SYSTEMIC LUPUS ERYTHEMATOSUS(SLE)- A BRIEF OUTLOOKBY- VISHNU.R.NAIRTHIRD YEAR PHARM.DKERALA UNIVERSITY OF HEALTH SCIENCES (KUHS)KERALA STATE.

A. GENERAL FEATURES:• “Autoimmune disease, in which body’s immune system mistakenly

attacks healthy tissue”• Can affect almost any part of body• Follows a relapsing and remitting course• Also has PROTEAN manifestations………………………

B. EPIDEMIOLOGY:• Occurs in 5 out of every 10,000 people• More frequent in Asian women than in Whites• Higher rates reported in Blacks• Highest in women aged 14-64 years• 90% cases occur in women, mostly in the age of midwifery…………….

C. ETIOLOGY:• A. FAMILIAL:- 8% of affected patients have at least one first degree family member with SLE- For identical twins : 24% chances- For fraternal twins : 2% chanceB. GENETIC:- 35 genes are known to increase risk for SLE- Loci associated with SLE include:a. TNF A1P3b. BANK 1- Human leucocytic antigen (HLA):• HLA-A1, HLA-DR3 and HLA-88 are more common in patients with SLE- Presence of null complement alleles- Congenital abnormalities of complement (C2, C4) Associated with SLE risk

CONTINUED………………….- DNAase 1 enzyme deficiency:. Also known as “GARBAGE DNA”. Enzyme eliminates cellular debris, by chopping them into smaller fragments for easier disposal. Enzyme deficiency increases risk for SLE.

C. VIRUSES:- EBV (Epstein-Barr Virus) causes T-cell abnormality failure in normal immunoregulation of B-cell response (causes B cell hyperactivity)D. ENVIRONMENT n MISCELLANEOUS CAUSES:- Silica dust- Cigarette smoking- Estrogen administered to post-menopausal women increased SLE risk- Decreased breast feeding- Photosensitivity- UV light stimulates KERATINOCYTES causes over-expression of nuclear ribonucleoproteins

(snRNPs) on their cell surface , and stimulates cytokine secretion leading to Auto-antibody production…………………….

CONTINUED…………………..E. NUTRITIONAL DEFICIENCY:- Vitamin D deficiency has three SLE related effects:a. Increases auto-antibody productionb. B-cell hyperactivityc. Interferon-alpha activityF. DRUGS:- Drugs , that increase SLE risk, include:a. Hydralazine (APRESOLINE)b. Quinidine sulphate / gluconatec. Procainamide (PROCANBID)d. Phenytoin (DILANTIN)e. INH (LANIAZID)f. D- Penicillamine………………………..

D. PATHOPHYSIOLOGY OF SLE:• Mainly the flowchart of SLE can be summarized like this:(INNATE SUSCEPTIBILITY with or without ENVIRONMENTAL STIMULI) AUTOIMMUNE PROLIFERATION AUTO- ANTIBODY PRODUCTION Signs and symptoms of SLE, depending on the organ/tissue targeted by the immune system…………………….• Factors that come under INNATE SUSCEPTIBILITY include:- HLA type (DR 3/2)- Immunoregulatory genes (multiple)- Complement levels- Hormonal levels• Factors that come under ENVIRONMENTAL STIMULI include:- UV response- Microbial response- Drugs.

CONTINUED…………………………• Factors that come under AUTOIMMUNE PROLIFERATION include:- Hyperactive B and T cell activation- High ratio of CD4:CD8 T cells- Defective immune complex clearance- Impaired tolerance• Factors that come under AUTO-ANTIBODY PRODUCTION, include:- Apoptosis- Self-exposure- Self-recognition- Foreign antibody cross reaction………………………………..

E. SIGNS AND SYMPTOMS:• SLE is a chronic auto-immune disease, that can affect any organ system• Symptoms range from INDOLENT to FULMINANT• For children:a. Malar rashesb. Ulcersc. Renal manifestationsd. Proteinuriae. Urinary cellular castsf. Seizuresg. Thrombocytopeniah. Hemolytic anemiai. Feverj. Lymphadenopathy….• For adults:- Raynaud’s pleuritis- Keratoconjunctivitis sicca

CONTINUED………………….• For midwives:- Fever- Joint pain- Rashes• GENERALIZED MANIFESTATIONS:1. Constitutional symptoms:- Fatigue- Fever- Arthralgia- Weight changes2. Musculoskeletal symptoms:- Arthralgia- Myalgia- Arthropathy- Frank arthritis- Avascular necrosis

CONTINUED………………………..3. Dermatologic symptoms:- Malar rash- Discoid lupus- Photosensitivity4. Renal symptoms:- ARF- CRF- Acute nephritis disease (lupus nephritis)5. Neuropsychiatric symptoms:- Seizure- Psychosis6. Pulmonary symptoms:- Pleurisy - Pleural effusion- Pneumonitis- Pulmonary HTN- Interstitial lung disease

CONTINUED………………………….7. GI symptoms:- Nausea- Dyspepsia- Abdominal pain8. Cardiac symptoms:- Pericarditis- Myocarditis9. Hematologic symptoms:- Leucopenia- Lymphopenia- Anemia- Thrombocytopenia……………………………..

F. DIAGNOSIS OF SLE • Based on combination of clinical findings and lab evidence• According to American College of Rheumatology (ACR), presence of ANY 4 of the following 11 criteriae

makes the patient positive/ susceptible to SLE : (Remember code of criteria is SOAP BRAIN MD)- S: SEROSITIS- O: ORAL ULCERS- A: ARTHRITIS- P: PHOTOSENSITIVITY

- B: BLOOD DISORDERS- R: RENAL MANIFESTATIONS- A: ANTI NUCLEAR ANTIBODIES- I: IMMUNOLOGIC INVOLVEMENTS ( Example dsDNA, Anti-Smith antibodies)- N: NEUROLOGIC DISORDERS

-M: MALAR RASH-D: DISCOID RASH…………………

CONTINUED………………….• LAB TESTS USED FOR SLE DIAGNOSIS:- CBC , with differential counts- Serum creatinine levels- Microscopial urine analysis- ESR/ CRP results- Complement levels- LFTs (LIVER FUNCTION TESTS)- Creatine kinase assay- (Spot protein/ spot creatinine ) ratio- Auto antibody tests• IMAGING TESTS USED FOR SLE DIAGNOSIS:- Joint radiography- Chest radiography- Chest CT Scan- Echocardiography- Cardiac MRI

CONTINUED………………………..

• PROCEDURES PERFORMED ON PATIENTS TO DIAGNOSE SLE:- Arthrocentesis- Renal biopsy- Lumbar puncture…………………………………..

G. MANAGEMENT OF SLE:• Depends on patient’s disease severity and manifestations• Here, we will discuss:I. GOALS OF THERAPYII. PHARMACOTHERAPYIII. NON-PHARMACOTHERAPYIV. PATIENT COUNSELLING………………………………..

I. GOALS OF THERAPY:• To prevent symptomatic flares• To stress on self-care (Maintenance of healthy lifestyle)• Organ damage prevention• Minimizing ADRs• Medication adherence• Prevention of complication• Reduce mortality and morbidity• Improve QOL (QUALITY OF LIFE)……………………………..

2. PHARMACOTHERAPY OF SLE:• Here, we will include:- Medication classification- EULAR recommendations for SLE management- Drug details………………………

MEDICATION CLASSIFICATION • BIOLOGIC DMARDs (Disease modifying anti-rheumatoid drugs):- Belimumab- Rituximab- Immunoglobulin i.v (IGIV)• NON-BIOLOGIC DMARDS:- Cyclophosphamide- Methotrexate- Azathioprine- Mycophenolate- Cyclosporine• NSAIDs:- Ibuprofen- Naproxen- Diclofenac• CORTICOSTEROIDS:- Methyl prednisolone- Prednisone

CONTINUED…………………………..

• ANTI-MALARIALS:- Hydroxychloroquine (HCQ)- Chloroquine (CQ)• ANTI-NEOPLASTIC (For cutaneous lupus erythematosus):- Thalidomide………………………….

EULAR RECOMMENDATIONS FOR SLE MANAGEMENT

• In 2007, the European League Against Rheumatism (EULAR) released recommendations for SLE treatment

• Recommendations include:- For SLE patients, without major organ manifestations Use glucocorticoids and anti-

malarial agents (mainly HCQ)- Use NSAIDs for short periods to avoid risk of complications from these drugs- Consider immunosuppressants (azathioprine, methotrexate) in refractory cases or when

steroid doses cant be decreased to levels for long term use- Above guidelines also apply to patients with neuropsychiatric manifestations- Cutaneous, musculoskeletal manifestations and serositis represent milder disease- The above symptoms are controlled with the following medication regimen :(NSAIDs / low potency immunosuppressants) + HCQ +/- Corticosteroids (short course)- For patients with vital organs (CNS, renal) involvement Treat with more aggressive immunosuppression…………………………………….

DRUG DETAILS A. NSAIDS:- Provide symptomatic relief for arthralgias, fever, headache, and serositis- M.O.A(Mechanism of action): Drug inhibits COX-1 and COX-2 (Cyclooxygenase pathway) Prostaglandin synthesis inhibited decreased pain Drug has 4 actions that ultimately decrease inflammation:a. Inhibition of neutrophil aggregation and activationb. Chemotaxis inhibitionc. Decreased pro-inflammatory cytokine levelsd. Altered lymphocyte activity- ADRs:a. Cholestasisb. BUN levels > 40 mg/dlc. Hepatitisd. Nephrotoxicitye. Serum creatinine levels > 2 mg/dl

CONTINUED……………………………….

- Drug interactions:a. NSAIDs + methotrexate decreased renal clearance of methotrexate (MTX) Increased MTX levels

MTX toxicity severe hematologic and GI toxicity deathb. NSAIDs + cortisone / prednisone pharmacodynamics synergism increases toxicity of one another

increased GI ulceration- Contraindications:a. ARF patientsb. Active GI bleeding- Ibuprofen (NEOPROFEN, ADVIL):a. Drug of choice for mild-moderate painb. Dose: 400-800 mg P.O (per oral) every 6-8 hrs- Naproxen (NAPROSYN):a. For mild-moderate painb. Dose: 750-1000 mg/day (P.O)- Diclofenac (CATAFLAM):a. Take with food to avoid GI ADRsb. Dose : 100 mg/day………………………….

CONTINUED……………………………B. CORTICOSTEROIDS:

- Used predominantly for anti-inflammatory action, and as immunosuppressant- Preparations include oral, i.v, topical and intra-articular injections- ADRs:a. Diabetes mellitusb. Headachec. Weight gaind. Osteoporosise. Oral candidiasisf. Hepatomegaly- Contraindications:a. Documented hypersensitivityb. Systemic fungal infections- Methyl prednisolone (A-METHAPRED):a. Used for acute organ threatening exacerbationsb. Drug suppresses Polymorphonuclear lymphocytes migration and reverses capillary permeability

leads to decreased inflammation…………………..

CONTINUED………………………c. Drug interaction:Methyl pred. + Loratadine increased levels or effect of formerd. Dose : 0.5-1 g i.v over 1 hr. OD for 3 days ( for lupus nephritis)

- Prednisone (DELTASONE):a. Mainly immunosuppressantb. Drug has the following actions, that ultimately reduce inflammation:• Suppresses PMN (Polymorphonuclear neutrophils) migration• Reverses increased capillary permeability• Stabilizes lysosomal membrane• Suppresses antibody production• Suppresses lymphocytesc. For Mild SLE use low dose oral formd. For severe SLE use high doses of oral/ i.v forme. Dose : 60 mg P.O for 1 week………………………….

CONTINUED………………………….C. ANTI-MALARIALS:- Cause immunomodulation without hyper immunosuppression- Used to prevent and treat lupus like skin rashes, constitutional symptoms , arthralgias, arthritis- Prevent lupus flares- Decreases morbidity- Decreases mortality- HCQ (PLAQUENIL):a. According to LUMINA (Lupus in Minorities: Nature vs Nurture ) study and other trials,

patients who have been given HCQ Showed decreased flares and prolonged lifeb. Thus HCQ is also known as “cornerstone of SLE management”c. Drug has 3 actions:• Inhibits eosinophil chemotaxis• Inhibits neutrophil locomotion• Impairs complement dependent Antigen-antibody reactionsd. Dose : Hydroxychloroquine sulphate : 200 mg

CONTINUED………………………………e. ADRs:

• Retinal toxicity• Alopecia• Pruritus• Weight lossf. Drug interactions:• HCQ + Anakinra increased immunosuppressive effects increased risk of

infections• HCQ + Digoxin increased levels of digoxing. Contraindications :• Porphyria• Psoriasis………………………………….

CONTINUED………………………………D. NON-BIOLOGIC DMARDs:- Function as immunosuppressives, cytotoxic, and anti-inflammatory

medications- Medications that we will discuss are:1. Cyclophosphamide2. Methotrexate3. Azathioprine4. Mycophenolate…………………………………….

CONTINUED…………………………..1. CYCLOPHOSPHAMIDE ( CYTOXAN):

- Due to increased toxicity, it is reserved only for severe organ threatening disease (CNS involvement, vasculitis, lupus nephritis)

- Drug enters body forms active metabolite (4-aldophosphamide) in liver causes DNA cross-linkage- Drug shows function similar to nitrogen mustards (alkylating agents)- ADRs:a. Interstitial pulmonary fibrosisb. Infertility, sterilityc. Secondary malignancies- Contraindications:a. Severe myelosuppressionb. Hypersensitivity- Drug interactions:Cyclo. + Allopurinol increased toxicity of former- Dose : (mainly for lupus nephritis)a. For low dose : 500 mg. iv every 2 weeks for 6 doses + corticosteroids + maintenance with mycophenolate

mofetil / azathioprineb. For High dose : 500-1000 mg iv monthly for 6 doses + corticosteroids……………………..

CONTINUED…………………………….2. METHOTREXATE (RHEUMATREX):

- Drug has 2 blocking actions, that increased anti-inflammatory adenosine concentration at sites of inflammation:a. Blocks purine synthesisb. Blocks 5-amino imidazole -4- carboxamide ribonucleotide (5-AICAR)- Manages arthritis, serositis, cutaneous and constitutional symptoms- ADRs:a. BMT (bone marrow toxicity)b. Nausea and vomitingc. Anorexiad. Renal failure- Contraindications:a. Pregnancyb. Alcoholicsc. Bone marrow hyperplasia-Drug interactions:Aspirin+ MTX Increased levels of MTX (due to decreased renal clearance) increased MTX Toxicity-Dose : 7.5-15 mg / week (for arthritis), and 10-25 mg weekly (for psoriasis)…………………………….

CONTINUED……………………………..3. AZATHIOPRINE (IMURAN):

- Immunosuppressant- Less toxic alternative to cyclophosphamide- Used as steroid sparing agent in non-renal disease- Drug converted to 6-mercaptopurine antagonizes purine function, inhibits DNA, RNA ,Protein synthesis

decreases immune cell proliferation decreased auto-immune activity- ADRs:a. Leukopeniab. Infectionsc. BMTd. SWEET SYNDROME ( Acute febrile neutrophilic dermatosis)- Drug interaction:Febuxostat + Azathioprine decreased metabolism of latter increased levels of latter- Contraindication:a. Pregnancyb. Documented hypersensitivity- Dose: 2 mg/kg/day P.O with /without low-dose corticosteroids…………………………

CONTINUED………………………….4. MYCOPHENOLATE ( MYFORTIC):- Mainly used as maintenance therapy (in lupus nephritis)- Drug inhibits inosine monophosphate dehydrogenase (IMPDH) , Suppresses purine

synthesis by lymphocytes , Inhibits antibody production- ADR:a. DMb. Back painc. Hypomagnesemia- Drug interaction:Cholestyramine + mycophenolate decreased GI absorption of latter- Contraindication:Hypersensitivity-Dose :2-3 gram for 6 months, with glucocorticoids……………………..

CONTINUED………………………E. BIOLOGIC DMARDs:1. BELIMUMAB (BENLYSTA):- Monoclonal antibody- B-lymphocyte stimular specific inhibitor- BLys (B-lymphocyte stimulator ):a. Naturally occurring proteinb. Required for survival and development of B-cells into mature plasma B-cells, that produce

antibodiesc. In autoimmune diseases increased BLys levels production of auto antibodiesd. Drug specifically recognizes and binds to Blys inhibits Blys stimulation of B-cell

development restores potential for auto antibody producing cells to undergo normal process of apoptosis (programmed cell death)

- Decreases disease activity, severe flares and corticosteroid need- Used as combination therapy, with steroids, HCQ, azathioprine, MTX- Used to treat auto-antibody positive SLE

CONTINUED……………………….- ADRs:a. Infusion reactions (nausea, headache, skin reactions)b. Hypersensitivityc. Diarrhea- Drug interactions:Hydroxyurea+ Belimumab increased risk for infections- Contraindicated in:Hypersensitivity- Dose:(10 mg/kg iv every 2 weeks ) for 3 doses……………….

CONTINUED……………………………..2. RITUXIMAB (RITUXAN):

- Depletes B-cells- Humanized monoclonal antibody- Drug binds to CD20 antigen induces complement/ antibody mediated cytolysis- Used for patients who do not respond to immunosuppressants- Used in severe refractory SLE- More effective, when used in combination with COSTIMULATION INHIBITORS- ADRs:a. Angioedemab. Feverc. Pruritus- Drug interactions:Rituximab + certolizumab pegol increased immunosuppressive effects increased risk of infections.- Contraindications:a. Hypersensitivity b. Angina- Dose : 1000 mg iv infusion ( repeat after 2 weeks). Give glucocorticoids 30 minutes before giving rituximab to decrease risk of infusion reactions………………….

CONTINUED…………………………….3. IMMUNOGLOBULIN I.V (OCTAGAM, HIZENTRA):

- Used for immunosuppression, in severe SLE flares- Has the following actions:a. Neutralizes circulating myelin antibodies through anti- idiotypic

antibodiesb. Downregulates pro-inflammatory cytokines (interferon-gamma)c. Blocks Fc receptors on macrophagesd. Suppresses inducer T and B cellse. Augments suppressor T cellsf. Blocks complement cascadeg. Promotes remyelinationh. May increase CSF immune globulin (G) concentration by 10%

CONTINUED…………………………….- ADRs:

a. Chillsb. Headachec. Hypotension- Drug interactions:Immune globulin i.v + bacitracin increased nephrotoxicity and ototoxicity- Contraindications:a. Isolated IgA deficiencyb. Hypersensitivity to gamma-globulin, thiomersal- Dose:400 mg/kg i.v every 3-4 weeks……………………………

CONTINUED…………………………..F. THALIDOMIDE (THALOMID):

- Good option for treatment of cutaneous lupus erythematosus- Complete remission observed in 72% cases- Drug actions:a. Decreased expression of MHC (major histocompatibility complex) Class II antigens

on keratinocytesb. Decreased expression of ICAM-1 on keratinocytesc. May cause decrease in CD4+ T cells- ADRs:a. Teratogenicityb. Neuropathyc. Constipationd. Drowsinesse. Paresthesia in hands

CONTINUED……………………………….- Drug interaction:

Thalidomide + Anakinra :a. Increased toxicity of thalidomideb. Increased infection risk- Contraindications:a. Pregnancyb. Hypersensitivityc. Venous thromboembolism (VTE)- Dose:Thalidomide (100-300 mg/day) decrease dose gradually + prednisone (15-60 mg/day)……………………………

III. NON-PHARMACOTHERAPY FOR SLE :

• Sufficient amount of sleep• Carefully prescribed exercise to maintain muscle tone• Avoid direct skin exposure• Use sunscreens and sun protection clothing• For skin rash, use DAPSONE and RETINOIC ACID (RETIN-A)• For patients, with lupus cerebritis/ lupus nephritis opt

PLASMAPHERESIS (Removes antibodies and other immune substances from body)• For patients, with ESRD associated with SLE: Go for DIALYSIS/

RENAL TRANSPLANTATION

CONTINUED…………………• Diet:- Low dose diet supplementation with omega-3-fish oils has 3 actions:a. Decreased heart disease riskb. Decreased disease activityc. Decreased inflammation- Consume more plant based foods- Consume lean sources of protein- DHEA (Dehydroepiandrosterone) decreases fatigue , improves

thinking difficulties and improves QOL in SLE patients- Consume Vitamin D supplements……………………………….

IV. PATIENT COUNSELLING TIPS FOR SLE:

1. Stress on the importance of medications and follow-up appointments to detect and control SLE

2. Instruct SLE patients to seek medical care for evaluation of new symptoms , including fever

3. Advise patients regarding increased risk of infection and cardiovascular disease

4. Educate patient that lupus cant be cured, but symptoms can be reduced , and QOL can be prolonged and made worthwhile

5. Educate patients regarding avoidance of sunlight / UV exposure6. Encourage to receive non-live vaccines during stable periods of

disease, mostly against encapsulated organisms, like :

CONTINUED……………………a. Pneumococcusb. Meningococcusc. H.influenzaed. Influenza virus7. Educate patients regarding aggressive B.P and lipid goals to decrease risk for CAD (coronary artery disease)8. Quit smoking9. Carefully plan pregnancies

CONTINUED…………………………10. During SLE in pregnancy avoid most medications during 1st trimester11. Opt progesterone only contraception (since estrogen is a risk factor for SLE)12. For steroid induced osteoporosis use bisphosphonates (alendronate,ibandronate,risedronate) , along with Vitamin. D supplements13. For renal diseases use ACE-inhibitors, ARBs (Angiotensin receptor blockers), non-DHP (Dihydropyridines, most safe)……………………………………………………………………….

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