Living well with lupus

FACT SHEET Lupus Canada

Immunosuppressive drugs used in treating lupus

Immunosuppressive drugs can be of great value in Some believe that immunosuppressive drugs may increase the treatment of systemic lupus erythematosus (SLE the risk of certain cancers. The most common problem is a or lupus). They may help to reduce disease symp- precancerous abnormality that, if undetected, could lead to Itoms, prevent damage to vital organs (such as the kidneys cervical cancer. In fact, this condition is quite common even andlungs), andhelp put the diseaseinto remission. in women without lupus. For this reason, regular gynecological check-ups with pap smear Immunosuppressive drugs are used testing are recommended for all women, only when lupus is active, especially Some believe that andis especially important for women with if there are severe kidney problems. immunosuppressive drugs lupus. Fortunately, with regular checks to They are almost always taken along may increase the risk of ensure that there is no precancerous with corticosteroids and, in fact, are changes in the cervix, the more serious often used to help gradually reduce certain cancers. consequences relatedto cervical cancer the dose of corticosteroids. (Ideally, can be avoided, even if you take they eventually allow the corticosteroids to be discontinued.) immunosuppressive drugs.

Like any medication, these agents may have adverse effects. Other cancers that are more common in people with lupus Because they suppress the over-active immune system, most are lymphoma andlung cancer. However, there is no clear of these drugs can make you more susceptible to infection. evidence that this increased risk is primarily caused by drug Some of the drugs can cause bone marrow suppression. exposures. Though some lymphomas may be relatedto Cells are produced in the bone marrow, so the interference medication use, research suggests that lymphoma risk may of these drugs can leadto decreasednumbers of redblood also be increasedby uncontrolledlupus. It is important to cells (the cells that carry oxygen in your blood), white blood know that, though they occur more often in people who cells (the cells that fight infection) andplatelets (the cells have lupus than in the general population, lymphomas still that aidin bloodclotting). only arise in a very small number of people with lupus. Thus, when they are requiredto control lupus, the benefits If you are taking an immunosuppressive drug that may of immunosuppressive drugs are generally believed to suppress the bone marrow, regular bloodtests must be outweigh the risks. done to monitor your blood cell levels. Because the development of infection is more likely when you are Finally, don’t forget that some of the greatest risk taking an immunosuppressive, it is important to notify factors for cancer are ones that you can modify. These your doctor if you develop a fever or any other risk factors include smoking, a high-fat diet and new symptoms. obesity. Paying attention to these factors (especially

Working together to conquer lupus quitting smoking) is the best cancer-preventing strategy PREGNANCY Cyclophosphamide that you can take. AND LACTATION (Cytoxan): This The use of many immunosuppressive drugs may agent inhibits cell Types of immunosuppressive present risks to an unborn baby. If you are beginning these division and growth, drugs drugs, talk to your doctor about your long-term plans for andit is a strong im- Various types of immunosup- pregnancy. Your doctor will be able to suggest contraceptive munosuppressive pressive drugs are available to measures during treatment. If you have uncontrolled lupus, drug. Cyclophos- treat lupus. Although they have pregnancy should be avoided until the lupus is controlled, as phamide in lupus different mechanisms of outcomes will be better for the baby and for you. Your doctor treatment is reserved action, each drug works to may also suggest delaying pregnancy for several months for very serious kid- decrease the body’s over-active after stopping certain drugs to allow them to be cleared ney disease or other immune response. from your system and avoid affecting your unborn baby. internal organ involvement. It has It is important that you under- Some drugs may pass into breast milk. Expectant mothers the potential for standexactly how andwhen to who plan to breastfeed and who take any medications severe side effects, take your medications, and should consult their lupus specialists to ensure that including the risk of what the potential side effects breastfeeding is safe for the baby. serious infection. are. You needto work with Although well toler- your doctor to make sure that atedby most people, the dosage delivers benefits with cyclophosphamide as few side effects as may cause nausea andvomiting, andits use may decrease possible. The effects of these drugs build up gradually, so bloodcell counts. Hair loss may also be a problem. you may not notice the benefits for several months. Additional side effects can include temporary or permanent These are the immunosuppressive drugs most frequently sterility in both women andmen. There may be options for usedin the treatment of lupus: limiting this risk, so discuss with your specialist. This drug can also damage a developing fetus if a woman becomes pregnant Azathioprine (Imuran): One of the most widely used while being treatedwith the drug, so using contraception is immunosuppressive drugs for lupus, azathioprine works by very important. blocking immune cell function. Side effects can include nausea, loweredbloodcell counts, andliver inflammation. Because this medication is cleared by the kidneys and If you are receiving this drug, you should have regular blood excretedin the urine, it can cause inflammation andbleeding tests to determine that your cell counts and liver remain in the bladder. One way to try to prevent this is to drink extra normal. If the tests indicate a problem, your doctor will fluids, as directed by your doctor. The drug is usually given by adjust the drug dose. injection in lupus, often with another intravenous medication Living well with lupus

(Mesna or Uromitexan®) to limit adverse effects on function. For these reasons, its use in lupus treatment the bladder. has decreased.

Bloodtests to determine cell counts shouldbe done Mycophenolate mofetil (CellCept): Developedto prevent regularly. If your cell counts are seriously decreased, your the rejection of transplantedorgans, mycophenolate is doctor will adjust the drug dosage, which generally allows increasingly usedas an alternative to cyclophosphamidefor the bloodcounts to rise. Monitoring of urine tests is lupus with kidney involvement. It may be useful for other important. After stopping the drug, you should continue forms of lupus activity also. Mycophenolate works by urine tests to check for abnormalities in the bladder. Bladder curbing excessive activity of lymphocytes (a type of white cancer is a possible side effect of high doses of bloodcell). It is often well tolerated,although it can cause cyclophosphamide, although it appears to be a very rare nausea and diarrhea. When you take this drug, regular lab occurrence in lupus. tests, including cell counts, are required.

Methotrexate (Rheumatrex): Methotrexate may be useful Leflunomide (Arava): Leflunomide is an anti-inflammatory for certain types of lupus activity when other drugs (e.g., medication that can help to reduce the pain and swelling nonsteroidal anti-inflammatory drugs (NSAIDs) or anti- of arthritis and can decrease damage to joints. Like malarials) do not adequately control the symptoms. In fact, cyclosporine, this medication is not used very often in methotrexate is often usedin combination with these drugs. lupus treatment. Some people like this drug because it is only taken once a week. Methotrexate is generally not chosen for very severe Rituximab (Rituxan) is a cancer drug that works by lupus, however. decreasing the activity of white blood cells known as lymphocytes. Studies of people with severe lupus who did Side effects of methotrexate may include liver and lung not respondto initial treatment with other drugs andwere reactions, as well as loweredcell counts. Stomach upset or then treatedwith rituximab have shown great promise. hair loss may also be a problem. If you are receiving this Because this drug is relatively new, must be given by drug, you shouldhave bloodtests to monitor your cell injection, andis very expensive, it is reservedfor very counts and liver regularly; your doctor will modify the severe cases. Recently, reports of a rare but serious dosage if you experience side effects. To reduce toxicity, a complication have arisen, relatedto a brain infection supplement (folic acid) is prescribed. causing death. However, this drug has been used safely in many people with severe lupus who didnotrespondto Cyclosporine (Neoral): Originally developed to prevent other treatment; thus, rituximab is an option for rejection of kidney and other organ transplants, difficult cases. cyclosporine has been usedto treat rheumatic diseases, including lupus. This medication modifies the immune New treatments system without decreasing cell counts. However, it Researchers continue to look for more effective lupus may elevate bloodpressure andreducekidney treatments. Some studies have focused on blocking the

Working together to conquer lupus expression of genes that may cause some of the symptoms of lupus. Many advances have been made, and trials of such agents are underway, although it may be some time before they are routinely usedin lupus treatment.

Risks and benefits When considering cytotoxic drug therapy, it is important to weigh the benefits against the risks. Doctors use the term "risk-benefit ratio" to describe the comparison of a medication’s side effects and beneficial effects. While cytotoxic medications are generally not used if your lupus is mild, these drugs may be very helpful and even life-saving if your lupus is quite active and symptomatic or if you have major organ involvement.

Your doctor may order a kidney biopsy or other tissue FOR MORE INFORMATION • Lupus Canada: www.lupuscanada.org. This site biopsy before recommending one of these drugs. includes electronic versions of the Living Well with Lupus fact sheets.

• Lupus: The Disease with a Thousand Faces, edited by Dr. Sasha Bernatsky and Dr. Jean-Luc Senécal, Key Porter Books (2004) ISBN 1-55263-603-8. Contact Lupus Canada to order this book.

• The Arthritis Foundation: www.arthritis.ca

• Lupus Foundation of America: www.lupus.org

Disclaimer Systemic lupus erythematosus is an autoimmune disease that affects thousands of Canadians, mostly women in their childbearing years. Symptoms vary greatly from person to person and treatment is highly individualized. Patients are urged to contact their physician or healthcare professional with any questions or concerns they might have. Lupus Canada 590 Alden Road, Suite 211 Markham, Ontario L3R 8N2 (905) 513-0004 [email protected] www.lupuscanada.org

Publication Date: April 2007