Systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is the most common form of lupus. Lupus is an autoimmune disease, meaning that the body's immune system mistakenly attacks healthy organs and tissue. Lupus can affect any part of the body, causing inflammation and damage in joints, skin, kidneys, heart, lungs, blood vessels, or the brain.

More than 90% of people with lupus have skin rashes, often triggered by exposure to the sun. About half have kidney and lung problems. Because lupus affects the joints, it is considered a rheumatic (arthritis) disease.

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Signs and Symptoms

Lupus is often accompanied by the following signs and symptoms:

• Extreme fatigue
• Painful or swollen joints (arthritis)
• Muscle pain and stiffness
• Unexplained fever
• Skin rashes, including a characteristic "butterfly" rash over the nose and cheeks
• Kidney problems
• Hair loss
• Nausea, vomiting, abdominal pain
• Mouth and nose ulcers
• Headaches, migraine, seizures, stroke
• Anemia
• Depression
• Photosensitivity (sensitivity to sunlight)

What Causes It?

Scientists do not know what causes lupus, although genetics and environment probably play a part. Lupus usually first affects people 15 to 45 years old, but it can also happen in childhood or later in life. Lupus is a long-lasting disease, and symptoms tend to come and go.

Because more women than men have lupus, some researchers think hormones play a part in the disease. And some researchers believe lupus may develop after a person is infected with an organism that looks like particular proteins in the body. In this theory, the body later mistakes the proteins for the organism and attacks them. Lupus also seems to run in families.

Who is Most At Risk?

The following people are at higher risk for lupus:

• More women than men have lupus.
• Lupus is more common in black women and women of Hispanic, Asian, and Native American descent than in white women.
• Lupus can run in families, but the likelihood that a child, or a brother or sister of a person, also will have lupus is quite low.

What to Expect at Your Provider's Office

Your doctor will refer you to a rheumatologist, a doctor who specializes in treating joint diseases. The rheumatologist can diagnose and treat lupus, and a team of specialists usually helps determine which treatment may work best for you. Lupus can be hard to identify, and it may take time to make the diagnosis. Its symptoms can look like other autoimmune diseases, such as rheumatoid arthritis.

Your doctor will examine you and may order tests, including:

• Complete blood count
• Erythrocyte sedimentation rate (ESR). An elevated ESR means there is inflammation in the body.
• Urinalysis
• Blood tests to check your kidney and liver function
• Complement test, a blood test that measures severity of infection
• Antinuclear antibody test (ANA). Positive in most people with lupus.
• Other antibody tests
• Syphilis test (may be falsely positive in people with lupus)
• Skin or kidney biopsy

Treatment Options

Prevention

While you cannot prevent lupus, you can help prevent flare-ups:

• Avoid sun exposure, high-dose birth control pills, penicillin, and sulfonamides (antibacterial agents)
• Exercise regularly
• Get flu and pneumonia vaccines
• Reduce stress

Treatment Plan

There is no known cure for lupus. However, your team of health care providers can develop a treatment plan to prevent flare-ups, to treat them when they do occur, and to minimize complications.

Drug Therapies

Your provider may prescribe the following medications:

• Corticosteroids (such as prednisone), to quickly reduce inflammation. Side effects from long-term use include increased risk of osteoporosis.
• Nonsteroidal anti-inflammatory drugs (NSAIDs), to control pain, swelling, and fever. These drugs include ibuprofen (Advil, Motrin), aspirin, and naproxen (Aleve). Ask your doctor before taking any of these drugs over the counter.
• Drugs that suppress the immune system, to help keep the disease under control and prevent flares, for severe cases of lupus. These drugs include belimumab (Benlysta), cyclophosphamide (Cytoxan), and azathioprine (Imuran), mycophenolate (CellCept), and methotrexate.
• Antimalarial drugs, to treat fatigue, joint pain, skin rashes, and inflammation of the lungs. One of these drugs, hydroxychloroquine (Plaquenil), also helps prevent flares.

Complementary and Alternative Therapies

A comprehensive treatment plan for lupus may include a range of complementary and alternative therapies (CAM).

Nutrition and Supplements

Eating a healthy diet with plenty of fruits, vegetables, and whole grains is important for anyone with a chronic disease. You may also want to try these tips:

• 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 coconut 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 contains omega-3 fatty acids and alpha-linolenic acid, which may help reduce inflammation. One preliminary study suggested that people with lupus who took flaxseed had better kidney function. That is important because kidney disease (lupus nephritis) is a major complication of lupus. Talk to your doctor before taking a flaxseed supplement if you also take blood-thinning medications, including warfarin (Coumadin).
• Fish oil, which also contains omega-3 fatty acids, may help reduce inflammation. Evidence is mixed about taking a fish oil supplement. But 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 does not cause the same risk.
• Dehydroepiandrosterone (DHEA). DO NOT take DHEA without your doctor's supervision. DHEA is made into the hormones estrogen and testosterone in the body. 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 DHEA acts like a hormone, people with a history or higher risk of breast, uterine, ovarian, or prostate cancer should not take it.
• Calcium and vitamin D supplement, if taking corticosteroids. Corticosteroids can raise the risk of osteoporosis, and calcium and vitamin D can help keep bones strong.
• Methylsulfonylmethane (MSM) may help prevent joint and connective tissue breakdown.
• Turmeric may help reduce disease activity. Talk to your doctor before taking turmeric if you also take blood-thinning medications, including warfarin (Coumadin). Turmeric may not be appropriate for people who have gall bladder issues, couples who are trying to conceive, and people who have iron deficiency anemia, as it can potentially worsen these conditions. Talk to your doctor.

Herbs

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 to 2 heaping tsp. per cup of water steeped for 10 to 15 minutes (roots need longer).

Astragalus (Astragalus membranaceus): Seemed to reduce overactive immune systems in people with lupus in one study. However, the study was preliminary. More research is needed to know whether astragalus works, especially because astragalus is usually thought to stimulate the immune system. DO NOT take astragalus without talking to your doctor first, especially if you already take medications to suppress your immune system, or if you take lithium.

Thunder god vine (Tripterygium wilfordii), a Chinese herb: You may also make 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 taking it for a long time may reduce bone density in women. Having low bone density raises your risk of osteoporosis. There are other reports of 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 not take alfalfa supplements, and they should talk to their doctor before taking any herb that is used to strengthen the immune system, such as echinacea or gingko.

Homeopathy

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, includes your physical, emotional, and intellectual makeup. An experienced homeopath assesses all of these factors when determining the most appropriate remedy for a particular individual.

• Apis mellifica
• Arsenicum album
• Calcarea carbonica
• Causticum
• Rhus toxicodendron
• Ruta graveolens
• Thuja occidentalis

Acute dose is 3 to 5 pellets of 12X to 30C every 1 to 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. Ninety percent of people with lupus have a survival rate of 10 years, and 63 to 75% have a survival rate of 20 years. People with certain complications from lupus tend to have a poor prognosis.

Following 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.

Supporting Research

Amital H, Szekanecz Z, Szücs G, et al. Serum concentrations of 25-OH vitamin D in patients with systemic lupus erythematosus (SLE) are inversely related to disease activity: is it time to routinely supplement patients with SLE with vitamin D? Ann Rheum Dis. 2010 Jun;69(6):1155-7. (Epub ahead of print)

Bast A, Haenen GR. Lipoic acid: a multifunctional antioxidant. Biofactors. 2003;17(1-4):207-13.

Chang DM, Lan JL, Lin HY, Luo SF. Dehydroepiandrosterone treatment of women with mild-to-moderate systemic lupus erythematosus: a multicenter randomized, double-blind, placebo-controlled trial. Arthritis Rheum. 2002 Nov;46(11):2924-7.

Costenbader KH, Kang JH, Karlson EW. Antioxidant Intake and Risks of Rheumatoid Arthritis and Systemic Lupus Erythematosus in Women. Am J Epidemiol. 2010 Jun 9. [Epub ahead of print]

Dryden GW Jr, Deaciuc I, Arteel G, McClain CJ. Clinical implications of oxidative stress and antioxidant therapy. Curr Gastroenterol Rep. 2005;7(4):308-16.

El-Badri NS, Hakki A, Ferrari A, Shamekh R, Good RA. Autoimmune disease: is it a disorder of the microenvironment? Immunol Res. 2008;41(1):79-86.

Ferri: Ferri's Clinical Advisor 2015. 1st ed. Philadelphia, PA: Elsevier Mosby; 2014.

Greco CM, Nakajima C, Manzi S. Updated review of complementary and alternative medicine treatments for systemic lupus erythematosus. Curr Rheumatol Rep. 2013;15(11):378.

Gurevitz SL, Snyder JA, Wessel EK, Frey J, Williamson BA. Systemic lupus erythematosus: a review of the disease and treatment options. Consult Pharm. 2013;28(2):110-21.

Hartkamp A, Geenen R, Godaert GL, Bijl M, Bijlsma JW, Derksen RH. Effects of dehydroepiandrosterone on fatigue and well-being in women with quiescent systemic lupus erythematosus: a randomised controlled trial. Ann Rheum Dis. 2010 Jun;69(6):1144-7. (Epub ahead of print)

Kamen D, Strange C. Pulmonary Manifestations of Systemic Lupus Erythematosus. Clinics in Chest Medicine. Philadelphia, PA: Elsevier Saunders; 2010:31(3).

Nordmark G, Bengtsson C, Larsson A, Karlsson FA, Sturfelt G, Rönnblom L. Effects of dehydroepiandrosterone supplement on health-related quality of life in glucocorticoid treated female patients with systemic lupus erythematosus. Autoimmunity. 2005 Nov;38(7):531-40.

Perl A. Oxidative stress in the pathology and treatment of systemic lupus erythematosus. Nat Rev Rheumatol. 2013;9(11):674-86.

Simopoulos AP. Omega-3 fatty acids in inflammation and autoimmune diseases. J Am Coll Nutr. 2002;21(6):495-505.

Tao X, Fan F, Hoffmann V, Gao CY, Longo NS, Zerfas P, Lipsky PE. Effective therapy for nephritis in (NZB x NZW)F(1) mice with triptolide and tripdiolide, the principal active components of the Chinese herbal remedy Tripterygium wilfordii Hook F. Arthritis Rheum. 2008 Jun;58(6):1774-83.

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Wright SA, O'Prey FM, McHenry MT, Leahey WJ, Devine AB, Duffy EM, et al. A randomised interventional trial of omega-3-polyunsaturated fatty acids on endothelial function and disease activity in systemic lupus erythematosus. Ann Rheum Dis. 2008 Jun;67(6):841-8.

Zhao XZ. Effects of Astragalus membranaceus and Tripterygium hypoglancum on natural killer cell activity of peripheral blood mononuclear cells in systemic lupus erythematous. Zhongguo Zhong Xi Yi Jie He Za Zhi. 1992 Nov;12(11):669-71, 645.

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Review Date: 1/5/2015  

Reviewed By: Steven D. Ehrlich, NMD, Solutions Acupuncture, a private practice specializing in complementary and alternative medicine, Phoenix, AZ. Review provided by VeriMed Healthcare Network.

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