Pharmacological Treatment of SLE
As we have actually published on the Lupus Procedure Tips, which is mainly go over regarding Non Pharmacological Lupus Procedure. In this part The Pharmacological Procedure of Lupus will be described. Below are the Pharmacological representatives:.
Is the primary medicine in extreme organ system conditions, especially lupus nephropathy. Therapy with Corticosteroid and cyclophosphamide (iv bolus 0.5 to 1 gram/m2) is much more effective compared to just a corticosteroid alone, in the prevention of renal system sequele, keep renal function and renal generate remission. Effective non-renal indications with cyclophosphamide is sitopenia, main nerves abnormalities, lung hemorrhage and vasculitis.
Oral administration at a dose of 1 to 1.5 mg / kilograms might be raised to 2.5 to 3 milligrams / kilograms with the disorder of neutrophils> )1000/mm3 and leukocytes> )3500/mm3. Tracking the number of leukocytes were reviewed every 2 weeks and intravenous therapy with an amount of 0.5 to 1 gram/m2 every 1-3 months.
Negative side effects that frequently happen are nausea or vomiting, vomiting, hair loss can sometimes be discovered but it disappeared when the drug is stopped.Dose-dependent leukopenia often develops after 12 days of procedure to ensure that dose change is needed with leukocytes. The danger of microbial infections, fungi and pc virus, especially herpes zoster increases. Negative effects on the gonads that is triggering the failing of ovarian feature and azospermia. Stipulation of gonadotropin hormone launching bodily hormone or oral contraceptive pills has actually not been shown reliable. In SLE people with lupus nephropathy that become pregnant this course of medicines need to be stayed away from.
2. Mycophenolate mofetil (MMF).
MMF is a relatively easy to fix prevention of inosine monophosphate dehydrogenase, an enzyme important for purine synthesis. MMF would certainly stop the expansion of B and T cells and decreased expression of adhesion molecules. MMF successfully decrease proteinuria and improve serum creatinine in people with SLE and nephritis resistant to cyclophosphamide. Negative side effects that take place are typically leukopenia, queasiness and diarrhea. The combo of MMF and Prednisone as effective as dental management cyclophosphamide and prednisone adhered to by azathioprine and prednisone. MMF is provided at a dosage of 500-1000 mg two times daily until the response to drug treatment and amount adapted to feedback. In SLE clients with lupus nephropathy that become pregnant this course of medicines must be avoided.
Azathioprine is a purine analog that inhibits nucleic acid synthesis and influences the cellular and humoral invulnerable function. In SLE this drug is used as an option to cyclophosphamide for the therapy of lupus nephritis or as a steroid sparing agent for non-renal manifestations such as myositis and refractory synovitis. Giving beginnings with a dosage of 1.5 milligrams / kg / day, if needed could be boosted with the moment interval 8-12 weeks to be 2.5 to 3 mg / kg / day supplied that the leukocyte matter>) 3500/mm3 and metrofil>) 1000. If given up combination with the allopurinol dosage ought to be decreased to 60-75 %. Negative effects that happened a lot more highly effective than cyclophosphamide, which usually happens is bone bottom reductions and food poisonings. Azathioprine is also usually related to hypersensitivity to the sign of fever, skin rashes and increased serum transaminases. Complaints are generally relatively easy to fix and vanish after the drug is stopped. Consequently metabolized in the liver and secreted in the k.idneys liver and kidney function should be checked periodically. This drug is an immunomodulatory options in patients with lupus nephropathy who become pregnant, given at a dose of 1 to 1.5 mg / kg / day because it is relatively safe.
Leflunomide is an inhibitor of de novo synthesis of pyrimidin approved in the treatment of rheumatoid arthritis. Several studies have reported benefits in patients with SLE which was originally given because of steroid dependence. Giving starts with a loading dose of 100 mg / day for 3 days followed by 20 mg / day.
Methotrexate is administered at a dose of 15-20 mg orally once a week, and proved particularly effective for skin and joint complaints. Side effects that usually happens is an increase in serum transaminases, gastrointestinal disorders, infections and oral ulcers, so it needs to be monitored closely liver and kidney function. In SLE patients with lupus nephropathy who become pregnant this class of drugs should be avoided.
Giving a dose cyclosporine 2.5 to 5 mg / kg / day was generally well tolerated and lead to real improvements to the proteinuria, sitopenia, immunological parameters (C3, C4, anti-ds DNA) and disease activity. If creatinine increased by more than 30% or hypertension arises then the dose should be adjusted to a common side effect is hypertension, gum hyperplasia, hipertrikhosis, and increased serum creatinine. Cyclosporine is especially beneficial to membranous nephritis and nephrotic syndrome refractory to, so monitoring blood pressure and kidney function should be performed routinely. Cyclosporine A may be given to people with lupus nephropathy who become pregnant, given at a dose of 2 mg / kg / day because it is relatively safe.
1.Activation of T cells, the interaction of T cells and B cells, B cell depletion
Recent developments have focused therapy of B cell function in taking autoAg and present it through the immunoglobulin-specific T cells in the cell surface, further influence T cell-dependent immune response Anti CD 20 is a monoclonal antibody against the receptor CD 20 B lymphocytes presented
2.Anti CD 20
Anti-CD 20 (Rituximab; Rituxan) has the potential of the therapy for refractory SLE. Several studies provide therapeutic efficacy in refractory lupus manifestations such as central nervous system, vasculitis and hematological disorders.
LJP 394 (Abetimus sodium; Riquent) has been designed to prevent recurrence of renal flare in nephritis patients by reducing antibody against ds-DNA through a selective antigen-specific tolerance. The substance is a synthetic compound that consists of a series of deoxyribonucleotides which bound to the triethylene glycol chains.
4.Anti-B lymphocyte stimulator
B lymphocyte stimulator (BlyS) is part of the cytokine TNF (tumor necrosis factor), which presented the B cellsLymphoStatB a monoclonal antibod against BlyS.
Although there have been studies showing decreased secretion of TNF alpha and melioration leukopenia, proteinuria and immune complex deposition in experimental animals, but no clinical studies that administered anti-TNF agents in patients with SLE.
Antimalarial drugs used in SLE is hydroxychloroquine, chloroquine, and quinakrin. Used to constitutional complaints, manifestations in the skin, musculoskeletal and serositis. Antimalarial drug combinations have a synergistic effect and is used when the use of one drug is not effective. Hidroksiklotokuin (200-400 mg / day) and Quinakrin (100 mg / day) as a steroid sparing agents have side effects are mild and reversible, ie the skin becomes yellowish discoloration.
The mechanism of how hydroxychloroquine to prevent organ damage is unclear. Hydroxychloroquine lowering lipid levels and possible anti-thrombotic. Noteworthy are the side effects on the eye although it is relatively safe when used at low dois (<6.5 mg / kg / day). However, the current recommendation is to perform eye examinations before starting treatment and every 6-12 months later. Antimalarial rarely cause congenital abnormalities in the fetus. Therefore direkomendasaikan to be given also in patients with lupus nephropathy of pregnancy and lactation can be given up. Incidence of IUGR was also reduced by administering hydroxychloroquine.
Bromocriptine which selectively inhibits the anterior pituitary to secrete prolactin prove useful to reduce SLE disease activity. Dehydroepiandrosterone (DHEA) is useful for SLE with mild to moderate activity. Danazole (synthetic steroids) with doses of 400-1200 mg / day to control cytopenia especially thrombocytopenia and autoimmune hemolytic anemia. Estrogen replacement therapy (ERT) may be considered in patients with SLE who experience menopause, but there is still debate about the ability of oral contraceptives or ERT in the cause of SLE flares. For that this therapy should be postponed in patients with a history of thrombosis.
Corticosteroids are effective in treating a variety of clinical manifestations of SLE. Topical or intralesional dosage used for skin lesions, intra-articular preparations used for arthritis, while preparations for oral or parenteral systemic abnormalities. Giving oral dose varied from 50-30 mg of prednisone (methylprednisolone) per day in single or divided doses, is effective for treating the constitutional complaints, skin disorders, arthritis and serositis. Often given concurrently with corticosteroids or immunomodulatory antimalarials in order to get a quick induction then lowered the dose.The involvement of vital organs such as nephritis, cerebritis, hematological abnormalities or systemic vasculitis, generally require high doses of prednisone (1-2 mg / kg / day). Parenteral Corticosteroids can also be used in cases of very severe, life-threatening, with a bolus dose of 1000 mg methylprednisolone for 3 consecutive days.
Undesirable effects of glucocorticoids on long including cushingoid habitus, weight gain, hypertension, infection, capillary fragility, acne, hirsutism, accelerated osteoporosis, ischemic bone necrosis, cataract, glaucoma, diabetes mellitus, myopati, hypokalemia, irregular periods, irritability, insomnia, and psychosis. Therefore after a controlled disease activity, corticosteroid dose should be lowered or discontinued if possible or given in daily doses of the smallest interval.
To minimize osteoporosis, calcium supplements can be given 1000 mg / day in patients with 24-hour urinary calcium excretion over 120 mg. Given 50,000 units of vitamin D is also 1-3 times a week (monitor hypercalcaemia). In preventing osteoporosis can also be given calcitonin and bisphosphonates (alendronate, Didronel or Actonel). Corticosteroids are generally well tolerated during pregnancy although it can cause exacerbation of diabetes and hypertension. There is no evidence that corticosteroids cause congenital defect but may cause low birth weight babies and premature rupture of membranes.
NSAIDs (Non Steroid Anti Inflammatory Drug)
NSAIDs are used to deal with complaints of musculoskeletal pain, pleurisy, pericarditis, and headache. Side effects of NSAIDs on the kidneys, liver, central nervous system should be distinguished from the intense activity of lupus. The presence of proteinuria is an emerging or worsening renal function may be caused by SLE activity or effects of NSAIDs. NSAIDs can also cause aseptic meningitis, headache, psychosis and cognitive impairment, increased serum transaminase reversibly. Gastrointestinal disorders are the most frequent side effects caused by non-selective COX inhibitor. COX-2 selective inhibitors fewer gastrointestinal side effects. In SLE patients with lupus nephropathy who become pregnant this class of drugs should be avoided because it can lead to congenital abnormalities and is excreted in breast milk.
The role of plasmapheresis in lupus nephropathy remains controversial. The indication is a case of lupus with cryoglobulinaemia, hyperviscosity syndrome and TTP (Thrombotyc Thrombocytopenic Purpura).
Intravenous immunoglobulin (IV Ig) are immunomodulators with a wide working mechanism, including Fc receptor blockade, complement regulation and T cellUnlike immunosuppressant, IV Ig has no effect to increase the risk of infection. Dose of 400 mg / kg / day for 5 consecutive days provide improvements to the thrombocytopenia, arthritis, nephritis, fever, skin manifestations and parameters of immunologically. Side effects that occur are fever, myalgia, headache and arthralgia, and occasionally aseptic meningitis. Contraindications given to patients with SLE with IgA deficiency.
To be able to diagnose lupus required a good understanding of Lupus pathophysiology. In addition to symptoms and signs listed in the ACR criteria we need to know that many variations of other manifestations, especially in the skin and the central and peripheral nervous system. More often handling must be carried out in patients who do not fully meet the ACR criteria but suffered life-threatening condition, such as CNS lupus, hemolytic crisis, severe nephritis and poliserositis that does not prove there are other causes. On the other hand we too are required not to overdiagnostic for cases not yet clear. Handling of lupus often require cooperation intra-and inter-disciplinary branch of medicine. It is wise if the doctors who deal with lupus we include peer group or support group in providing education to patients with lupus. Lupus Treatment requires comprehensive understanding as well as astute skills.
A comprehensive treatment plan for lupus may include a range of complementary and alternative therapies (Natural remedies for lupus).
Nutrition and Supplements
Eating a healthy diet with plenty of fruits, vegetables, and whole grains is important for anyone with a chronic disease. People with lupus may also benefit from the following strategies:
Eat more antioxidant-rich foods (such as green, leafy vegetables) and fruits (such as blueberries, pomegranates, and cherries).
Avoid refined foods, such as white breads, pastas, and sugar.
Eat fewer red meats and more lean meats, cold-water fish, or beans for protein.
Use healthy cooking oils, such as olive oil or vegetable oil.
Avoid coffee and other stimulants, alcohol, and tobacco.
Drink plenty of fluids.
Exercise moderately at least 30 minutes daily, 5 days a week.
The following supplements may also help:
Flaxseed (30 g per day) contains omega-3 fatty acids and alpha-linolenic acid, which may help decrease inflammation. One preliminary study suggested that people with lupus who took flaxseed had better kidney function — important because kidney disease (lupus nephritis) is a major complication of lupus.
Fish oil, which also contains omega-3 fatty acids, may help decrease inflammation. Although evidence is mixed about taking a fish oil supplement, doctors do suggest that people with lupus eat more fish. Cold-water fish, such as salmon or halibut, are good sources. Talk to your doctor before taking a fish oil supplement if you also take anticoagulants (blood-thinners), such as warfarin (Coumadin). Eating fish doesn’ t cause the same risk.
Dehydroepiandrosterone (DHEA), start at 5 mg three times a day and work up to 100 – 200 mg per day for 7 – 12 months. Do not take DHEA without your doctor’ s supervision. DHEA is a precursor to the hormones estrogen and testosterone in the body, and several clinical trials show that it may help improve symptoms of lupus. However, side effects — including acne, increased facial hair, and excessive sweating — were common. DHEA may also lower HDL (good) cholesterol, which could contribute to heart disease. Because of DHEA’ s hormone-like effects, people with a history or higher risk of breast, uterine, ovarian, or prostate cancer should not take DHEA.
Calcium and vitamin D supplement, 1 – 2 tablets daily if taking corticosteroids. Corticosteroids can raise the risk of osteoporosis, and calcium and vitamin D can help keep bones strong.
Methylsulfonylmethane (MSM), 3,000 mg two times per day, may help prevent joint and connective tissue breakdown.
Herbs – Natural Remedies For Lupus
Herbs are generally available as standardized, dried extracts (pills, capsules, or tablets), teas, or tinctures/liquid extracts (alcohol extraction, unless otherwise noted). Mix liquid extracts with favorite beverage. Dose for teas is 1 – 2 heaping teaspoonfuls per cup of water steeped for 10 – 15 minutes (roots need longer).
Astragalus (Astragalus membranaceus) appeared to reduce overactive immune function in people with lupus in one study. However, the study was preliminary; more research is needed to know whether astragalus works. Do not take astragalus without talking to your doctor first, especially if you already take medications to suppress your immune system.
Tripterygium wilfordii, 30 – 45 mg daily, a Chinese herb. You may also prepare teas from the root of this herb. Two preliminary studies suggest that this herb may help suppress the immune system and reduce joint pain and inflammation. However, not much is known about its safety, and one report suggests that using it long-term may reduce bone density in women. Low bone density is a risk factor for osteoporosis. There are other reports of possibly more serious side effects. Do not take this herb without your doctor’ s supervision. Do not take tripterygium if you are pregnant.
People with lupus should avoid alfalfa supplements, and should talk to their doctor before taking any herb that is used to strengthen the immune system, such as echinacea or gingko.
Few studies have examined the effectiveness of specific homeopathic remedies. Professional homeopaths, however, may recommend one or more of the following treatments for lupus based on their knowledge and clinical experience. Before prescribing a remedy, homeopaths take into account a person’s constitutional type – your physical, emotional, and intellectual makeup. An experienced homeopath assesses all of these factors when determining the most appropriate remedy for a particular individual.
Acute dose is 3 – 5 pellets of 12X to 30C every 1 – 4 hours until symptoms are relieved.
Prognosis/Possible Complications :
The prognosis for people with lupus is mixed. Half of people who go into remission stay in remission for decades, but 90% of people with lupus have complications. For women, symptoms tend to get better after menopause. 90% of people with lupus have a survival rate of 10 years, and 63 – 75% have a survival rate of 20 years. People with certain complications from lupus tend to have a poor prognosis.
Follow Up :
Your doctor should monitor you closely during a flare to make sure you get the right treatment, and should watch your condition long-term to spot any complications with your lungs, kidneys, or other organs.