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Systemic Lupus
Erythematosus (SLE) Elizabeth Boldon RN, MSN
Liz Boldon is a Nurse Education Specialist at Mayo Clinic in Rochester, Minnesota. She received a BSN from Allen College in Waterloo, Iowa in 2002 and an MSN with a focus in education from the University of Phoenix in 2008. She has bedside nursing experience in medical neurology and the neuroscience ICU.
Abstract:
Systemic Lupus Erythematosus (SLE) is a chronic inflammatory autoimmune disease of unknown cause that affects multiple organ systems. Lupus is associated with significant mortality and morbidity. There is currently no cure for lupus and treatments vary widely.
This course will discuss the symptoms, causes, risk factors and complications related to lupus as well as its diagnosis, common tests and treatments both traditional and complimentary. This course will also address the important aspect of coping and support of those who are dealing with lupus.
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Continuing Nursing Education Course Director & Planners William A. Cook, PhD, Director, Douglas Lawrence, MS, Course Planner Webmaster
Susan DePasquale, CGRN, MSN, FPMHNP-BC, Lead Nurse Planner
Accreditation Statement This activity has been planned and implemented in accordance with the policies of NurseCe4Less.com and the continuing nursing education requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses.
Credit Designation
This educational activity is credited for 3 hours. Nurses may only claim credit commensurate with the credit awarded for completion of this course activity.
Course Author & Planner Disclosure Policy Statements
It is the policy of NurseCe4Less.com to ensure objectivity, transparency, and best practice in clinical education for all CNE educational activities. All authors and course planners participating in the planning or implementation of a CNE activity are expected to disclose to course participants any relevant conflict of interest that may arise.
Statement of Need Systemic Lupus Erythematosus affects individuals differently and nurses will care for individuals that present with varying symptoms. Although there is no cure for SLE, there are effective treatments for it. Nurses need to have a good understanding of the disease to provide individuals diagnosed with SLE safe and appropriate care and to educate them about how to maintain qualify of life and wellness.
Course Purpose This course will increase learners’ knowledge and skills related to Systemic Lupus Erythematosus.
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Learning Objectives
Describe the symptoms of lupus. List some of the tests & procedures used to diagnose lupus. Discuss medications and guiding principles used in treating lupus. Explain what a flare is and its significance. Identify resources for further support and information related to lupus.
Target Audience Advanced Practice Registered Nurses, Registered Nurses, Licensed Practical Nurses, and Associates
Course Author & Director Disclosures Elizabeth Boldon, RN, MSN, William S. Cook, PhD, Douglas Lawrence, MS,
Susan DePasquale, CGRN, MSN, FPMHNP-BC – all have no disclosures
Acknowledgement of Commercial Support:
There is no commercial support for this course.
Activity Review Information:
Reviewed by Susan DePasquale, CGRN, MSN, FPMHNP-BC
Release Date: 1/1/2015 Termination Date: 8/1/2016
Please take time to complete the self-assessment Knowledge Questions before reading the article. Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course.
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1. Skin problems that are common features of lupus include: a. rashes b. oral ulcers c. alopecia d. all of the above
2. An SLE flare is diagnosed based on: a. increased signs and symptoms interfering with the patient’s quality of life b. laboratory indicators c. imaging studies d. all of the above
3. Risk factors for SLE include:
a. one’s gender – is more common in men b. age – generally diagnosed between ages of 15 and 40 c. racial origin – is most common in Caucasions d. geographic location – is most common in European countries
4. True or False. There is no risk to pregnancy during active disease.
a. True
b. False
5. True or False. Quality of life (QOL) is generally compromised in the lupus patient, due to everyday symptoms and the problems of flares, depression, treatment, frequent hospital visits and restrictions on many aspects of life such as travel and pregnancy.
a. True b. False
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INTRODUCTION
Systemic lupus erythematosus (SLE) is a chronic inflammatory autoimmune disease of unknown cause that affects multiple organ systems. SLE, also simply referred to as
Lupus, is associated with significant mortality and morbidity. There is currently no cure for lupus and treatments vary widely. This course will discuss the symptoms, causes, risk factors and complications related to lupus as well as its diagnosis, common tests and treatments both traditional and complimentary. This course will also address the important aspect of coping and support of those who are dealing with lupus.
Lupus is prevalent worldwide but the proportion of patients with lupus varies between different ethnic groups. Lupus affects approximately 40 of every 100,000 northern
Europeans, more than 200 out of every 100,000 black African and black Caribbean people and about 100 of every 100,000 Asian people. Lupus mostly affects women of childbearing age (15-50 years.) The ratio of females to males with lupus is 9:1.
(Ferenkeh-Koroma, 2012.) The Lupus Foundation of America estimates that 1.5 million
Americans have some form of lupus and that 90% of those diagnosed are women
(Mendelson, C., 2009.)
The following is a quote from a lupus patient that helps illustrates the complexity of this disease:
“So I was on this low-level of not quite feeling right, but not sure what was wrong
with me type of feeling for quite a long time. I had some other weird ‘medical
oddities’ show up – swollen lymph nodes under my arm pit, low grade fever,
chest pain. Horrible hip pain that required the use of a cane – nothing was really
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checked out, just more drugs prescribed to ease the symptoms.” (Mendelson, C.,
2008.)
No two cases of lupus are exactly alike. Signs and symptoms may come on suddenly or develop slowly, may be mild or severe, and may be temporary or permanent. Most people with lupus have mild disease characterized by episodes, or flares, when signs and symptoms worsen for a while, then improve or even disappear completely for a time. Some individuals may have multiple-organ involvement, while others only have one system of the body involved, for example the skin. Lupus is often called the great imitator because signs and symptoms may be vague and nonspecific and mimic other disorders such as:
Fibromyalgia
Sjögren syndrome
Hematologic problems
Drug-induced lupus
This quote from a lupus patient illustrates the way the disease is not always recognized immediately:
“After a while, I would just keep going even though I felt so horrible because my
family doctor kept asking me if I was depressed. When I starting having
abdominal pain, difficulty swallowing, and nausea, he said it was stress induced.
He told me the same thing when my hair began to thin… The doctor just kept
trying to push anti-depressants and I kept refusing even though I was beginning
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to think that maybe I could use some. So I stayed away from the doctor for quite
some time.” (Mendelson, C., 2008.)
The signs and symptoms of lupus that one may experience will depend on which body systems are affected by the disease. The next section of this course will describe some of the common symptoms of lupus by system.
SYSTEMIC SIGNS AND SYMPTOMS
Dermatologic
Skin problems including photosensitivity, rashes, oral ulcers, and alopecia are a common feature of lupus. Besides the characteristic butterfly-shaped facial rash (see picture below), patients may develop flat or raised rashes or lesions everywhere on the body. A definitive diagnosis requires a biopsy. Although skin problems may not be life threatening, they can be uncomfortable or painful and decrease the patient’s quality of life due to disfigurement and altered body image. Skin conditions may occur alone or accompany a more serious inflammatory response that affects vital organs.
webmd.com
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Musculoskeletal
Most patients with lupus have nonerosive arthritis, including joint tenderness, edema, and effusions that are symmetric and usually nondeforming. The nondeforming arthritis of lupus differentiates it from rheumatoid arthritis, which causes progressive joint destruction. The arthritis of lupus frequently involves the joints of the hands as well as the wrists and knees. Joint symptoms occur in over 90% of lupus patients at some time during the illness and are often seen as the earliest manifestation. Arthritis, with inflammation, occurs in 65 to 70% of patients and tends to migratory and symmetrical
(Schur, P. & Gladman, D., 2013.)
Neurologic
Patients with lupus may be depressed because of cerebral vasculitis or because they are trying to cope with the stress of a chronic illness. In some patients, central nervous system involvement causes strokes, seizures, cognitive impairment, headaches, visual disturbance, or psychosis. Other less common problems are movement disorders, cranial neuropathies, myelitis, and meningitis (Schur, P. & Gladman, D., 2013.)
Gastrointestinal (GI)
Patients with lupus may have abdominal discomfort or pain, diarrhea, anorexia, or nausea. Vasculitis of the intestine can cause acute abdominal pain with cramps, vomiting, and diarrhea. These problems may result from pancreatitis, vasculitis, and bowel infarction secondary to lupus vasculitis. Other potential neurologic symptoms include cognitive defects, organic brain syndromes, delirium, psychosis, seizures, headache, and/or peripheral neuropathies.
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Hematologic
Autoantibodies may be produced against cell surface antigens of blood cells, including red blood cells, and platelets. This results in hemolytic anemia, leukopenia, or thrombocytopenia.
Renal
About 50% of patients with lupus have renal involvement such as glomerulonephritis, usually from deposition of immune complexes and resultant inflammation and tissue damage. Most of the remaining 50% of lupus patients have subclinical disease that can be demonstrated if renal biopsy is performed. Renal involvement usually develops in the first few years of illness and should be detected early by periodic urinalysis, and lab tests (Schur, P. & Gladman, D., 2013.)
Cardiopulmonary
Pericarditis and pleuritis, the most common cardiopulmonary disorders in lupus occur when immune complexes are deposited in the pericardial and pleural spaces producing an inflammatory response. Other potential pulmonary symptoms include pleurisy, pleural effusions, pneumonitis, lung disease, pulmonary hypertension, and alveolar hemorrhage (Schur, P. & Gladman, D., 2013.)
Other Common Symptoms:
Other common symptoms of lupus include fatigue, myalgia, weight changes and fever.
Fatigue is the most common complaint and is occasionally the most debilitating. It occurs in 80 to 100% of patients, and its presence is not clearly correlated with other
nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 10 measures of disease activity. Fatigue is strongly associated with diminished exercise tolerance. Fatigue, however, may not be related to active lupus, but to one or more of the following: increased work load, depression, unhealthful habits, stress, anemia, hypothyroidism, use of certain medications, any inflammatory and/or infectious disease, coexistent fibromyalgia, sleep disturbances, deconditioning, or a perception of poor social support. Fatigue due to lupus may respond to glucocorticoids, antimalarials, and, in some studies, to exercise and psychosocial interventions.
Weight changes are frequent in patients with lupus and may be related to the disease or its treatment. Weight loss often occurs prior to the diagnosis of lupus. Unintentional weight loss may be due to decreased appetite, to the side effects of medications, and to gastrointestinal disease. Weight gain in lupus is usually due to one of two factors: salt and water retention associated with hypoalbuminemia or increased appetite associated with the use of glucocorticoids.
Fever that is thought to be due to active disease is seen in over half of lupus patients.
Fever may also represent infection or a drug reaction.
Because of the complexity and variety of symptoms, patients with lupus often find it takes time to receive a proper diagnosis. Interviews conducted with 147 SLE patients revealed that on average, patients spend two to four years and see three physicians before the disease is correctly diagnosed (Manzi, S., 2009.)
Patients with lupus can be classified into three basic categories, as below:
Quiescent
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Lead a normal life
May only present with a rash and/or fatigue
Treatment may NSAIDs and topical applications
Stable with occasional flare
May present with rash and/or chest pain
Occasionally calls the nurse advice line
Treatment may include intravenous or oral corticosteroids
Serious
Presents with kidney, hematological and/or brain involvement
Treatment may include continuous corticosteroids and immunosuppressive drugs
Most patients with lupus can expect to live a normal lifespan with appropriate treatment and lifestyle changes, but exacerbations or flares can be life-threatening (Ferenkeh-
Koroma, 2012.)
Lupus Flares
Lupus flares are exacerbation of disease. A flare is diagnosed based on an increase in signs and symptoms that interfere with the patient’s quality of life, lab indicators, and imaging studies. Sometimes, however, a flare may be underway when the lab and imaging studies are normal. At other times, the patient may not have an increase in symptoms, but their lab values may indicate increased inflammation.
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Flares are common and can be triggered by many factors: too much work or not enough rest, stress an emotional crisis, an infection, an injury, surgery, pregnancy, the postpartum period, ultraviolet light exposure, or sudden discontinuation of lupus medications.
Signs of a flare include increasing fatigue, pain, headache, fever, general ill feeling, and onset of new rash. Even a low-grade fever or new rash can signal that a flare is under way. Patients with lupus should pay close attention to any signs or symptoms, however subtle, as they may indicate an increase in disease activity. A lupus flare can affect different organs and may cause serious damage if left untreated. Flares may occur several times a year and last days or weeks. During a flare, patients may need to use analgesics for pain syndromes associated with the joints, skin, or other areas of the body. For mild to moderate pain, an NSAID, such as ibuprofen, or tramadol (Ultram) are often effective. If the flare causes more intense pain, a more potent opioid analgesic such as hydrocodone, oxycodone, or fentanyl may be necessary (Pullen, R., Brewer, S.
& Ballard, A., 2009.)
Patients with lupus should follow these guidelines (Pullen, R., 2008) to minimize flares and reduce negative outcomes from flares:
Recognize the symptoms of a flare
Protect themselves from light exposure
Prevent and recognize infection
Take medications as prescribed
Be aware of pregnancy risks
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Avoid undue emotional and physical stress and get sufficient rest
Don’t smoke and limit alcohol intake
Chose a healthy and balanced diet
Ask questions of healthcare providers if things are not understood
Be aware of available support groups for patients and families
SLE CAUSES AND RISK FACTORS
Lupus is an autoimmune disease. The immune system is designed to protect the body.
In patients with lupus, the immune system malfunctions and attacks the healthy cells of the body. The exact cause of lupus, the resulting autoimmune inflammatory response and the risks of inheriting the disease are not clear. It is likely that lupus results from a combination of genetics and environment. It appears that people with an inherited predisposition for lupus may develop the disease when they come into contact with something in the environment that can trigger lupus. The cause for lupus in most cases, however, is unknown. Some potential triggers include the following:
Sunlight
Exposure to the sun may bring on lupus skin lesions or trigger an internal response in susceptible people. A helpful education tool for health professionals to share with patients is the Lupus Foundation of America (2013) website, which informs on exposure to ultraviolet rays and reactions that can take many forms; available at http://www.lupus.org/webmodules/webarticlesnet/templates/new_newsroom.aspx?articl eid=3940&zoneid=8.
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Medications
Certain types of anti-seizure medications, blood pressure medications and antibiotics can trigger Lupus. People who have drug-induced lupus usually see their symptoms go away when they stop taking the medication. Approximately 15,000 cases of drug- induced lupus are reported each year (Ferenkeh-Koroma, 2012.)
Stress Stress has been implicated in causing flares, particularly of mild disease.
Unfortunately, stress as an entity has never been clinically defined, except as it relates to its psychosomatic effects (Schur & Gladman, 2013.)
Occupational exposure to toxins / pesticides
These environmental contributors are difficult to isolate, but researchers have established links between lupus and a variety of toxins, such as cigarette smoke, silica, and mercury (Schur & Gladman, 2013.)
Trauma
Tissue damage associated with a severe injury can result in profound inflammatory responses that may trigger autoimmune development in lupus-prone individuals (Anam,
Amare, Naik, Szabo & Davis, 2009.)
Illness or Infection Infectious disease agents such as the Epstein-Barr Virus
(EBV, which causes mononucleosis or “mono”), herpes zoster virus (the virus
that causes shingles), and cytomegalovirus have also been implicated in
exacerbating SLE (Schur & Gladman, 2013.)
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Surgery
Surgery is another insult that can increase lupus activity. The mechanism is unclear
but may be related to the release of nuclear and other antigens into the bloodstream,
in which they bind to circulating antinuclear antibodies to form immune complexes
(Schur and Gladman, 2013.)
Pregnancy
Pregnancy can cause an exacerbation or can even trigger the first symptoms of lupus; a relapse is more likely to develop in the immediate postpartum period. The hormonal adjuvants that are used during ovulation induction and during ovarian stimulation in preparation for in vitro fertilization may also cause exacerbations of SLE. Therapeutic abortions can also induce a relapse, perhaps via mechanisms related to pregnancy or to the surgery itself (Schur and Gladman, 2013.)
Risk Factors
Risk factors of lupus include the following:
Gender-specific - lupus is more common in women.
Age Specific - although lupus affects people of all ages, it's most often
diagnosed between the ages of 15 and 40.
Race - lupus is more common in African Americans, Hispanics and Asians.
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COMPLICATIONS OF SLE
Inflammation caused by lupus can affect many areas of the body; these areas can include the following systems:
Kidneys
Lupus can cause serious kidney damage, and kidney failure is one of the leading causes of death among people with lupus. Signs and symptoms of kidney problems may include generalized itching, chest pain, nausea, vomiting and leg swelling (edema).
Brain
If the brain is affected by lupus, one may experience headaches, dizziness, behavior changes, hallucinations, and even strokes or seizures. Many people with lupus experience memory problems and may have difficulty expressing their thoughts.
Blood and blood vessels
Lupus may lead to blood problems, including anemia and increased risk of bleeding or blood clotting. It can also cause vasculitis.
Lungs
Having lupus increases the chances of developing pleurisy, which can make breathing painful.
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Heart
Lupus can cause inflammation of the heart muscle, the arteries or heart membrane
(pericarditis). The risk of cardiovascular disease and heart attacks increases greatly as well.
Other types of complications
Having lupus also increase the risk of the following comorbid conditions:
Infection
Individuals with lupus are more vulnerable to infection because both the disease
and its treatments weaken the immune system. Infections that most commonly
affect people with lupus include urinary tract infections, respiratory infections,
yeast infections, salmonella, herpes and shingles.
Cancer
Having lupus appears to increase the risk of cancer.
Bone tissue death (avascular necrosis)
This occurs when the blood supply to a bone diminishes, often leading to tiny
breaks in the bone and eventually to the bone's collapse. The hip joint is most
commonly affected.
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Pregnancy complications
Women with lupus have an increased risk of miscarriage. Lupus increases the
risk of high blood pressure during pregnancy (preeclampsia) and preterm birth.
To reduce the risk of these complications, doctors recommend delaying
pregnancy until the disease has been under control for at least six months.
TESTS AND DIAGNOSIS
Diagnosing lupus is difficult because signs and symptoms vary considerably from person to person. Signs and symptoms of lupus may vary over time and overlap with those of many other disorders. No one test can diagnose lupus. The combination of blood and urine tests, signs and symptoms, and physical examination findings leads to the diagnosis. Best practice for the testing patients to rule in or out SLE will vary depending on the constellation of symptoms for each patient. Providers should be knowledgeable of the signs and symptoms of SLE and consider it in the differential diagnosis for patients as appropriate. As discussed above, patients often have delays in receiving an appropriate diagnosis of SLE, however, a timely diagnosis and initiation of treatment is in the best interest of all patients.
Laboratory tests
Blood and urine tests may include:
Complete Blood Count (CBC)
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This test measures the number of red blood cells, white blood cells and platelets
as well as the amount of hemoglobin, a protein in red blood cells. Results may
indicate anemia, which commonly occurs in lupus. A low white blood cell or
platelet count may occur in lupus as well. (Schur & Wallace, 2013.)
Erythrocyte Sedimentation Rate (ESR)
This blood test determines the rate at which red blood cells settle to the bottom of
a tube with one hour. A faster than normal rate may indicate a systemic disease,
such as lupus. The sedimentation rate isn't specific for any one disease. It may
be elevated if one has lupus, another inflammatory condition, cancer or an
infection (Schur & Wallace, 2013.)
C-reactive protein (CRP). A protein that is elevated when inflammation is found
in the body. Although ESR and CRP reflect similar degrees of inflammation,
sometimes one will be elevated when the other is not. This test may be repeated
to test response to medications (Schur & Wallace, 2013).
Kidney and Liver Assessment
Blood tests can assess how well the kidneys and liver function. Lupus can affect
these organs.
Urinalysis (UA)
Because the body’s waste is processed by the kidneys, testing a sample of urine
can reveal any problems with the way the kidneys are functioning. Lupus can
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attack the kidneys without any warning signs, so these tests can be very
important. The most common urine tests look for cell casts (bits of cells that
normally would be removed when the blood is filtered through your kidneys), and
proteinuria (protein being spilled into the body because the kidneys are not
filtering the waste properly). An examination of a sample of urine may also show
an increased protein level or red blood cells in the urine, which may occur if lupus
has affected the kidneys.
24-Hour Urine Collection
This test is done for calculation of creatinine clearance and for quantitation of
proteinuria or protein/creatinine ratios.
Antinuclear Antibody (ANA) Test
A positive test for the presence of these antibodies — produced by the immune
system — indicates a stimulated immune system. While most people with lupus
have a positive ANA test, most people with a positive ANA do not have lupus. If
one tests positive for ANA, a provider may advise more-specific antibody testing.
Antinuclear antibodies (ANA) are antibodies that connect, or bind, to the nucleus
-- the "command center" -- of the cell. This process damages, and can destroy,
the cells. The ANA blood test is a sensitive test for lupus, since these antibodies
are found in 97 percent of people with the disease. When three or more typical
features of lupus are present -- such as involvement of the skin, joints, kidneys,
lungs, heart, blood, or nervous system -- a positive ANA test will confirm a
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diagnosis of lupus. However, a positive ANA test result does not always mean
one has lupus. The ANA can be positive in people with other illnesses, or positive
in people with no illness. The ANA can also change from positive to negative, or
negative to positive, in the same person. Still, lupus is usually the diagnosis when
these antinuclear antibodies are found in the blood (Schur & Wallace, 2013.)
Comprehensive Metabolic Panel (CMP)
A comprehensive metabolic panel is a blood test that measures one’s sugar
(glucose) level, electrolyte and fluid balance, kidney function, and liver function.
This panel measures the blood levels of sodium, potassium, calcium, chloride,
carbon dioxide, glucose, blood urea nitrogen, creatinine, protein, albumin,
bilirubin, and liver enzymes. This test may be used to monitor the effects of
medications, or to monitor the effects and potential complications of SLE itself
(Schur & Gladman, 2013.)
Imaging tests
If a provider suspects that lupus is affecting the lungs or heart, he or she may suggest:
X-ray
An x-ray of involved body areas affected may be ordered, such as joints and
especially a chest x-ray. The test ordered would depend on the body part being
affected. An image of the chest may reveal abnormal shadows that suggest fluid
or inflammation in the lungs.
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Echocardiogram
The electrocardiogram uses sound waves to produce real-time images of the
beating heart. It can check for problems with the valves and other portions of the
heart.
Renal Ultrasonography
Ultrasonography is used to assess kidney size and to rule out urinary tract
obstruction when there is evidence of renal impairment.
Computed Tomography (CT)
The CT is indicated for abdominal pain, suspected pancreatitis, interstitial lung
disease.
Magnetic Resonance Imaging (MRI)
MRI may be ordered to rule out focal neurologic deficits or cognitive dysfunction.
Contrast angiography
This may be helpful if vasculitis affecting medium sized arteries is suspected.
Biopsy
Lupus can harm the kidneys in many different ways and treatments can vary, depending on the type of damage that occurs. In some cases, it's necessary to test a small sample
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The American College of Rheumatology (ACR) has produced a set of 11 classification criteria used in the diagnosis of lupus (see Table 1). Typically, the ACR classification criteria are used for research purposes. Individuals fulfilling any of the 11 criteria can be included in lupus studies. Individuals fulfilling two or three of the criteria, especially immunological, antinuclear antibody and hematological blood tests, may develop lupus, but do not yet fulfill sufficient criteria to make a formal diagnosis of the disease. To be diagnosed with lupus, a patient must present with four or more of the ACR classification criteria. Because of the complexity of the disease and its symptoms, diagnosing lupus can be a challenge to even the most experienced clinician. The average time between initial presentation and definitive diagnosis is between two and four years (Weinstein,
P., 2012) and patients see an average of three physicians during that time.
Table 1 – Classification Criteria used in the Diagnosis of SLE
1. Malar rash – a rash over the cheeks and nose, often in the shape of a butterfly 2. Discoid rash – a rash that appears as red, raised, disk-shaped patches 3. Photosensitivity – a reaction to sun or light that causes a skin rash to appear or get worse 4. Oral ulcers – sores appearing in the mouth 5. Arthritis – joint pain and swelling of two or more joints in which the bones around the joints do not become destroyed 6. Serositis – inflammation of the lining around the lungs (pleuritis) or inflammation of the lining around the heart that causes chest pain which is worse with deep breathing (pericarditis) 7. Kidney disorder – persistent protein or cellular casts in the urine 8. Neurological disorder – seizures or psychosis 9. Blood disorder – anemia (low red blood cell count), leukopenia (low white blood cell count), lymphopenia (low level of specific white blood cells), or thrombocytopenia (low platelet count) 10. Immunologic disorder T– REATMENTabnormal anti-double AND- strandedMEDICATIONS DNA or anti -Sm, positive antiphospholipid antibodies 11. Abnormal antinuclear antibody (ANA)
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Morbidity and mortality associated with lupus is significant with a fourfold increased risk of death reported in patients with lupus compared with the general population. In 1955, the reported survival rate of lupus was around 50% at 5 years; and, more recently, survival was 80% at 15 years. Survival has improved significantly over the past 50 years with 93% of patient with lupus surviving for 5 years and 92% surviving for more than 10 years. These improved survival rates may be related to advanced medical therapy in general (notably renal transplantation and the use of immunosuppressive drugs) along with a better understanding of the pathogenesis of the disease and early diagnosis
(Ferenkeh-Koroma, 2012.)
Despite improved life expectancy of lupus patients during the past few decades, available evidence suggests that the quality of this extended life remains poor compared with that of the general population and worse than that of individuals with some other chronic diseases (Toloza, S., Sequeira, W. & Jolly, M., 2011.)
Early on, patients tend to die of active disease (manifestations of vasculitis, pulmonary hemorrhage, kidney problems) or infection. Over time, cardiovascular disease and osteoporosis become more of a problem. Patients also have a higher risk of cancer throughout life. Lupus has an unpredictable course, with flares and remissions. But underlying the reversible inflammatory changes is irreversible organ damage caused by the disease itself and, possible, by treatment. Preventing bone disease, heart disease, and cancer now play more prominent roles in managing lupus (Manzi, S., 2009.)
Treatment of lupus aims to reduce the over-activity of the immune system to reduce the associated inflammation, and to control symptoms. Immunosuppression may be
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An individual’s treatment for lupus depends on their signs and symptoms. Determining whether the signs and symptoms should be treated and what medications to use requires a careful discussion of the benefits and risks with a care provider. There are some general guidelines all patients with lupus should follow, as specified below (Schur,
P. & Wallace, D., 2013):
Lifestyle and Prevention
Sun protection
Individuals with lupus should avoid exposure to direct or reflected sunlight and
other sources of ultraviolet (UV) light (e.g. fluorescent and halogen lights.) They
should use sunscreens, preferably those products that block both UV-A and UV-
B, with a high skin protection factor (SPF). A sunscreen with an SPF of 55 or
greater is recommended.
Diet and nutrition
A balanced diet is recommended, consisting of carbohydrates, proteins, and fats.
Exercise
Inactivity produced by acute illness causes a rapid loss of muscle mass, bone
demineralization, and loss of stamina resulting in a sense of fatigue. This can
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usually be treated with isometric and graded exercise. In selected refractory
cases, relief can be obtained with antimalarial drugs.
Smoking Cessation
Cigarette smoking may increase the risk of developing lupus and smokers in
general have more active disease. Patients should be counseled not to smoke or
to quit smoking and should be provided with help to do so.
Immunizations
Patients with lupus should receive appropriate immunizations prior to the
institution of immunosuppressive therapies.
Avoidance of specific medications
Some data suggest that sulfonamide-containing antibiotics may cause
exacerbations and should, therefore, be avoided.
Pregnancy and contraception
Pregnancy should be avoided during active disease (especially with significant organ impairment) due to the high risk of miscarriage and exacerbation of lupus. Women with lupus should be counseled not to become pregnant until the disease has been quiescent for at least six months. Thus, contraception and family planning are particularly important for women with SLE. Maternal health and fetal development should be monitored frequently during pregnancy. If possible, delivery should occur in a controlled setting. In addition, many women with SLE should be followed by an obstetrician knowledgeable in high-risk pregnancies.
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Patients with SLE with one or more of the following features should be followed by an obstetrician experienced in management of high risk pregnancies:
. Prior history of poor obstetric outcomes
. Renal involvement
. Cardiac involvement
. Pulmonary hypertension
. Interstitial lung disease
. Evidence of active lupus
. High-dose glucocorticoid therapy
. Immunosuppressive therapy
. Antiphospholipid antibodies/syndrome
. Antibodies to Ro/La (predisposing to neonatal lupus)
. Multiple gestation
The following characteristics are associated with high maternal and fetal risk:
. Severe pulmonary hypertension (mean pressure >50 mmHg)
. Restrictive lung disease (forced vital capacity <1 liter)
. Heart failure
. Chronic renal failure (creatinine >2.8 mg/dL)
. Active renal disease
. History of severe preeclampsia or HELLP syndrome
. Stroke within the previous six months
. Severe lupus flare within the previous six months
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If any of the listed high risk factors for poor maternal/fetal outcomes are present, a decision to pursue pregnancy should be carefully considered and made with an awareness of the potentially serious consequences (Schur & Bermas, 2013.)
There are two issues related to therapy of women with lupus who become pregnant: monitoring of disease activity in both asymptomatic and symptomatic patients and treatment of active disease. Mothers should be assessed for disease activity at least once each trimester and more often if they have active lupus. Treatment of SLE during pregnancy is associated with some unique problems. Consideration must be given to the following issues:
. Medications used to treat SLE may cross the placenta and cause fetal harm.
Thus, the risks and benefits of treatment during pregnancy must be
repeatedly weighed against the risk of activity of SLE having a deleterious
effect on the mother and the fetus.
. Nephritis in pregnancy requires special consideration because of its potential
morbidity and possible confusion with preeclampsia (Schur & Bermas, 2013).
Pregnant women with SLE should be aware of the risks and signs and symptoms of complications some resources available to them; helpful resources include:
The Lupus Foundation of America - http://www.lupus.org/webmodules/webarticlesnet/templates/new_donate.aspx?a=314&z
=6&page=1
Web MD - http://lupus.webmd.com/guide/pregnancy-lupus
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Medication
As signs and symptoms flare and subside, medications or dosages may need to be altered. The medications most commonly used to control lupus include:
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Over-the-counter NSAIDs, such as naproxen (Aleve) and ibuprofen (Advil,
Motrin, others), may be used to treat pain, swelling and fever associated with
lupus. Stronger NSAIDs are available by prescription. Side effects of NSAIDs
include stomach bleeding, kidney problems and an increased risk of heart
problems.
Antimalarial drugs
Medications commonly used to treat malaria, such as hydroxychloroquine
(Plaquenil), also can help control lupus. Side effects can include stomach upset
and, very rarely, damage to the retina of the eye.
Corticosteroids
Prednisone and other types of corticosteroids can counter the inflammation of
lupus, but often produce long-term side effects — including weight gain, easy
bruising, osteoporosis, hypertension diabetes and increased risk of infection. The
risk of side effects increases with higher doses and longer-term therapy.
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Immune suppressants
Drugs that suppress the immune system may be helpful in serious cases of
lupus. Examples include cyclophosphamide (Cytoxan), azathioprine (Imuran,
Azasan), mycophenolate (Cellcept), leflunomide (Arava) and methotrexate
(Trexall). Potential side effects may include an increased risk of infection, liver
damage, decreased fertility and an increased risk of cancer. A newer medication,
belimumab (Benlysta) also reduces lupus symptoms in some people. Side effects
include nausea, diarrhea and fever.
Belimumab
In March of 2011, the FDA granted approval for this new targeted therapy for the
treatment of lupus. This was the first such medication to receive such a
designation in over 50 years (Lo, M. & Tsokos, G., 2011.)
Alternative and Complementary Medicine (CAM) Therapies
Those who suffer from lupus should take steps to care for their bodies. Simple preventative measures can help reduce the incidence of lupus flares and, should they occur, help the individual better cope with the signs and symptoms they experience.
These individuals should try to perform the following:
Adequate rest
People with lupus often experience persistent fatigue that's different from normal
tiredness and that isn't necessarily relieved by rest. For that reason, it can be
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hard to judge when one needs to slow down. Those with lupus should get plenty
of sleep at night and naps or breaks during the day as needed.
Be sun smart
Because ultraviolet light can trigger a flare, those with lupus should wear
protective clothing, such as a hat, long-sleeved shirt and long pants, and use
sunscreens with a sun protection factor (SPF) of at least 55 every time they go
outside.
Regular exercise
Exercise can help one recover from a flare, reduce the risk of heart attack, help
fight depression and promote general well being.
Avoid Smoking
Smoking increases the risk of cardiovascular disease and can worsen the effects
of lupus on the heart and blood vessels.
Eat a healthy diet
A healthy diet emphasizes fruits, vegetables and whole grains. Sometimes one
with lupus may have dietary restrictions, especially if they have hypertension,
kidney damage or gastrointestinal problems.
Additionally, there are CAM therapies that may benefit people with lupus. However, these therapies are usually used with conventional medications, as adjuncts or in
nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 32 combination. These treatments should be discussed with a provider before initiating them. The provider can help weigh the benefits and risks and advise if the treatments will interfere with current lupus medications.
It is important for clinicians to create a therapeutic relationship with patients, inform them of all treatment options, explain one’s own bias as a provider, and form an agreement to collaborate to avoid working at cross purposes to medical therapies.
Healthcare consumers are increasingly savvy and with all the resources available via technology, they are likely to discover and learn about CAM therapies on their own if not through a clinician. They may begin CAM therapies on their own due to their anxiety to feel better, and not readily disclose this information unless asked directly.
CAM treatments for lupus include the following:
Dehydroepiandrosterone (DHEA)
Supplements containing this hormone have been shown to reduce the dose of
steroids needed to stabilize symptoms in some people who have lupus.
Flaxseed
Flaxseed contains a fatty acid called alpha-linolenic acid, which may decrease
inflammation in the body. Some studies have found that flaxseed may improve
kidney function in people who have lupus that affects the kidneys. Side effects of
flaxseed include bloating and abdominal pain.
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Fish oil
Fish oil supplements contain omega-3 fatty acids that may be beneficial for
people with lupus. Preliminary studies have found some promise, though more
study is needed. Side effects of fish oil supplements can include nausea,
belching and a fishy taste in the mouth.
Vitamin D
There is some evidence to suggest that people with lupus may benefit from
supplemental vitamin D to manage osteoporosis secondary to lupus and
corticosteroid use.
B12 and folic acid
This can be effective in managing anemia.
St. John’s wort
This has mild serotonin-boosting properties, and may be used to fight fatigue and
depression.
COPING AND SUPPORT
Individuals with lupus are likely to have a range of painful feelings about their condition, from fear to extreme frustration. The challenges of living with lupus increase the risk of depression and related mental health problems, such as anxiety, stress and low self- esteem. Things that may help those with lupus and families cope include:
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Learn as much as possible about lupus
Write down questions about lupus and ask them at doctor appointments. Ask
doctors or nurses for reputable sources of further information. The more one
knows about lupus, the more confident they'll feel in their treatment choices.
Gather support among friends and family
Talk about lupus with friends and family and explain ways they can help out
during flares. Lupus can be frustrating for loved ones because they usually can't
see it and the person may not appear sick. They can't tell if the individual is
having a good day or a bad day unless they communicate that. Those with lupus
should be open about what they're feeling so that friends and family know what to
expect.
Take time out
Those with lupus can cope with stress in life by taking time for themselves. They
can use that time to read, meditate, listen to music or write in a journal. They
should find activities that calm and renew themselves.
Connect with others who have lupus
It may be helpful for those with lupus to talk to other people who have lupus.
They can connect with other people who have lupus through support groups in
the community or through online message boards. Other people with lupus can
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offer unique support because they're facing many of the same obstacles and
frustrations that the individual is facing.
A final quote that illustrates the frustration that can accompany the journey to diagnosis of lupus is as follows (Mendelson, C., 2008):
“I complained and complained about tiredness, swollen glands, fevers,
migraines, coldness. I was sick with pneumonia/pleurisy at least once a year. My
tendons swelled and weakened. Periods of illness grew longer. Doctor shopping,
always trying to find an answer – but mostly being diagnosed with Disaffected
Housewife Syndrome, may name for what male doctors see as a women’s
problem of complaining of being ick when he believed they really weren’t (often
on first sight).”
Quality of life (QOL) is generally compromised in the lupus patient, due to everyday symptoms and the problems of flares, depression, treatment, frequent hospital visits and restrictions on many aspects of life such as travel and pregnancy. The Quality of
Life Scale (QOLS), created originally by American psychologist John Flanagan in the
1970's, has been adapted for use in chronic illness groups. Although the definition of
QOL is still evolving, one researcher defines QOL as "a broad range of human experiences related to one's overall well-being. It implies value based on subjective functioning in comparison with personal expectations and is defined by subjective experiences, states and perceptions. Quality of life, by its very natures, is idiosyncratic to the individual, but intuitively meaningful and understandable to most people." This definition denotes a meaning for QOL that transcends health. Flanagan’s Quality of Life
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Scale (QOLS), befits this definition of QOL (Burckhardt & Anderson, 2003.) Table 2 shows this QOLS.
Table 2 – The Quality of Life Scale
The Quality of Life scale (QOL) in Table 2 involves asking the person with lupus to answer questions according to the following instructions:
Read each item and circle the number that best describes how satisfied you are
at this time.
Answer each item even if you do not currently participate in an activity or have a
relationship. You can be satisfied or dissatisfied with not doing the activity or
having the relationship.
The QOLS is scored by adding up the score on each item to yield a total score for the instrument. Scores can range from 16 to 112. The QOLS scores are summed so that a higher score indicates higher quality of life. Average total score for healthy populations is about 90.
For rheumatic disease groups, the average score ranges are 83 for rheumatoid arthritis,
84 for systemic lupus erythematosus, 87 for osteoarthritis, and 92 for young adults with juvenile rheumatoid arthritis (Burckhardt & Anderson, 2003.)
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Living with lupus can have a profound effect on a person’s mental and emotional well- being. Patients are likely to experience mental and physical problems such as difficulty concentrating or sleeping. Emotions such as grief, fear, anxiety, and depression are also common. The feelings associated with lupus can have multiple causes, including:
Outward effects of the disease or its treatment
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Work and activity limitations
Pain, fatigue and other physical symptoms
Social isolation
Uncertainty about the future
Difficulty with family relationships
Sometimes the mental and emotional effects of lupus can be related to the disease process itself or medications used to treat it. Common problems that may be associated with the disease include:
Cognitive dysfunction
Depression and anxiety
Mood swings and personality changes
If patients are experiencing any of these problems, it’s important to discuss them with a healthcare provider, who can help to find solutions. This may include a change in medication to control the lupus, or the provider may add medications to treat problems like anxiety and depression. Other options may include a referral to a mental health professional, who will be able to help identify additional ways to cope with lupus (Schur
& Wallace, 2013.)
Lupus is not a well-known disease to the general public; sufferers may find it difficult to explain their limitations to friends and colleagues. Family life can suffer too, particularly as this disease often strikes women who are mothers of young children. Chronic sleep disturbance affected 72% of lupus outpatients in one study (Wheeler, T., 2010), which also showed severe anxiety and depression in about 25% of this cohort. The sleep
nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 39 disturbance contributes to, but is by no means the only factor in, the chronic debilitating fatigue that is a major feature of the disease for so many; varying estimates put the incidence between 50 and 100% of sufferers (Wheeler, T., 2010.) This is why having support from family, friends and support groups is so important for those who suffer from lupus. Some of those support groups and reputable sources of information include:
The Lupus Foundation of America - www.lupus.org
Lupus Research Institute – www.lupusresearchinstitute.org
Dorough Lupus Foundation – www.doroughlupusfoundation.org
S.L.E. Lupus Foundation – www.lupusny.org
Lupus Alliance of America – www.lupusalliance.org
Lupus International - www.lupusinternational.com
Molly’s Fund – www.mollysfund.org
WebMD - http://lupus.webmd.com/default.htm
MayoClinic.com - http://www.mayoclinic.com/health/lupus/DS00115
Medline Plus - http://www.nlm.nih.gov/medlineplus/lupus.html
There are numerous other helpful websites related to lupus for health providers and individuals affected by lupus; these may be found at http://cure4lupus.org .
SUMMARY
Systemic lupus is an incurable and potentially debilitating disease that carries with it the risk of serious multi-organ complications and early death. Understanding the basics of the this disease and related treatments not only helps healthcare workers to interact
nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 40 with these patients more sensitively and competently, but also brings educational benefits since this is a multi-system disease that involves grappling with the complexities of the immune system. This course has discussed the symptoms, causes, risk factors and complications related to lupus as well as its diagnosis, common tests and treatments both traditional and complimentary. This course also addressed the important aspect of coping and support of those who are dealing with lupus, offering additional resources for those who are interested.
Please take time to help the NURSECE4LESS.COM course planners evaluate nursing knowledge needs met following completion of this course by completing the self- assessment Knowledge Questions after reading the article. Correct Answers, page 42.
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1. Skin problems that are common features of lupus include: a. rashes b. oral ulcers c. alopecia d. all of the above
2. An SLE flare is diagnosed based on: a. increased signs and symptoms interfering with the patient’s quality of life b. laboratory indicators c. imaging studies d. all of the above
3. Risk factors for SLE include:
a. one’s gender – is more common in men b. age – generally diagnosed between ages of 15 and 40 c. racial origin – is most common in Caucasians d. geographic location – is most common in European countries
4. True or False. There is no risk to pregnancy during active disease.
a. True
b. False
5. True or False. Quality of life (QOL) is generally compromised in the lupus patient, due to everyday symptoms and the problems of flares, depression, treatment, frequent hospital visits and restrictions on many aspects of life such as travel and pregnancy.
a. True b. False
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Correct Answers:
1. d
2. d
3. b
4. b
5. a
Footnotes:
1. Anam, K., Amare, M, Naik, S, Szabo, K.A. & Davis, T.A. (2009.) Severe tissue trauma triggers the autoimmune state systemic lupus erythematosus in the MRL/++ lupus-prone mouse. Lupus, April 18(4), 318-331. 2. Burckhardt, C.S. & Anderson, L.A. (2003.) The Quality of Life Scale (QOLS): Reliability, Validity, and Utilization. Health and Quality of Life Outcomes, 1(60), 1-7. 3. Dall’Era, M. & Chakravarty, E.F. (2011.) Treatment of Mild, Moderate, and Severe Lupus Erythematosus: Focus on New Therapies. Current Rheumatology Reports, 13, 308-316. 4. Ferenkeh-Koroma A. (2012.) Systemic lupus erythematosus: nurse and patient education. Nursing Standard, 26 (39), 49-57. 5. Lo, M.S. & Tsokos, G.C. (2012.) Treatment of systemic lupus erythematosus: new advances in targeted therapy. Annals of the New York Academy of Sciences, The Year in Immunology, 1247, 138-152. 6. Mayo Clinic Staff. (October 26, 2011.) Lupus. Retrieved April 14, 2013, from http://www.mayoclinic.com/health/lupus/DS00115 7. Manzi S. (2009.) Lupus update: Perspective and clinical pearls. Cleveland Clinic Journal of Medicine, 76 (2), 137-142. 8. Mendelson, C. (2009.) Diagnosis: A Liminal State for Women Living With Lupus. Health Care for Women International, 30, 390-407. 9. Pullen, R.L. (2008.) Stay in the loop about lupus. Nursing made incredibly easy!, January/February, 44-54. 10. Pullen, R.L., Brewer, S. & Ballard, A. (2009.) Putting a face on systemic lupus erythematosus. Nursing 2009, 23-28. 11. Schur, P.H. & Bermas, B.L. (2013.) Pregnancy in women with systemic lupus erythematosus. In D.S. Pisetsky (Ed.),UpToDate. Available from http://www.uptodateonline.com.
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12. Schur, P.H. & Gladman, D.D. (2013). Overview of the clinical manifestations of systemic erythematosus in adults. In D.S. Pisetsky (Ed.),UpToDate. Available from http://www.uptodateonline.com. 13. Schur, P.H. & Wallace, D.J.. (2013). Diagnosis and differential diagnosis of systemic erythematosus in adults. In D.S. Pisetsky (Ed.),UpToDate. Available from http://www.uptodateonline.com. 14. Schur, P.H. & Wallace, D.J.. (2013). Overview of the therapy and prognosis of systemic erythematosus in adults. In D.S. Pisetsky (Ed.),UpToDate. Available from http://www.uptodateonline.com. 15. Toloza S.M.A., Sequeira, W. & Jolly, M. (2011.) Treatment of Lupus; Impact on Quality of Life. Current Rheumatology Reports, 13, 324-337. 16. Weinstein, P.K. (2012.) The Face of Lupus. The Nurse Practitioner, 37 (12), 38-45. 17. Wheeler, T. (2010.) Systemic lupus erythematosus: the basics of nursing care. British Journal of Nursing, 19 (4), 249-253.
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