Lupus - 2001 National Meeting Reports

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Dr. Shiel Gives Perspectives Of Interest On Systemic Lupus Erythematosus (Lupus) From 2001 Annual Scientific Meeting Of The American College Of Rheumatology

Introduction

Lupus is a chronic inflammatory condition that is caused by autoimmune disease. Autoimmune diseases are illnesses that occur when the body's tissues are attacked by its own immune system. The immune system is a complex organization within the body that is designed normally to fight infections and other foreign invaders. Patients with lupus have unusual antibodies in their blood that target their own body tissues. Lupus can cause disease of the skin, heart, lungs, kidneys, joints, and nervous system. Generally, when only the skin is involved, the condition is called discoid lupus. When internal organs are involved, the condition is called systemic lupus erythematosus.

Below are perspec

tives on key reports presented at the recent national meeting of the American College of Rheumatology:

Estrogen Replacement Issues

Hormone (estrogen) replacement that is given to postmenopausal women did not increase disease activity. It did, however, increase clotting events.

Dr. Shiel's Perspective: The question as to whether or not estrogens given to lupus women could actually cause their lupus to worsen has been debated for some time now. This study showed that they did not exacerbate the lupus and were well tolerated. However, there was a slight increase risk of clotting events, such as phlebitis. I generally avoid estrogens, both in the form of hormone replacement and in the form of birth control, in lupus women who have antiphospholipid antibodies (such as cardiolipin antibodies) because of their association with clotting events.

Cancer Risks

Lupus patients are at an increased risk for developing cancer. The cancer risk is most dramatic for blood cancers, such as leukemia and lymphoma, but is also increased for breast cancer.

Dr. Shiel's Perspective: Doctors and lupus patients should be especially vigilant for cancer with periodic general re-examinations.

Cigarette Smoking

Lupus patients who smoke have increased measures of disease activity.

Dr. Shiel's Perspective: The lupus patients who currently were smoking were found to have increased activity of their disease than non-smokers or former smokers! Lupus patients have even more reason NOT to smoke.

M

ale vs. Female Lupus

Men with lupus had higher death rates and more tissue damage than women of the same age and duration of lupus.

Dr. Shiel's Perspective: This goes along with a longstanding belief that men with lupus, on the whole, can have worse outcomes. It does not apply in individual situations, but for the male group as a whole.

Disease Activity

Lupus patients with elevated levels of DNA antibody had an increased risk of relapse of their disease.

Dr. Shiel's Perspective: Doctors treating lupus have long been using DNA antibodies to monitor disease activity.

Seizures in lupus patients were reported to be associated with increased signs of disease activity and high levels of cardiolipin antibodies. Seizures recurred in 8.2% of patients and were most common in those with severe strokes and a late onset of seizures.

Dr. Shiel's Perspective: This feature of seizures will heighten doctors' awareness of this condition in their lupus patients.

A repeat kidney biopsy can be helpful in making treatment decisions. Researchers reported that repeat kidney biopsy helped change the treatment plan in 85% of patients. The biopsies were repeated generally because of worsening kidney function (especially protein in the urine) in these patients.

Dr. Shiel's Perspective: Lupus kidney disease continues to present a challenge for the patient and the doctor. This study provides some justification for considering a second kidney biopsy if the kidney status is deteriorating down the road. It seems that the pattern of kidney involvement can change over time and the treatments can vary for different patterns of disease.

The early diagnosis and treatment of lupus children with serious nervous system manifestations can improve outcome. Typical treatment included high doses of steroids plus monthly doses of intravenous cyclophosphamide (Cytoxan).

Dr. Shiel's Pe

rspective: An early diagnosis is generally beneficial in rheumatic diseases. Neuropsychiatric lupus in children is no exception.

Hydroxychloroquine protects against both heart and kidney damage in lupus patients. Another paper also found protection for nervous system damage.

Dr. Shiel's Perspective: Earlier studies had suggested this protective effect years ago. I tend to favor long-term usage of Plaquenil for such preventative purposes.

High doses of Arava were successful in treating 30% of lupus patients with resistant arthritis.

Dr. Shiel's Perspective: Arava is a drug that is used to treat inflammatory arthritis, such as rheumatoid arthritis. The doses used in this study were double the recommended doses. I won't be using this one until many follow-up studies are performed that verify safety and effectiveness.

Birth Order Risks

First born children were reported at significantly higher risk for developing lupus than subsequent births.

Dr. Shiel's Perspective: This is an interesting observation. The doctor presenting the paper hypothesized that it occurred as a result of some environmental or genetic effects influencing the first born child differently than subsequent siblings.

Heart Disease

Heart disease was reported as a major cause of death in lupus patients.

Dr. Shiel's Perspective: This increased risk of heart disease and death signals the need for more research to determine what factors can help identify these high-risk patients and what the optimal preventative treatment strategies might be.

Phospholipid Antibodies

Blood clotting is common in lupus children with phospholipid antibodies, such as the lupus anticoagulant.

Dr. Shiel's Pe

rspective: This means that in this group of children, long-term anticoagulation will be considered.

Exercise

Supervised aerobic exercise did not seem to worsen disease activity in lupus patients. Another paper also demonstrated that aerobic exercise actually decreased fatigue and increased an overall sense of well-being in lupus patients.

Dr. Shiel's Perspective: The number of patients studied in this research was small, but this is encouraging news. As doctors, we always wonder about the effects of over-exercising lupus patients. It seems that a balance can be reached that can allow these patients to pursue physical exercise.

Diet

Environmental factors, including alfalfa sprouts, eggs, parvovirus and mono, and birth control pills were associated with a later onset of lupus.

Dr. Shiel's Perspective: This study incriminates environmental exposures as causes of lupus. The investigators looked at what lupus patients were exposed to 5 years before developing their disease. Lupus has long thought to be triggered by environmental factors, such as ultraviolet light and sulfonamide antibiotics. We need more research into these areas.

Stress

Stress reduction was shown to improve lupus disease activity.

Dr. Shiel's Perspective: This has long been anecdotally accepted by doctors who treat lupus patients. In fact, the opposite also seems to hold. That is, stress can be associated with disease flare-ups in lupus patients.

Va

ccinations

Lupus patients were able to mount an immune response to flu vaccine.

Dr. Shiel's Perspective: Lupus patients should feel comforted that they can benefit from influenza vaccinations.

For more, please see MedicineNet.com' s Systemic Lupus Erythematosus (Lupus) article.

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Reviewed on 12/29/2004

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