NSAID like naproxen, and some insurers do not pay for them. More research is needed to confirm or refute any possible hazards from taking coxibs and also to determine whether their benefits are worth the higher cost.
Other Investigative Alternatives to NSAIDs
NO-NSAIDS. Experimental agents are being developed that combine nitric oxide with NSAIDs (NO-NSAIDs). Nitric oxide increases blood flow in the mucous lining and secretions of mucus and bicarbonate. Combining nitric oxide with NSAIDs may provide benefits similar to the COX-2 inhibitors.
Antimalarial Drugs
Antimalarial drugs may be prescribed for discoid lupus or for mild lupus when skin problems and joint pains are the predominant symptoms:
- The most common antimalarial agent used for SLE is hydroxychloroquine (Plaquenil). This agent is effective as maintenance therapy to reduce flares in patients with mild or inactive disease. Hydroxychloroquine may help protect against blood clots in people with antiphospholipid syndrome, high cholesterol levels, and bone loss.
- Other antimalarial agents include chloroquine (Aralen) or quinacrine (Atabrine).
High doses may be prescribed initially in order to accumulate high levels of the drug in the blood stream. It is not known why antimalarials work. Some researchers believe they inhibit the immune response and others think they interfere specifically with inflammation.
Side Effects. Side effects of the antimalarials include the following:
- Skin rash.
- Change in skin color (yellow in the case of quinacrine).
- Gastrointestinal problems.
- Headache.
- Hair loss.
- Muscle aches.
- The most serious is damage to the retina, although this is very uncommon when low doses are used. Eye damage after taking hydroxychloroquine is reversible when caught in time and treated, but it is not reversible if it develops after taking chloroquine. An eye exam is advisable every six months or so.
Antimalarials may also be used in combination with other anti-SLE drugs, including immunosuppressants and corticosteroids. It should be noted that smoking significantly reduces the effectiveness of antimalarial drugs.
Thalidomide
Thalidomide inhibits a number of potent cytokines and reduces the formation of new blood vessels that allow the disease to progress. In low doses it has been found to be safe and effective for severe cutaneous lupus in many patients. It does not appear to have any benefits for systemic complications of lupus. A major side effect is peripheral neuropathy, which can cause numbness, tingling, or other altered sensation in the nerves of limbs (feet, legs, hands, fingers). The drug should be taken for the shortest time possible. The drug is also notorious for producing very serious birth defects in children. Women who are in their reproductive years must be sure they are not pregnant before taking thalidomide and they must use very reliable birth control while taking it.
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