Fighting lupus from within with the right drugs

American actress and singer Selena Gomez has been open about her SLE journey, including sharing that she suffers from hand tremors that are a side effect of one of her SLE drugs. — Handout

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that can affect multiple organ systems.

It occurs when the immune system mistakenly attacks the body’s own tissues, leading to widespread inflammation.

The term “lupus” originates from the Latin word for “wolf”, while “erythematosus” refers to redness or rashes.

The disease was first identified in the 18th century by a physician who named it after the characteristic erosive facial lesions that resemble wolf bites.

Although the term was inspired by skin manifestations, lupus is not confined to the skin alone; it can impact various organs throughout the body.

Risk factors and symptoms

Interestingly, while SLE can affect anyone, women are nine times more likely to develop the disease than men.

In Malaysia, the prevalence of SLE is reported to be 69 per 100,000 people, with the highest rates observed among the Chinese ethnic group, followed by Malays, and the lowest among Indians.

In addition to gender and race, other risk factors for SLE include genetic predisposition, hormonal influences, sun exposure, the use of certain medicines, smoking, and environmental triggers such as viral infections.

The symptoms of SLE vary widely from person to person.

Common manifestations can be categorised into skin-related and systemic reactions.

Individuals with SLE may develop a facial rash across the nose and cheeks, oral ulcers and hair loss.

Systemic symptoms, such as fatigue, abdominal pain, joint pain and swelling, and changes in the colour of fingers and toes, may also indicate the disease.

Decreasing UV ray exposure through wearing hats and clothes that cover most of the body, as well as using umbrellas and sunscreen, are some of the precautions SLE patients need to take to prevent their disease from getting worse. — FAIHAN GHANI/The Star

Standard medications

Despite advancements in modern medicine and technology, there is still no cure for SLE.

The primary goals of treatment are to achieve disease remission, prevent flare-ups, avoid organ damage, improve quality of life and minimise side effects.

Common medicines used to manage SLE include:

> Corticosteroids

Corticosteroids remain the cornerstone of SLE treatment due to their potent anti-inflammatory properties and rapid onset of action, making them effective for managing mild to severe cases.

The dosage and duration of corticosteroid therapy is carefully tailored based on the severity of the disease and the patient’s response to the drug.

Although corticosteroids are highly effective, it is crucial to use the lowest effective dose or discontinue them when feasible after consulting a doctor, in order to minimise the risk of serious long-term side effects.

These may include elevated blood pressure, increased blood glucose levels and hyperlipidaemia (high blood fat levels).

Furthermore, their immunosuppressive effects can increase susceptibility to infections and raise the risk of bone fractures over time.

> Hydroxychloroquine

Although hydroxychloroquine was originally developed as an antimalarial medicine, it plays a vital role in treating SLE.

Studies have shown that it reduces SLE activity, prevents disease flares and decreases the long-term need for corticosteroids.

Hydroxychloroquine typically takes two to eight weeks to become effective and is usually prescribed once daily due to its long duration of action.

For individuals who experience gastrointestinal disturbances, which are among the most common adverse effects, the dose may be divided to minimise the risk.

Additionally, because hydroxychloroquine carries a rare risk of retinal toxicity, individuals initiating this medicine should undergo a baseline ophthalmologic (eye) assessment.

> Immunosuppressants

In cases involving major organs or when the disease presents with life-threatening symptoms, immunosuppressants become essential in treating SLE.

Azathioprine suppresses the immune system by disrupting the production of white blood cells responsible for inflammation.

Before initiating this medicine, patients should undergo a baseline full blood count and liver function tests, which must be repeated regularly after starting the treatment.

This monitoring is crucial, as azathioprine might lower white blood cell counts, thereby increasing the risk of infections.

As an alternative, methotrexate is another immunosuppressant used to control inflammation.

It can be given either as an oral tablet or through a subcutaneous injection.

Individuals taking methotrexate need to take folic acid supplements, as they help reduce the adverse effects and toxicity associated with the medicine.

A minimum dose of 5mg per week is usually recommended.

> Calcineurin inhibitors

Calcineurin inhibitors such as cyclosporin and tacrolimus suppress the immune system by preventing the activation and proliferation of white blood cells, which play a vital role in immune response.

Both medicines are usually administered in two divided doses per day. 

Individuals taking cyclosporin should check their blood pressure regularly, as it can cause hypertension (high blood pressure).

Other possible side effects include excessive hair growth, gum enlargement, tingling sensations and tremors.

Both cyclosporin and tacrolimus may also lead to gastrointestinal discomfort and impaired kidney function.

Therefore, a renal (kidney) profile test should be repeated after initiating the therapy to monitor renal safety.

> Cyclophosphamide

Cyclophosphamide is another option used in the treatment of SLE.

It works by halting cell division, thereby preventing the multiplication of white blood cells that contribute to inflammation.

When taken orally, it is usually prescribed as a once-daily dose.

Common side effects of cyclophosphamide include gastrointestinal discomfort, hair loss and abnormal blood cell counts.

These adverse effects are similar to those associated with leflunomide, which may be considered as an alternative when cyclophosphamide or other agents are unsuitable or unavailable.

> Mycophenolate mofetil

Mycophenolate mofetil is often the choice for individuals with kidney involvement in SLE.

It works by suppressing the overactive immune response, reducing inflammation and lowering the risk of disease flares.

The medicine is typically administered in two divided doses each day.

As with other immunosuppressants, mycophenolate can cause abnormal blood counts and gastrointestinal intolerance.

Importantly, it should be discontinued at least six weeks before a patient plans to try becoming pregnant due to potential risks during pregnancy.

> Biologics

Biologics are used as adjunctive treatment for SLE, particularly when standard therapies have been optimised without producing an adequate response, or when contraindications or intolerances limit their use.

One such option is rituximab, which is administered intravenously.

It has been reported to have a good safety profile, with the most commonly reported side effects being infusion-related reactions and infections.

Advice for patients

Lifestyle modifications play an important role in managing SLE. 

Research has shown that individuals with SLE experience an improved quality of life through regular exercise, which helps reduce fatigue and depressive symptoms.

Photoprotection is also essential for individuals with SLE, as ultraviolet (UV) exposure can exacerbate the disease.

Studies indicate that using sunscreen helps to reduce the expression of inflammatory markers in skin exposed to the sun.

In addition to sunscreen, wearing a hat or seeking shade can further minimise UV exposure, offering additional protection for the skin.

Another important lifestyle modification is smoking cessation.

Studies have shown that smoking contributes to increased disease activity and can reduce the effectiveness of medicines in individuals with SLE.

Therefore, individuals with SLE should avoid smoking at all costs to help manage their condition effectively.

In conclusion, SLE is a chronic condition that requires ongoing management and personalised care.

A number of medicines are available for treating SLE, and the choice of treatment depends on the doctor’s assessment of the patient’s health status and the severity of the disease.

Patients must follow the correct dosage and administration of the medicines to ensure their effectiveness and minimise the risk of side effects.

Lifestyle modifications also play an essential role in managing SLE.

For any inquiries regarding medicines, please call the National Pharmacy Call Centre (NPCC) at the toll-free number 1-800-88-6722 during weekdays from 8am to 5pm, except on public holidays.

Annie Su Yun Jun is a pharmacist at Sarawak General Hospital. This article is courtesy of the Health Ministry’s Pharmacy Practice and Development Division. For more information, email [e-mail]. The information provided is for educational and communication purposes only, and should not be considered as medical advice. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this article. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.