Systemic lupus erythematosus

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Systemic lupus erythematosus
Classification and external resources

A drawing of the typical "butterfly rash" ICD-10 ICD-9 OMIM DiseasesDB MedlinePlus eMedicine MeSH L93., M32. 710.0 152700 12782 000435 med/2228 emerg/564 D008180

Systemic lupus erythematosus ( i/sɨˈstɛmɪk ˈluːpəs ˌɛrɨθiːməˈtoʊsəs/), often abbreviated to SLE or lupus, is a systemic autoimmune disease (or autoimmune connective tissue disease) that can affect any part of the body. As occurs in other autoimmune diseases, the immune system attacks the body's cells and tissue, resulting in inflammation and tissue damage.[1] It is a Type III hypersensitivity reaction caused by antibody-immune complex formation. SLE most often harms the heart, joints, skin, lungs, blood vessels, liver, kidneys, and nervous system. The course of the disease is unpredictable, with periods of illness (called flares) alternating with remissions. The disease occurs nine times more often in women than in men, especially in women in child-bearing years ages 15 to 35, and is also more common in those of non-European descent.[2][3][4]

SLE is treatable using immunosuppression, mainly with cyclophosphamide, corticosteroids and other immunosuppressants; there is currently no cure. SLE can be fatal, although with recent medical advances, fatalities are becoming increasingly rare. Survival for people with SLE in the United States, Canada, and Europe has risen to approximately 95% at five years, 90% at 10 years, and 78% at 20 years,[4] and now approaches that of matched controls without lupus.

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1 Signs and symptoms 2 Causes o 2.1 Genetics o 2.2 Environmental triggers o 2.3 Drug reactions o 2.4 Non-SLE forms of lupus 3 Pathophysiology o 3.1 Transmission o 3.2 Abnormalities in apoptosis o 3.3 Clearance deficiency o 3.4 Accumulation in germinal centres o 3.5 Anti-nRNP autoimmunity o 3.6 Others 4 Diagnosis o 4.1 Laboratory tests o 4.2 Diagnostic criteria 5 Prevention 6 Treatment o 6.1 Medications o 6.2 Lifestyle changes o 6.3 Renal transplantation o 6.4 Hughes syndrome o 6.5 Management of pregnancy 7 Prognosis 8 Epidemiology 9 History and culture o 9.1 Etymology o 9.2 History 10 Notable cases 11 Research 12 See also 13 References 14 External links

[edit] Signs and symptoms

Common symptoms of SLE.[5] SLE is one of several diseases known as "the great imitators" because it often mimics or is mistaken for other illnesses.[6] SLE is a classical item in differential diagnosis,[2] because SLE symptoms vary widely and come and go unpredictably. Diagnosis can thus be elusive, with some people suffering unexplained symptoms of untreated SLE for years. Common initial and chronic complaints include fever, malaise, joint pains, myalgias, fatigue, and temporary loss of cognitive abilities. Because they are so often seen with other diseases, these signs and symptoms are not part of the diagnostic criteria for SLE. When occurring in conjunction with other signs and symptoms (see below), however, they are considered suggestive.[7] Dermatological manifestations As many as 30% of sufferers have some dermatological symptoms (and 65% suffer such symptoms at some point), with 30% to 50% suffering from the classic malar rash (or butterfly rash) associated with the disease. Some may exhibit thick, red scaly patches on the skin (referred to as discoid lupus). Alopecia; mouth, nasal, urinary tract and vaginal ulcers, and lesions on the skin are also possible manifestations. Tiny tears in delicate tissue around the eyes can occur after even minimal rubbing. Musculoskeletal The most commonly sought medical attention is for joint pain, with the small joints of the hand and wrist usually affected, although all joints are at risk. The Lupus Foundation of America estimates more than 90 percent of those affected will experience joint and/or muscle pain at some time during the course of their illness.[8] Unlike rheumatoid arthritis, lupus arthritis is less

disabling and usually does not cause severe destruction of the joints. Fewer than ten percent of people with lupus arthritis will develop deformities of the hands and feet.[8] SLE patients are at particular risk of developing osteoarticular tuberculosis.[9] A possible association between rheumatoid arthritis and SLE has been suggested,[10] and SLE may be associated with an increased risk of bone fractures in relatively young women.[11] Hematological Anemia may develop in up to 50% of cases. Low platelet and white blood cell counts may be due to the disease or a side effect of pharmacological treatment. People with SLE may have an association with antiphospholipid antibody syndrome[12] (a thrombotic disorder), wherein autoantibodies to phospholipids are present in their serum. Abnormalities associated with antiphospholipid antibody syndrome include a paradoxical prolonged partial thromboplastin time (which usually occurs in hemorrhagic disorders) and a positive test for antiphospholipid antibodies; the combination of such findings have earned the term "lupus anticoagulantpositive". Another autoantibody finding in SLE is the anticardiolipin antibody, which can cause a false positive test for syphilis.[citation needed] Cardiac A person with SLE may have inflammation of various parts of the heart, such as pericarditis, myocarditis, and endocarditis. The endocarditis of SLE is characteristically noninfective (Libman-Sacks endocarditis), and involves either the mitral valve or the tricuspid valve. Atherosclerosis also tends to occur more often and advances more rapidly than in the general population.[13][14][15] Pulmonary Lung and pleura inflammation can cause pleuritis, pleural effusion, lupus pneumonitis, chronic diffuse interstitial lung disease, pulmonary hypertension, pulmonary emboli, pulmonary hemorrhage, and shrinking lung syndrome. Renal Painless hematuria or proteinuria may often be the only presenting renal symptom. Acute or chronic renal impairment may develop with lupus nephritis, leading to acute or end-stage renal failure. Because of early recognition and management of SLE, end-stage renal failure occurs in less than 5% of cases. A histological hallmark of SLE is membranous glomerulonephritis with "wire loop" abnormalities.[16] This finding is due to immune complex deposition along the glomerular basement membrane, leading to a typical granular appearance in immunofluorescence testing. Neuropsychiatric

seizures.[21] More rare manifestations are acute confusional state.[18] The most common neuropsychiatric disorder people with SLE have is headache. Neurological Neural symptoms contribute to a significant percentage of morbidity and mortality in patients with lupus.[27] Neonatal lupus is usually benign and self-limited. and sometimes with systemic abnormalities such as heart block or hepatosplenomegaly.[27] .Neuropsychiatric syndromes can result when SLE affects the central or peripheral nervous systems. psychosis. One aspect of this disease is severe damage to the epithelial cells of the blood-brain barrier. mood disorder. The neurological symptoms include headaches.[20] Other common neuropsychiatric manifestation of SLE include cognitive dysfunction. movement disorder (more specifically. Lupus has a wide range of symptoms which span the body.[19] seizures. myelopathy. and in some extreme cases.[17] The diagnosis of neuropsychiatric syndromes concurrent with SLE is one of the most difficult challenges in medicine.[19] anxiety disorder. depression reportedly affects up to 60% of women suffering from SLE. demyelinating syndrome. mononeuropathy (which might manifest as mononeuritis multiplex). papilledema. most commonly presenting with a rash resembling discoid lupus erythematosus.[26] Neonatal lupus is the occurrence of SLE symptoms in an infant born from a mother with SLE. and psychosis. the neural side of lupus is being studied in hopes of reducing morbidity and mortality rates. cerebrovascular disease.[17] The neural manifestation of lupus is known as neuropsychiatric systematic lupus erythematosus (NPSLE). chorea). some of which may be mistaken for signs of infectious disease or stroke. Guillain-Barré syndrome.[23] In certain regions.[19] although the existence of a specific lupus headache and the optimal approach to headache in SLE cases remains controversial. cranial neuropathy and plexopathy. and headache with occasional abducens nerve paresis. personality disorders. polyneuropathy.[25] Pregnancy outcome appears to be worse in SLE patients whose disease flares up during pregnancy. absence of a space-occupying lesion or ventricular enlargement. myasthenia gravis. cognitive dysfunction. and normal cerebrospinal fluid chemical and hematological constituents. aseptic meningitis. cerebrovascular disease. mood disorder.[24] Reproductive Further information: Systemic lupus erythematosus and pregnancy SLE causes an increased rate of fetal death in utero and spontaneous abortion (miscarriage).[19] depression. because it can involve so many different patterns of symptoms. It can rarely present with intracranial hypertension syndrome.[19] anxiety disorder. The overall live-birth rate in SLE patient has been estimated to be 72%.[19] polyneuropathy. characterized by an elevated intracranial pressure.[22] As a result. autonomic disorder. The American College of Rheumatology defines 19 neuropsychiatric syndromes in systemic lupus erythematosus.

and phenytoin. More than 38 medications can cause this condition.[33] TNFSF4 and BANK1. HLA class I. depression. hydralazine. These factors may not only exacerbate existing SLE conditions. symptoms of drug-induced lupus generally disappear once the medication that triggered the episode is stopped. There are. where mutations may occur randomly (de novo) or may be inherited.[2] [edit] Non-SLE forms of lupus . but also to pain. a number of environmental triggers and a number of genetic susceptibilities.[30][31] [edit] Genetics The first mechanism may arise genetically. but only classes I and II contribute independently to increased risk of SLE. quinidine. There is also a small but growing body of evidence linking SLE to lipstick usage.[34] ITGAM. However. and there are no data that show these antibodies cause connective tissue diseases such as SLE. STAT4. Some researchers have found that women with silicone gel-filled breast implants have produced antibodies to their own collagen. poor sleep quality.[36][37][38] [edit] Drug reactions Drug-induced lupus erythematosus is a (generally) reversible condition that usually occurs in people being treated for a long-term illness.[33] [edit] Environmental triggers The second mechanism may be due to environmental factors. Research indicates SLE may have a genetic link. Instead. and class III are associated with SLE.[35] Some of the susceptibility genes may be population specific. but it is not known how often these antibodies occur in the general population.Systemic Fatigue in SLE is probably multifactorial and has been related to not only disease activity or complications such as anemia or hypothyroidism. The most important genes are located in the HLA region on chromosome 6. Researchers have sought to find a connection between certain infectious agents (viruses and bacteria). however. Drug-induced lupus mimics SLE.[28][29] [edit] Causes There is no one specific cause of SLE. PTPN22. the most common of which are procainamide. class II.[33] CDKN1A. but also trigger the initial onset. multiple genes appear to influence a person's chance of developing lupus when triggered by environmental factors. poor physical fitness and perceived lack of social support. SLE does run in families. BLK.[32] Other genes which contain risk variants for SLE are IRF5. but no single causal gene has been identified. but no pathogen can be consistently linked to the disease.

These stimuli cause the destruction of cells and expose their DNA. Researchers are now identifying the individual genes. SLE is triggered by environmental factors that are unknown. significantly fewer TBMs can be found. and other proteins.[42] [edit] Abnormalities in apoptosis    Apoptosis is increased in monocytes and keratinocytes Expression of Fas by B cells and T cells is increased There are correlations between the apoptotic rates of lymphocytes and disease activity. Also. the population must have enough genetic diversity to protect itself against a wide range of possible infection. and researchers are trying to find drugs to break each of those links. In some people with SLE. and viruses.Discoid (cutaneous) lupus is limited to skin symptoms and is diagnosed by biopsy of rash on the face. particularly against proteins in the cell nucleus. The immune system must have a balance (homeostasis) between being sensitive enough to protect against infection. drugs. Each protein is a link on the autoimmune chain. scalp or arms. these antibody complexes damage blood vessels in critical areas of the body. some genetic combinations result in autoimmunity. Tingible body macrophages (TBMs) – large phagocytic cells in the germinal centers of secondary lymph nodes – express CD68 protein. neck.[41] Reticulate and stellate acral pigmentation should be considered a possible manifestation of SLE and high titers of anticardiolipin antibodies. the body's immune system produces antibodies against itself. a type of programmed cell death in which aging or damaged cells are neatly disposed of as a part of normal growth or functioning. Because of genetic variations in different components of the immune system. These cells normally engulf B cells that have undergone apoptosis after somatic hypermutation. [edit] Transmission In SLE. and SLE is the prototypical autoimmune disease. or a consequence of therapy. such as the glomeruli of the kidney. In the end. these antibody attacks are the cause of SLE. in some people the immune system attacks these nuclear-related proteins and produces antibodies against them. according to Crow. histones. and their role in the immune system. "All the key components of the immune system are involved in the underlying mechanisms [of SLE]" according to Rahman. From an evolutionary perspective. the proteins they produce. particularly parts of the cell nucleus. This material may present a threat to the tolerization of B cells and T cells. and these cells rarely contain material from apoptotic B cells. uningested apoptotic nuclei can be found outside of TBMs. [edit] Pathophysiology One manifestation of SLE is abnormalities in apoptosis. The likely environmental triggers include ultraviolet light. and being too sensitive and attacking the body's own proteins (autoimmunity).[2][39][40] SLE is a chronic inflammatory disease believed to be a type III hypersensitivity response with potential type II involvement. Dendritic cells in the germinal center may endocytose such .

[43] [edit] Clearance deficiency Clearance deficiency The exact mechanisms for the development of SLE are still unclear. Most of the monocytes and tingible body macrophages (TBMs). Also. since the pathogenesis is a multifactorial event. apoptotic chromatin and nuclei may attach to the surfaces of follicular dendritic cells and make this material available for activating other B cells that may have randomly acquired self-specificity through somatic hypermutation.antigenic material and present it to T cells. With SLE. Serum components like complement factors. This includes deficient phagocytic activity and scant serum components in addition to increased apoptosis. or NET protecting factors in patient serum. That leads to maturation of DCs and also to the presentation of intracellular antigens . furthermore. It leads to a progression of the apoptosis process and finally to secondary necrosis of the cells if this ability is disturbed. and some glycoproteins are. decisively important for an efficiently operating phagocytosis.[44] DNAse1 mutations in lupus have so far only been found in some Japanese cohorts. as well as internal danger signals. rather than abnormalities in the DNAse1 itself. or inefficient. Recent research has found an association between certain lupus patients (especially those with lupus nephritis) and an impairment in degrading neutrophil extracellular traps (NETs). they are smaller or scarce and die earlier. diminished. these components are often missing. which are found in the germinal centres of lymph nodes. CRP. activating them. Increased appearance of apoptotic cells also simulates inefficient clearance. Monocytes isolated from whole blood of SLE sufferers show reduced expression of CD44 surface molecules involved in the uptake of apoptotic cells. since they have lost their membranes' integrity. inducing maturation of dendritic cells (DCs). even show a definitely different morphology. impaired clearance of dying cells is a potential pathway for the development of this systemic autoimmune disease. Beside discussed causations. Necrotic cells release nuclear fragments as potential autoantigens.[45] The clearance of early apoptotic cells is an important function in multicellular organisms. These were due to DNAse1 inhibiting factors.

which promote the maturation of autoantibody-producing plasma . neither take it up nor present it via MHC molecules. follicular dendritic cells (FDC) are localised in GC.[46] Germinal centres [edit] Accumulation in germinal centres In healthy conditions.of late apoptotic or secondary necrotic cells. After migration into the mantle zone. In close proximity to TBM. In the case of clearance deficiency. accumulation of apoptotic debris can be observed in GC because of an ineffective clearance of apoptotic cells. In some people with SLE. apoptotic nuclear debris accumulates in the light zone of GC and gets attached to FDC. Autoreactive B cells can accidentally emerge during somatic hypermutation and migrate into the GC light zone. in contrast to bone marrow-derived DC. This serves as a germinal centre survival signal for autoreactive B-cells. normally do not receive survival signals by antigen planted on follicular dendritic cells. and the lymphocytes get activated by these autoantigens. maturated coincidentally. autoreactive B cells require further survival signals from autoreactive helper T cells. which attach antigen material to their surface and. A clearance deficiency in the skin for apoptotic cells has also been observed in people with cutaneous lupus erythematosus (CLE). Autoreactive B cells. via MHC molecules. inflammation and the production of autoantibodies by plasma cells is initiated. Autoimmunity possibly results by the extended exposure to nuclear and intracellular autoantigens derived from late apoptotic and secondary necrotic cells. which is why no free apoptotic and potential autoantigenic material can be seen. B and T cell tolerance for apoptotic cells is abrogated. the tingible body macrophages (TBM). apoptotic lymphocytes are removed in germinal centres by specialized phagocytes. and perish by apoptosis.

cells and B memory cells. the second is within the nuclei of the epidermal cells (antinuclear antibodies are present). The pattern of fluorescence suggests the type of antibody present in the patient's serum. In the presence of autoreactive T cells. The skin is from a person with systemic lupus erythematosus and shows IgG deposits at two different places: The first is a bandlike deposit along the epidermal basement membrane ("lupus band test" is positive). and may occur in normal individuals.[48] [edit] Diagnosis Microphotograph of a histological section of human skin prepared for direct immunofluorescence using an anti-IgG antibody. Antibody binding subsequently spread to other epitopes.[47] [edit] Others Elevated expression of HMGB1 was found in the sera of patients and mice with systemic lupus erythematosus. Several techniques are used to detect ANAs. high mobility group box 1 (HMGB1) is a nuclear protein participating in chromatin architecture and transcriptional regulation. Recently. Subtypes of antinuclear antibodies include antiSmith and anti-double stranded DNA (dsDNA) antibodies (which are linked to SLE) and anti- . [edit] Laboratory tests Antinuclear antibody (ANA) testing and anti-extractable nuclear antigen (anti-ENA) form the mainstay of serologic testing for SLE. Clinically the most widely used method is indirect immunofluorescence. [edit] Anti-nRNP autoimmunity Autoantibodies to nRNP A and nRNP C initially targeted restricted. The similarity and cross-reactivity between the initial targets of nRNP and Sm autoantibodies identifies a likely commonality in cause and a focal point for intermolecular epitope spreading. proline-rich motifs. ANA screening yields positive results in many connective tissue disorders and other autoimmune diseases. a chronic autoimmune disease may be the consequence. there is increasing evidence HMGB1 contributes to the pathogenesis of chronic inflammatory and autoimmune diseases due to its proinflammatory and immunostimulatory properties.

scaly patches on skin that cause scarring).[2] The anti-dsDNA antibody titers also tend to reflect disease activity. sensitivity = 27%.5% of people without SLE.[2] Other ANA that may occur in SLE sufferers are anti-U1 RNP (which also appears in systemic sclerosis). [edit] Criteria The American College of Rheumatology established eleven criteria in 1982. specificity = 37%. they are present in 70% of cases. however. whereas they appear in only 0.[50] [edit] Diagnostic criteria Some physicians make a diagnosis on the basis of the American College of Rheumatology (ACR) classification criteria. Oral ulcers (includes oral or nasopharyngeal ulcers). specificity = 86% (pleural is more sensitive. 1.histone antibodies (which are linked to drug-induced lupus). sensitivity = 57%. although not in all cases. specificity = 96%. Arthritis: nonerosive arthritis of two or more peripheral joints. specificity = 99%. with tenderness.[53] 3. Malar rash (rash on cheeks). liver enzymes.[53] 2. and they are also found in some people with rheumatoid arthritis. sensitivity = 86%. Photosensitivity (exposure to ultraviolet light causes rash.[53] 4. sensitivity = 56%.[51] which were revised in 1997[52] as a classificatory instrument to operationalise the definition of SLE in clinical trials. The criteria. They were not intended to be used to diagnose individuals and do not do well in that capacity. Discoid rash (red. SS-A (or anti-Ro) and SS-B (or anti-La.[53] 5. and drug sensitivities. Blood—hematologic disorder—hemolytic anemia (low red blood cell count) or leukopenia (white blood cell count<4000/µl). so some people with SLE may not pass the full criteria. cardiac is more specific). specificity = 96%. a person has SLE if any 4 out of 11 symptoms are present simultaneously or serially on two separate occasions. Because of this. both of which are more common in Sjögren's syndrome). and complete blood count. SS-A and SS-B confer a specific risk for heart conduction block in neonatal lupus. were established mainly for use in scientific research including use in randomized controlled trials which require higher confidence levels. or other symptoms of SLE flareups).[53] 6. scleroderma. specificity = 96%. Anti-dsDNA antibodies are highly specific for SLE. the LE cell test is now performed only rarely and is mostly of historical significance. The lupus erythematosus (LE) cell test was commonly used for diagnosis.[53] 7. lymphopenia (<1500/µl) or . For the purpose of identifying patients for clinical studies. swelling. but it is no longer used because the LE cells are only found in 50–75% of SLE cases. Serositis: Pleurisy (inflammation of the membrane around the lungs) or pericarditis (inflammation of the membrane around the heart). or effusion. electrolytes and renal function (disturbed if the kidney is involved). sensitivity = 43%. sensitivity = 18%.[49] Other tests routinely performed in suspected SLE are complement system levels (low levels suggest consumption by the immune system).

8. and/or false positive serological test for syphilis.[53] 10.[54] 11. specificity = 94%.[53] Hypocomplementemia is also seen. experience less pain. Antinuclear antibody test positive.[55][56][57] Recursive partitioning has been used to identify more parsimonious criteria. specificity = 89%. Early recognition of warning signs and good communication with a doctor can help individuals remain active. the St. It has sensitivity = 97% and specificity = 95%. when the disease develops. may have SLE without four of the above criteria. the likelihood of complications also increases in four areas: cardiovascular disease. or LE cells) or malar rash. Other alternative criteria have been suggested. Full classification tree: Uses 6 criteria.[53] This analysis presented two diagnostic classification trees: 1. Thomas' Hospital "alternative" criteria in 1998. sensitivity = 20%. pain. due to either consumption of C3 and C4 by immune complex-induced inflammation or to congenitally complement deficiency. antiphospholipid antibody. rash. Renal disorder: More than 0. but. quality of life can be improved through flare prevention.5 g per day protein in urine or cellular casts seen in urine under a microscope. which may predispose to SLE.[58] [edit] Prevention SLE is not understood well enough to be prevented.g. infections. Neurologic disorder: Seizures or psychosis. and cancer. sensitivity = 99%.thrombocytopenia (<100000/µl) in the absence of offending drug. Standard preventive measures. sensitivity = 51%. and dizziness.[59] As longevity of people with SLE increases.[60] [edit] Treatment .[53] [edit] Criteria for individual diagnosis Some people. anti-ds DNA.[53] Presence of anti-ss DNA in 70% of cases (though also positive with rheumatic disease and healthy persons). fever. headache. The warning signs of an impending flare include increased fatigue. screening for related diseases may be necessary to deal with the increased risks due to the side effects of medications. Simplest classification tree: SLE is diagnosed if a person has an immunologic disorder (anti-DNA antibody. Immunologic disorder: Positive anti-Smith. e. specificity = 93%. abdominal discomfort. anti-Smith antibody. especially those with antiphospholipid syndrome. and reduce medical visits. specificity = 49%. 2.[53] 9. and also SLE may present with features other than those listed in the criteria. false positive syphilis test. osteoporosis. sensitivity = 85%. Extra vigilance is considered warranted in particular for cancers affecting the immune system. It has sensitivity = 92% and specificity = 92%. specificity = 98%. sensitivity = 59%.

Hydroxychloroquine has relatively few side effects. Rather than suppressing the immune system nonspecifically. but it is not FDA-approved for this indication. In November 2010. and there is evidence that it improves survival among people who have SLE. the process of the disease. A number of potential treatments are in clinical trials.[63] [edit] Disease-modifying antirheumatic drugs Disease-modifying antirheumatic drugs (DMARDs) are used preventively to reduce the incidence of flares. The drug was approved by the FDA in March 2011. but long-term use of even low doses can cause elevated blood pressure and cataracts. Cellcept and Prograf have been used in the past.[61] Some drugs approved for other diseases are used for SLE 'off-label'. Hydroxychloroquine is an FDA-approved antimalarial used for constitutional. puffy round face. people who require steroids may develop Cushing's syndrome. and FDA is investigating reports that it may be associated with birth defects when used by pregnant women. Mycophenolic acid is also used for treatment of lupus nephritis. sometimes. Mild or remittant disease may. Hydroxychloroquine (HCQ) was the last medication approved by the FDA for lupus in 1955. methotrexate and azathioprine). Certain types of lupus nephritis such as diffuse proliferative glomerulonephritis require bouts of cytotoxic drugs. difficulty sleeping and osteoporosis. when flares occur. Medications such as Prednisone. These drugs include cyclophosphamide and mycophenolate. side-effects of which may include obesity. they are treated with corticosteroids. cutaneous. and lower the need for steroid use. Numerous new immunosuppressive drugs are being actively tested for SLE. Those side-effects can subside if and when the large initial dosage is reduced. they target the responses .[64] [edit] Immunosuppressive drugs In more severe cases. and articular manifestations. an FDA advisory panel recommended approving Benlysta (belimumab) as a treatment for the pain and flare-ups common in lupus. If required. nonsteroidal anti-inflammatory drugs and antimalarials may be used.[61] Cyclophosphamide is used for severe glomerulonephritis or other organ-damaging complications. DMARDs commonly in use are antimalarials such as plaquenil and immunosuppressants (e. as corticosteroids do.g.The treatment of SLE involves preventing flares and reducing their severity and duration when they occur. diabetes mellitus. medications that modulate the immune system (primarily corticosteroids and immunosuppressants) are used to control the disease and prevent recurrence of symptoms (known as flares). large appetite.[62] [edit] Medications Due to the variety of symptoms and organ system involvement with SLE. Depending on the dosage. be safely left untreated. its severity in an individual must be assessed in order to successfully treat SLE. Treatment can include corticosteroids and anti-malarial drugs.

drug tolerance. When opioids are used for prolonged periods. Lupuzor has given encouraging results in a phase IIb trial[65] [edit] Analgesia Since a large percentage of people with SLE suffer from varying amounts of chronic pain. Potent NSAIDs such as indomethacin and diclofenac are relatively contraindicated for patients with SLE because they increase the risk of kidney failure and heart failure.[61] Moderate pain is typically treated with mild prescription opiates such as dextropropoxyphene and co-codamol. Occupational exposure to silica. even though their mechanism of action is not well-understood. so there is less risk of serious infections with these drugs. and addiction may occur. Moderate to severe chronic pain is treated with stronger opioids. These two problems can lead to patients becoming housebound for long periods of time. It is believed that they reduce antibody production or promote the clearance of immune complexes from the body. such as oxycodone. which is one of the complications of lupus nephritis.[68] [edit] Hughes syndrome . since the condition is not likely to ever completely disappear. such as hydrocodone or longer-acting continuous-release opioids. or methadone. stronger prescription analgesics (pain killers) may be used if over-the-counter drugs (mainly nonsteroidal anti-inflammatory drugs) do not provide effective relief.of individual [types of] immune cells.[66] Unlike immunosuppressives and corticosteroids. IVIGs do not suppress the immune system. or vasculitis. [edit] Intravenous Immunoglobulins (IVIGs) Intravenous immunoglobulins may be used to control SLE with organ involvement.[67] [edit] Lifestyle changes Avoiding sunlight is the primary change to the lifestyle of SLE sufferers. as is the debilitating effect of intense fatigue. Opiate addiction is not typically a concern. chemical dependency. but the recurrence of the full disease is common in up to 30% of patients. Thus. MS Contin. The fentanyl duragesic transdermal patch is also a widely-used treatment option for the chronic pain caused by complications because of its long-acting timed release and ease of use.[30] [edit] Renal transplantation Renal transplants are the treatment of choice for end-stage renal disease.[61] See also Belimumab and Atacicept. as sunlight is known to exacerbate the disease. lifelong treatment with opioids is fairly common for chronic pain symptoms. Some of these drugs are already FDA-approved for treatment of rheumatoid arthritis. Drugs unrelated to SLE should be prescribed only when known not to exacerbate the disease. accompanied by periodic titration that is typical of any long-term opioid regimen. pesticides and mercury can also make the disease worsen.

[69] [edit] Management of pregnancy Further information: Systemic lupus erythematosus and pregnancy While most infants born to mothers who have SLE are healthy. Women pregnant and known to have anti-Ro (SSA) or anti-La antibodies (SSB) often have echocardiograms during the 16th and 30th weeks of pregnancy to monitor the health of the heart and surrounding vasculature.[55] If the thromboses migrate to the brain. [edit] Prognosis SLE is considered incurable.Hughes syndrome. is also related to the onset of neural lupus symptoms in the brain. Early mortality. however. most people diagnosed with SLE lived fewer than five years.[59] Contraception and other reliable forms of pregnancy prevention is routinely advised for women with SLE. The treatment plan for these patients requires thinning of the blood. SLE can flare up during pregnancy. the disease tends to run a more benign course. but highly treatable. since getting pregnant during active disease was found to be harmful. if symptoms are present after age 60. they can potentially cause a stroke by blocking the blood supply to the brain. In addition. aspirin is prescribed for this purpose. and proper treatment can maintain the health of the mother longer. Neonatal lupus is rare. which prove to be fatal if they move within the blood stream. also known as the antiphospholipid syndrome or sticky blood syndrome. pregnant mothers with SLE should remain under medical care until delivery. although in more severe cases anticoagulants such as warfarin are used. the leading cause of death for people with SLE. which can be attributed to cardiovascular diseases acquired from corticosteroid therapy. These scans can show localized areas of the brain where blood supply has not been adequate. Advances in diagnosis and treatment have improved survival to the point where over 90% now survive for more than ten years. brain scans are usually required for early detection. In the 1950s. but identification of mothers at highest risk for complications allows for prompt treatment before or after birth.[61] . is due to organ failure or overwhelming infections."[70]) Prognosis is normally worse for men and children than for women. but is merely the length of the referenced study. and many can live relatively asymptomatically. The mortality risk is fivefold when compared to the normal population in the late stages. If this disorder is suspected in patients. "the majority of people with lupus today can expect to live a normal lifespan. (It is important to note that "ten years" in this statistic does not indicate an average survival rate. Lupus nephritis was the most common manifestation. within 5 years. both of which can be modified by early diagnosis and treatment. According to the Lupus Foundation of America. Often. In this form of the disease the cause is very different from lupus: thromboses (blood clots or "sticky blood") form in blood vessels.

affects females more frequently than males.000 people. high blood pressure and high cholesterol should be prevented or treated aggressively. Steroids should be used at the lowest dose for the shortest possible period. created lesions that resembled wolf bites or scratches. Whether the increase is due to better diagnosis or to increasing frequency of the disease is unknown. like many autoimmune diseases. at a rate of almost 9 to 1. Another account claims that the term "lupus" did not come from Latin directly. Greek for "red." French for "wolf. gender. translating to about 159.[71] The ANA is the most sensitive screening test for evaluation.[73] SLE.[73] [edit] History and culture [edit] Etymology There are several explanations ventured for the term lupus erythematosus. doctors thought that the rash. hypertension. 1.[72] [edit] Epidemiology The rate of SLE varies considerably between countries.000 among those of Afro-Caribbean descent. nephrotic syndrome.To reduce potential for cardiovascular issues.[73][74] In Northern Europe the rate is about 40 per 100. 3. Lupus is Latin for wolf. some doctors thought the rash resembled the pattern of fur on a wolf's face.[73] In the United States the prevalence of SLE is estimated to be about 53 per 100. In various accounts.6 in 1974.[76] and "erythro" is derived from ερσθρός. In other accounts.000 out of 300 million people in the US being affected. but from the term for a French style of mask that women reportedly wore to conceal the rash on their faces." All explanations originate with the reddish. the dsDNA titre is sometimes useful to monitor disease flares or response to treatment.[75] SLE occurs more frequently and with greater severity among those of non-European descent. which was often more severe in earlier centuries.[73] The incidence of SLE in the United States increased from 1.000.[74] That rate has been found to be as high as 159 per 100. 2. The mask is called a "loup. butterfly-shaped malar rash that the disease classically exhibits across the nose and cheeks.0 in 1955 to 7. and changes over time.[61] High serum creatinine. anemia and hypoalbuminemia are poor prognostic factors. as such. The dsDNA (double-stranded DNA) antibody is also fairly specific and often fluctuates with disease activity. ethnicity. whereas anti-Sm (anti-Smith) is the most specific. and other drugs that can reduce symptoms should be used whenever possible." [edit] History .

American movie producer.[79] saying she hopes to avoid symptoms by maintaining a healthy lifestyle. British musician (discoid lupus) Sophie Howard. Arnold Klein.[77] Useful medication for the disease was first found in 1894. however she claims not to be affected by the symptoms yet. former anchor of CBS Sunday Morning. died of SLE complications in 1977. of the Backstreet Boys. has been suggested to have had SLE. known as dual. The term lupus is attributed to 12th-century physician Rogerius. homozygous. when Hench discovered the efficacy of corticosteroids in the treatment of SLE.[81] Inday Ba (also known as N'Deaye Ba). The neoclassical period was heralded by Móric Kaposi's recognition in 1872 of the systemic manifestations of the disease. The classical period began when the disease was first recognized in the Middle Ages and saw the description of the dermatological manifestation of the disorder.[86] Seal. due to the photosensitivity.[77] Medical historians have theorized that people with porphyria (a disease that shares many symptoms with SLE) generated folklore stories of vampires and werewolves. hair growth.[80] Louisa May Alcott.[88] Charles Kuralt. who used it to describe the classic malar rash. American author best known for her novel Little Women.[84] Lauren Shuler Donner.[89] . J Dilla (also known as Jay Dee). died of SLE complications in 1997. and confirmed by his dermatologist. sister of Howie D.[85] Hugh Gaitskell. This was the best available treatment until the middle of the twentieth century. a Swedish-born actress who died from SLE complications at age 32. as it occurs with other diseases as well) and is characterised by advances in our knowledge of the pathophysiology and clinical-laboratory features of the disease. scarring. and modern. The modern period began in 1948 with the discovery of the LE cell (the lupus erythematosus cell—a misnomer. died of SLE complications. British politician who died of SLE complications in 1963 aged 56. American chess player who died from SLE complications in 1976. The revelations caused considerable dismay amongst her fans. who presented legal documents during court depositions. when quinine was first reported as an effective therapy.[83] Caroline Dorough-Cochran. American singer. He founded the Dorough Lupus Foundation in her memory. Dr. a hip-hop producer and beat maker who died of SLE complications in 2006. neoclassical. or compound heterozygous porphyrias).The history of SLE can be divided into three periods: classical. and porphyrin brownish-red stained teeth in severe recessive forms of porphyria (or combinations of the disorder.[77] [edit] Notable cases              Michael Jackson suffered from both SLE and vitiligo. Lady Gaga has been tested borderline positive for SLE.[78] Diagnosed in 1986. Four years later.[82] Donald Byrne. British glamour model[87] Teddi King. leading to Gaga herself addressing the matter in an interview with Larry King. the use of salicylates in conjunction with quinine was noted to be of still greater benefit. as well as advances in treatment.

This blood brain barrier damage can . this means that either the barrier is damaged. former major league baseball player[94] Mercedes Scelba-Shorte.[98] Toni Braxton. or the transport proteins are not functioning well. American actress.          Ferdinand Marcos. current research is being geared towards finding a possible cause. Several papers discuss the importance of the presence of antibodies in the brain that are only produced in patients with lupus.[90] Mary Elizabeth McDonough. keeping it at a normal level. American R&B singer.[99] [edit] Research Since lupus is considered to be currently incurable. and producer. member of 90s British pop group Eternal.[102] This can be determined using various imaging methods as well as lumbar puncture (spinal tap) to assess cerebrospinal fluid. In a study conducted in London. died of heart failure resulting from SLE complications in 2003.[97] Kéllé Bryan. America's Next Top Model Season Two runner-up and model. researchers measured the albumin content in the brain using imaging and spinal fluid. British actress and singer[93] Tim Raines.[92] Elaine Paige. died of SLE complications in 1989.[95] Ray Walston. If the ratio of albumin outside the barrier to inside the barrier is high. They are extremely useful in that they provide a nutritional balance between ions in the brain. son of legendary actor John Wayne. American fiction writer who died of SLE complications in 1964. became ill with lupus in 1999. former Philippine president. character actor who died of SLE complications in 2001 after a six-year battle with the disease. One such paper highlights the inhibition of astrocyte proliferation in brain tissue from lupus patient serum.[100] Astrocytes are glial cells in the brain that participate in the support of cells that form the blood brain barrier. researchers used immunofluorescence to track the antibodies near the corpus callosum to determine whether anticardiolipin antibodies have an inhibitory effect on brain cells and whether they elicit thrombus formation in brain vessels.[101] In this study. and more effective treatment plans to extend and increase the quality of life for lupus patients. Hollywood director. which plays a part in neuropsychiatric lupus. blames her SLE on leaky silicone breast implants.[96] Michael Wayne. songwriter and actress. Albumin is a protein that can be carried into the brain through the blood brain barrier by other transport proteins. However.[91] Flannery O'Connor. The images were used to illustrate blood brain barrier damage while the spinal tap was used to measure the protein content in the brain. a cure. the majority of the recent papers focus on the effect of lupus on blood-brain barrier integrity. It was found that 20–70% of lupus patients with neurological symptoms have some form of a central nervous system involvement. part owner of Batjac Productions.

[62] At Stanford School of Medicine Institute for Immunity Transplantation and Infection. or Chinese origin. Other autoimmune diseases include diabetes. the FDA emphasized that the drug will not work in all cases. the most common being joint pains. and that more research and advanced therapies are called for. branded Benlysta. It is ten times more common in women than men. rheumatoid arthritis and thyroid disorders. It is more common in people from Afro-Caribbean. What causes SLE? SLE is an auto-immune disease. . The severity of SLE ranges from mild to severe. Although SLE can run in families. This means that the immune system (which normally protects the body from infections) mistakenly attacks itself. Notwithstanding the approval. only 3 in 100 of children of patients with SLE will actually develop the disease. LymphoStat-B ). Discoid lupus only affects only the skin and is not discussed in this leaflet. was approved by the FDA in March 2011. There are two main forms of lupus. It is commonly just called SLE or 'lupus'. skin rashes and tiredness. However. Steroids and/or other medication is sometimes also needed. The other form is systemic lupus erythematosus which involves the skin and joints and may involve internal organs such as the heart or kidney as well.[103] A study called BLISS-76 tested the drug. trials are underway for use of DHEA as a therapeutic agent for the treatment of mild to moderate SLE. Problems with kidneys and other organs can occur in severe cases.000 people in the UK. This can cause symptoms and may damage the affected parts of the body. Treatment includes anti-inflammatory painkillers to ease joint pains. which produce antibodies against foreign and self cells. Who gets SLE? SLE affects about 3 in 10. Belimumab (HGS1006. What is systemic lupus erythematosus? Systemic lupus erythematosus is a chronic (persistent) disease that causes inflammation in various parts of the body. It most typically develops in women aged between 20 and 40.[104] The drug. anyone at any age can be affected.impact lupus patients by increasing their discomfort and increasing the intensity of the disease.[105][106] Systemic Lupus Erythematosus Systemic lupus erythematosus (SLE) can cause various symptoms. Asian. BLyS stimulates and extends the life of B lymphocytes. a fully human monoclonal anti-BLyS antibody.

Mouth ulcers are more common in people with SLE. Skin. This can cause pleurisy (pains in the side of the chest) or pericarditis (central chest pains). In addition. What are the symptoms of SLE? The symptoms and severity of SLE vary tremendously between people. Heart and lungs The tissues that cover the heart and lung (the pleura and pericardium) may become inflamed. Blood and lymph A mild anaemia is common. Joint stiffness is common and is usually worse first thing in the morning. Many people have fatigue (tiredness). quite serious hair loss sometimes develops. Sometimes only a few joints are affected whereas other people have many joints affected. Mild joint swelling may occur but severe arthritis with joint damage is unusual. Hormone changes may play a role in SLE which could explain why it is much more common in women. Some factor may trigger the immune system to attack itself. drugs (for examples minocycline or hydralazine) or sunlight. Any hair loss tends to be minor and cause hair 'thinning' rather than bald patches. although the hair often grows back when SLE is less active. Possible triggers of SLE include infections. Various other rashes may develop. The blood vessels just under the skin may also be affected and cause poor circulation to the fingers and toes (Raynaud's phenomenon). Kidneys . etc) may also develop a rash. wrists. one or more of the following may develop: Joint and muscle pains Most people with SLE develop some joint and muscle pains. mouth and hair A red rash which develops over the cheeks and nose is common (the 'butterfly rash'). Some hair may fall out (alopecia).It is not known why SLE occurs. Other blood problems such as reduced numbers of white blood cells or platelets (the cells that help the blood to clot) are less common. weight loss and a mild fever. However. Other areas of skin exposed to sunlight (hands. The actual heart or lung tissue is less commonly affected. Some lymph glands may swell. About 6 in 10 people with SLE find that their skin is very sensitive to sunlight. The pains may 'flit' from joint to joint. The small joints of the hands and feet tend to be the ones affected most. A tendency to form blood clots is an uncommon complication.

headaches. (Antibodies are small proteins that are part of the immune system. they can also occur in perfectly well people who do not have SLE. typical symptoms combined with high levels of certain antibodies usually indicate that you have developed SLE. At first they may be confused with other problems as there are many possible causes of joint pains and tiredness. Various other antibodies are also associated with SLE. Sometimes several symptoms occur together.Around 1 in 3 people with SLE may develop inflammation of the kidneys which can lead to the kidneys leaking protein and blood into the urine. It is not uncommon for people to have difficulties in coping with having SLE. The level of this chemical reflects how 'active' the . Once SLE is diagnosed. migraines and other conditions. Brain and nervous system Mental health problems in SLE are fairly common and include depression and anxiety. brain or kidneys. How does SLE progress? In some cases the symptoms develop quite slowly. it can also be due to your reaction to having a serious illness. It is important to share any feelings you have have with your doctor as treatment can be really beneficial. sometimes longer. Typically. This includes some inflammation of other parts of the body apart from joints and skin. A blood test to measure a blood chemical called 'complement' (another part of the immune system) can assess the activity of the disease. lung. Symptoms range from mild to severe.) Another antibody called anti-doubled stranded DNA (dsDNA) is a often present in people with SLE. Severe SLE. This can even be life-threatening. you will normally be advised to have regular checks and tests. Many people with SLE just have joint and/or skin symptoms with tiredness. inflammation of the brain can lead to epilepsy. severe inflammation develops which can cause damage to organs such as the heart. However. For example. pericarditis or mild kidney inflammation. In some cases. These are unpleasant but are not serious or life threatening. Although mild depression can be part of the disease itself. How is SLE diagnosed? If your symptoms suggest SLE then your doctor will usually do some blood tests. However. For example:    Mild SLE. These relapses tend to alternate with times when symptoms settle down (remission). This does not usually cause problems unless the disease is very severe. The reason why symptoms flare-up or settle down is not yet fully understood. This may include pleurisy. there are times when the disease flares up (relapses) and symptoms become worse for a few weeks. Most people with SLE have an antibody called antinuclear antibody in their blood. Occasionally. Kidney failure is an uncommon complication. Moderate SLE. regular blood tests to check for anaemia and urine tests to check for kidney problems.

naproxen and diclofenac. Most people with SLE are seen regularly by a specialist who advises on treatment. depending on the severity of the disease or flare-up of symptoms and also which parts of the body are affected. The most serious is damage to the eye which is unusual. Immunosuppressants . If necessary. It may take 6-12 weeks for it to become fully effective. Steroids reduce inflammation and the dose is usually given as low as possible in order to reduce any side effects from the steroids. The dose is often reduced to a lower 'maintenance' dose once symptoms have eased.disease is. other medication can be prescribed to protect the stomach from these possible side-effects. The treatments may vary from time to time. Your doctor is likely to check your vision before you start it and then every year. muscle wasting. Steroids may cause side-effects if taken for long periods. Examples of these are ibuprofen. Other tests including scans and X-rays may be advised to check on the function of the heart. thinning of the skin. Many people with SLE take this drug long-term to keep symptoms away. high blood pressure and other problems. These include thinning of the bones (osteoporosis). this condition can usually be controlled and symptoms eased. weight gain. If you are taking this drug and notice any changes in your vision. It is not clear how this drug works in SLE. kidneys and other organs if the disease is thought to be affecting these areas of the body. You may even not need any treatment if you have very mild symptoms. What are the treatments for SLE? Although there is no cure for SLE. Hydroxychloroquine Hydroxychloroquine is often effective at improving skin problems. The main possible side-effects from these drugs are stomach and gut problems such as pain or bleeding in the stomach. Steroids Steroid tablets are usually advised if you develop more severe symptoms. tiredness and joint pains that are not well controlled by non-steroidal anti-inflammatory drugs. you should inform your doctor promptly. Treatment options include the following: Non-steroidal anti-inflammatory drugs (NSAIDs) These are often called anti-inflammatory painkillers and are commonly prescribed to ease joint or muscle pains. Side-effects are uncommon.

methotrexate and mycophenolate may be advised if you have severe SLE. Severe brain involvement is also rare but can be very serious. However. For a few people. If you take one of these you need to have regular blood and urine tests to look out for possible side-effects. some women with SLE have a higher chance of miscarriage. symptoms are mild or moderate with little risk to life. Strong sunlight can aggravate symptoms of SLE. What is the prognosis (outlook) for people with SLE? Most people with SLE lead active. Long sleeved clothing and wide brimmed hats are best in sunny weather. Some people find that symptoms settle in their middle age and they can come off all treatment. particularly if you take steroids or immunosuppressant medication. Although fertility is not usually affected in people SLE. These are sometimes tested for in people with SLE. Further help This leaflet is only an introduction to a disease that can be confusing. normal lives.Drugs such as azathioprine. Some contraceptive pills may not be advised depending on disease severity. support and information can be obtained from: . For most people with SLE. On hot sunny days you should wear a sunblock on exposed skin with a protection factor of 25 or above that protects against UVA and UVB. so if serious problems have not developed in this time then they are unlikely to do so. Try to avoid infections. For many people with SLE. the pattern of their disease becomes established within ten years. Severe inflammation of the kidneys leading to kidney failure can rarely occur. Avoid contact with people who have infections. Pregnancy. modern immunosuppressive treatments have improved the outlook even for people with severe disease. However. These drugs are called immunosuppressive drugs because they work by suppressing the immune system. If you have SLE you are more prone to infection. One side effect of these drugs is that you will be more prone to developing infections. but can usually be eased with treatment. ciclosporin. cyclophosphamide. SLE is severe and can be life-threatening. A doctor or nurse will advise on the best method of contraception. The outlook for people with SLE is much better than it was in the past. Modern treatments are more effective. The joint and skin symptoms may persist. Women who have badly inflamed kidneys due to SLE may have high blood pressure in pregnancy. Some other points about SLE      Avoid the sun. Other auto-immune diseases such as Sjögren's syndrome and thyroid problems are more common than average if you have SLE. Further help. most women with mild or well controlled SLE at the start of pregnancy are likely to go through pregnancy with few problems.

Chesterfield.Lupus UK 1 Eastern Road. fatigue. She described her situation as "desperate" and was on the verge of suicide. we were very hopeful that with hard work she could improve her health and vitality. had extremely low amino acid levels and abnormal bowel flora. Laboratory Studies: The patient was anemic. It took some time to convince the patient that her attitude needed to become more optimistic. Kozora E. that any recovery would be slow and difficult. This had become a selffullfilling prophecy. 2006 Apr 15.lupusuk. tried to dissuade her from consulting with us since there was "nothing of any usefulness for her condition outside of the drugs that she was already taking". St Mary's Gate. Ellison MC. An amino acid blend was constructed based on her laboratory study. Her husband. Accupressure was employed. and fast foods. Program of Care: Major dietetic reform was initiated with elimination of allergens and refined carbohydrates. She had numerous food and inhalant allergies. skin problems. British Association of Dermatologists (2004) CASE 3: SYSTEMIC LUPUS Patient Presentation: A twenty nine year old female presented with a ten year history of severe fatigue. In addition to a whole foods diet. West S. References      D'Cruz DP. Derbyshire. She was despondent over her condition and had been convinced by her medical physicians over the years that her condition was permanent and would get worse with time. and pain in systemic lupus erythematosus (SLE): relationship to the American College of Rheumatology SLE neuropsychological battery. S41 7TD Tel: 01246 558033 Web: www. mercury.arthritisresearchuk. pale. Lecture INFINITE VARIETY: An Introduction To Biochemical Individuality Part I Part II CASE STUDIES Part III The patient appeared weak. A glucose tolerance test revealed dysinsulinism. The patient began training in meditation and relaxation disciplines.55(4) Arthritis Research UK Copeman House. 2006 Aug 15. She had been diagnosed with Systemic Lupus Erythematosis. and immune dysregulation. St Mary's Court. Arthritis Rheum. and undergone years of corticosteroid usage including prednisone and methotrexate. [abstract] Ocular Toxicity and Hydroxychloroquine: Guidelines for Screening. but that due to her age. Systemic lupus erythematosus. coffee. The diet consisted of refined carbohydrates. joint pains. RM1 3NH Tel: 01708 731251 Web: www. Essex. specific supplements were given to improve functioning of the body as a whole and the immune system specifically. Hair analysis revealed elevated aluminum. and cadmium. The patient was advised to avoid future dental silver/mercury amalgams and consider replacements with composite fillings. BMJ. . a medical physician.332(7546):890-4. and had very poor muscle tone. Romford.

psychologists. Discuss evidence that supports self-management. Her skin began to improve and her color became more healthy. The patient missed the stimulation of her coffee and junk food and suffered withdrawal symptoms as she avoided her food allergens.   Patient History . nurses. Encouraged by the improvements. Within two months she began to notice improved energy and a decrease in muscle and joint pain. List other medical treatments that may be needed for people with SLE. RN." She is not on any medications. Included are specifics about chronic illness. and difficulty sleeping. MSN Overview This case describes a clinical presentation of a young woman with systemic lupus erythematosus (SLE) as well as medical treatment and self-management skills for persons to live successfully with SLE. She has been off work since the miscarriage and complains of arthralgia and extreme fatigue as well as feeling "blah. Her other complaints include decreased appetite. She ceased taking the steroids and methotrexate. She has only occasional joint discomforts which she describes as "minor in nature. Identify resources for further information about SLE. Describe how SLE is diagnosed. nutritionists. the patient increased her efforts and continued to reap health rewards. She does take a multivitamin. and other related fields of study." Systemic Lupus Erythematosus Marilee G. Patient Presents Sondra Lee Evan is a 30-year-old female who presented for an obstetrics follow-up 6 weeks post-miscarriage. Four years later the patient is pursuing a nursing career and enjoys good health. physicians. She was 10 weeks pregnant at the time of her miscarriage. self-management skills. learning selfmanagement skills and potential benefits of using self-management skills. Bomar. Objectives            Define systemic lupus erythematosus (SLE). Define self-management. occupational therapy. joint swelling and stiffness. Describe the main categories of medications used in the treatment of SLE. This case is designed for health professionals and students in physical therapy.Outcome: The first several weeks were rough. social workers.

Both sets of grandparents have died from a motor vehicle accident. Evan is of African American/American Indian descent. Initially she thought this was due to her pregnancy and the hot July weather. In the past 2 to 3 weeks she has noticed swelling in her knee along with difficulty rising from a seated position. I also find myself irritated at little things that normally would not bother me. She reports that she is only able to complete one or two other tasks such as vacuuming. Her parents are alive and in good health. then feeling like her sleep was not restful when she gets out of bed in the morning. if I don't write it down immediately. laundry or dusting before she needs to rest again. She attended two years of college and works full time as an accounting assistant for a large manufacturing firm. "I always prided myself on remembering names. Her father has hypertension that is controlled by lifestyle changes (dietary changes. She states. She first noted stiffness in her fingers in the morning and after activity such as typing on the computer. Evan describes pain. most notable in the morning and after activity involving her hands and knees. She also volunteers with her son's daycare and participates in his swimming and sporting activities. She describes the pain as intermittent." Mrs.6°F HR: 82 bpm Resp: 20/min. She describes needing to rest after her morning routine of showering. dates. Her mother has type 2 diabetes mellitus that is controlled with lifestyle changes and oral medications. dressing and fixing breakfast. or from complications from diabetes mellitus or heart disease. Evan has been married for six years and has one 5-year-old son. Now. waking after 2 to 3 hours followed by difficulty returning to sleep for 1 or more hours after waking.    Physical Exam Height: 64" Weight: 108 lbs Temperature: 99. She notes that her lack of sleep interferes with her memory and coping abilities. Mrs. I forget it. She denies any known family history of lupus. BP: 112/70 . Mrs. but reports that her arms and tops of her feet itch after she is in the sun without sunscreen.       Mrs. exercise. She denies any complications or prolonged illnesses or injuries. swelling and stiffness in her joints as progressing over the past 3 months. She denies any type of rash after sun exposure. and weight loss) and medication. Evan describes her sleeping pattern as follows: difficulty falling asleep. About 2 months ago she noticed swelling in her fingers and wrists. Evan explains that her appetite remained decreased after her morning sickness subsided 2½ months ago. Mrs. Mrs. Her pain is relieved by rest and by Tylenol or ibuprofen. and appointments. Evan reports having the "normal" childhood illnesses of chickenpox and mumps. She reports that her current level of fatigue is challenging to her as she was always active and energetic prior to her miscarriage. rheumatoid arthritis or other rheumatic conditions. She has been active in her community and church.

she feels Mrs. erythrocyte sedimentation rate (ESR).400.1 million/mm3 5. Smith checks to see that Mrs. Smith did not find an abdominal mass and there was no tenderness on palpation of the abdomen.10. physical exam. Complete blood count (CBC) Component Mrs. Evan. and a urinalysis.16 g/dl Male 14 . Evan exhibits the following signs: joint stiffness and swelling especially noted in her hands and wrists bilaterally. Evan chooses. Evan has a rheumatic condition that needs further investigation by a rheumatologist.4 million/mm3 Male 4.0 million/mm3 Normal Range * Female 4.47% Male 42 .000/mm3 Female 12 . In addition to the physical exam and diagnostic tests. She provides Mrs. Dr. and low-grade fever suggest the presence of a rheumatic condition. Evan's Results 4. Dr. Mrs. Evan has no drug allergies and prescribes Vioxx® [since 2004 removed from the US market]. and diagnostic test results. Evan if she has had any change in her symptoms and if she has ever been seen by a rheumatologist.5. On exam.000 .    Follow-up Phone Conference Two days later. chemistry profile. Dr. and reports that an acute infection has been ruled out.7 . Evan with the names of three local rheumatologists and will provide referral information along with a complete set of records to the one Mrs. Evan is given the schedule for her tests and is told she can expect a phone call with the results in approximately 48 hours. but must also rule out the possibility of a more acute problem such as an infection or thyroid disorder. Smith contacts Mrs. In addition. No heart murmur or irregularity is noted in Mrs.000 . history.000/mm3  Red blood cells (RBC) White blood cells (WBC) Hemoglobin (Hgb) Hematocrit (Hct) Platelet count 3.   Mrs.950/mm3 11 g/dl 36% 148. Smith explains that joint stiffness and swelling along with the decreased ROM.6. Dr.700/mm3 . Smith orders lab tests including complete blood count (CBC). Smith asks Mrs. the fatigue. At the conclusion of her visit. summarizes the test results. Dr.18 g/dl Female 37 . Dr. Her right knee is also noted to have some swelling along with decreased range of motion (ROM). Dr. Evan's heart rate on auscultation. Smith takes a detailed history and requests that Mrs.52% 150.2 . X-rays of Mrs. It is also noted that her weight had decreased by 10 pounds since her miscarriage. Dr. Smith explains to Mrs. Smith explains that given the symptoms. thyroid panel. Evan keep a daily log of her temperature. Dr. Evan that she suspects a rheumatic condition. Evan's hands and knees bilaterally and an abdominal ultrasound are ordered.

7.3 mg/dl 3 .11 µg/dl Triiodothyronine (T3) Thyroxine (T4) .2 mEq/L 25 mEq/L 8.39 U/ml 5 .70% 20 .7 . These normal ranges given are for adults.1 mg/dl 7.230 ng/dl 4 . Evan's Results Normal Range * 25 U/ml 13 .0 mg/dl 0.9 mg/dl 3.0% * Normal ranges may vary among different references.10.2 mg/dl 7.7 mg/dl 3.35 U/ml 8.42 * Normal ranges may vary among different references.40% 2 .5 mg/dl 2. These normal ranges given are for adults.5 mg/dl 137 .35 .5 .5 .45 Alkaline phosphatase Asparate amino transferase (AST) 28 U/ml Alanine amino transferase (ALT) 22 U/ml Blood urea nitrogen (BUN) Creatinine Sodium (Na) Chloride (Cl) Potassium (K) Carbon dioxide (CO2) Calcium (Ca) Phosphate Uric acid pH   25.8 mg/dl 138 mEq/L 104 mEq/L 4.1.5 mEq/L 24 .0 .29 mEq/L 8.5 .4.4% 0.7.6 . Thyroid panel Component Mrs.147 mEq/L 100 .106 mEq/L 3. Chemistry profile Component Mrs.8% 1 .25.5 mg/dl 1.Mean corpuscular volume (MCV) Mean corpuscular hemoglobin (MCH) Mean corpuscular hemoglobin concentration (MCHC) Neutrophils Lymphocytes Monocytes Eosinophils Basophils   86 µm 28 pg 33 g/dl 62% 28% 7% 2% 1% 80-95 µm 27-31 pg 32 . Evan's Results Normal Range * 167 ng/dl 6 µg/dl 110 .40 U/ml Female 5 .1.36 g/dl 55 .

Evan's Results Amber Clear 1. This test is nonspecific and is used to detect inflammatory. Interpretation of Lab Values. Urinalysis (UA)   Component Color Turbidity Specific gravity pH Glucose Ketones Blood Protein Bilirubin Urobilinogen Mrs.010 . and necrotic processes. wrists and knees showed soft tissue swelling and no joint space narrowing or bone damage.0 Negative Negative Negative Trace Negative 0. X-rays: Hands.8 Negative Negative Negative Negative Negative 0.0 Negative Negative Negative or rare Negative Negative or rare Few Nitrate for bacteria Negative Leukocyte esterase Negative Casts RBCs Crystals WBCs Epithelial cells    Occasional hyaline casts Negative to occasional hyaline casts Occasional Negative Rare Few * Normal ranges may vary among different references. fall and settle in the bottom of the glass tube over one hour. Female: up to 20 mm/hr. These normal ranges given are for adults. the greater the amount of inflammation.amber Clear to slightly hazy 1. These normal ranges given are for adults. History and Physical Exam .10 µU/ml * Normal ranges may vary among different references. For inflammation.025 4. Mrs.Thyroid stimulating hormone (TSH) 8 µU/ml    2 .1.1 .1. neoplastic. the higher the rate.4. The normal range for ESR: Male: up to 15 mm/hr. infectious.018 5.6 . Erythrocyte sedimentation rate (ESR) measures in millimeters how fast red blood cells cling together. Evan's results: 240 mm/hr.5 Normal Range * Yellow .

Dr. infections. As SLE progresses there will be periods when very few symptoms are noted (remissions) and other times when the disease is very active (flares). blood. Mrs. The cause of SLE is unknown. Smith. There are ongoing studies about the relationship of hormones in women from puberty to menopause and the incidence of SLE. Dr. The third type is drug-induced lupus. it is likely the rheumatologist will order further tests. Her physical exam remains unchanged from her visit with Dr. decreased appetite. Smith. Scientists currently believe that there is a genetic predisposition to the disease with environmental factors playing a triggering role in the symptoms being expressed. Given these results. and hormones. extreme fatigue.0°F to 99. At this point. is one of three types of lupus. creatinine and trace of protein in the urine also suggest the possibility of a rheumatic disease. and difficulty sleeping. joint swelling and stiffness. even life-threatening problems. the following month. Blue. SLE is a systemic. She has noted some relief from pain and the swelling in her hands and knee is somewhat less than it was before she started the medication.    Rheumatology Referral Mrs. . Blue states that further diagnostic tests are needed to determine the specific disease and that she suspects systemic lupus erythematosus. American Indian. joints. Smith as well as the temperature log Mrs. The temperature log shows daily temperatures ranging from 99. ultraviolet light. SLE can range from mild disease only affecting a few organs to severe. the test results suggest a rheumatic disease.5 million people have some form of lupus in the United States.8°F. given her symptoms of arthralgia. Lupus affects women 10 to 15 times more frequently than men. Blue reviews the records from Dr. Evan's symptoms remain unchanged since her visit with Dr. chronic inflammatory auto-immune disease that can affect the skin. Drug-induced lupus often occurs when certain prescribed medications bring about the signs and symptoms of lupus. kidneys. It is estimated that 1. Evan sees Dr. the high ESR and slightly high kidney function indicated by the BUN. and cardiovascular system. Systemic Lupus Erythematosus (SLE) SLE or lupus. In addition. and Asian ethnic origins are affected more often than Caucasian. Dr. Blue agrees that the signs and symptoms point to a rheumatic disease. The second type is discoid lupus which is limited to the skin. and swelling and decreased ROM in her right knee also support this conclusion. and African American. chemistry profile and UA.         Referral Results Mrs. Some environmental factors that have been studied include antibiotics. Evan's ANA is positive and the pattern interpreted is most suggestive of that seen with SLE. a rheumatologist. A blood test for antinuclear antibodies has been ordered as well as repeat CBC. The physical findings of joint stiffness and swelling in her hands and wrists. Evan has been keeping. Each case of SLE is unique as the symptoms and progression will vary. extreme stress.

loss of appetite. one of the newer NSAIDs but later withdrawn by the manufacturer. which come in many forms. They . thus limiting their ability to process antigens and lessening antibodies. In addition to preventing malaria. Evan's CBC. Their value in rheumatic diseases was originally discovered following anecdotal reports from soldiers who took Atabrine during the war in the 1940s to prevent malaria. and immunosuppressives. Over 20 NSAIDS are available by prescription or over-the-counter. Antimalarials work by blocking ultraviolet light from damaging skin. inflammation. Vioxx® was prescribed by Dr. We describe three categories of DMARDs for treating lupus: antimalarials. but the COX-2s do not influence natural protective mechanisms of the stomach and are less likely to cause gastrointestinal distress and stomach ulcers. Dr. regulate many of the body's physiologic functions. The results of Mrs. Glucocorticoids.2 (COX-2) inhibitor. glucocorticoids. Another important feature is that antimalarials do not lower blood counts or make patients more susceptible to infection. and altering the acidbase balance of cells. These hormones. Atabrine was discontinued and has since been replaced with hydroxychloroquine (Plaquenil®). rash and black spots in visual field. Smith. The NSAIDs (see also FDA warnings about NSAIDS and CV and GI risks) relieve fever. chemistry profile and UA remain unchanged from the initial information received from Dr. Antimalarials are not used in the management of organ-threatening lupus. lowering cholesterol levels. Atabrine improved their rashes and joint symptoms. The COX-2s act with basically the same inflammation-fighting properties as traditional NSAIDs. Report any medication side effects. Antimalarials. is classified as a cyclooxygenase . Medical Treatment Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) SLE is a chronic inflammatory disease. Eye exams are recommended before starting therapy and every year after. malaise. 1. they mainly stabilize the cells. making them less likely to engage in the inflammatory process. The onset of action is two to three months with benefits noted by patients in four to six months. Vioxx®. and serositis. Blue diagnoses SLE based on the signs and symptoms noted in the medical records and mentioned in the interpretation earlier along with the findings of the diagnostic tests. blocking cytokines that promote inflammation. 2. nausea. Blue uses the American College of Rheumatology's classification criteria. Disease-Modifying Antirheumatic Drugs (DMARDs) The DMARDs are used to alter the course of the destructive inflammatory process. When used for pharmacologic activities. Those most commonly noted include diarrhea. Smith. pain muscle aches. Dr.

difficulty concentrating. and . moon-face appearance. Patients with involvement of the heart.also block numerous chemical pathways and decrease the number of circulating lymphocytes. liver. 3. organ . Evan was placed on prednisone as she has beginning signs of kidney involvement based on her lab results and UA. impaired wound healing.threatening lupus. but it is important to recognize the possibility and monitor for them carefully. increased appetite. Prednisone is generally used for treating active. If steroids are used. or blood are begun on higher doses than patients with severe flare-ups of non-organ threatening lupus or patients with chronic. Patients should not stop taking this medication abruptly as the adrenal gland has not been producing glucocorticoids and cannot respond to an abrupt removal of prednisone. increased facial hair. heartburn which can lead to ulcers. side effects may include heartburn. hair loss (upper head and temples). every effort is generally explored to reduce the dosage to its lowest possible effective level. These include thin skin. In the beginning. muscle weakness. muscle weakness and brittle bones. and difficulty sleeping. non-organ-threatening lupus. kidneys. bruises. and a much greater risk of infection. Each one has specific uses in the treatment of lupus and side effects can be problematic. the most common chemotherapy agents include cyclophosphamide) and methotrexate (Rheumatrex®). elevated blood sugar. It may be ordered up to four times per day during acute inflammation as it is more quickly metabolized. Patient's Medication Mrs. The last group of patients are on the lowest daily doses. The most commonly-prescribed glucocorticoid used in the treatment of lupus is prednisone. Cushing's includes weight gain. Immunosuppressives. loss of calcium in bones. In lupus. hypertension. menstrual irregularity. thin skin. cataracts. decreased potassium levels. Patients should take this medication as directed. palpitations. weight gain (centrally . One group of these side effects are known as Cushing's syndrome. When ordered once daily. These medications fall into different categories according to the actions they perform. Additional side effects may occur over time. agitation. She was given information about lupus and about her medications. glaucoma. The dosage of this medication is designed to be reduced gradually (tapered). it should be taken at breakfast with food. Prednisone requires careful monitoring and can cause serious complications. mild. Not all patients experience these side effects. lungs. Azathioprine is an anti-rejection medication.noted at the belly and buttocks). They are also referred to as cytotoxic or "steroid sparing" medicines. fluid retention with bloating and puffiness (noted especially in face and ankles). confusion. Immunosuppressives are classified into chemotherapy agents and anti-rejection medications for transplant patients.

Chronic pain such as that experienced by someone with arthritis or lupus is different. Pain acts as a warning signal to our body indicating a problem. Acute health problems begin with a sudden onset. depression) may differ from one individual to the next. Medical treatment and self-management are important ways to intervene and stop the pain cycle. This information was reviewed with her. are easily diagnosed. Self-Management Skills in Chronic Illness Most people are capable of pulling their resources and energy together to deal with acute health problems such as a cold or pneumonia. Once the cycle begins it is difficult to stop. lasts for and indefinite amount of time. It is the continuous cycle that poses a problem as it can keep a person from pursuing . Often a pain cycle may develop. One example to consider is pain. once the cause is treated then the pain goes away. On the other hand. are relatively short lived. and the treatment results in cure of the acute illness.about community resources and how to contact the clinic. Chronic illness affects all aspects of a person's life and may require ongoing treatment and lifestyle changes for the person to continue functioning at a desirable level. The end points (pain. has a rocky course. She was encouraged to call with questions and to report any possible side effects of the medication. withdrawal. In acute pain. The pain cycle visually represents what may occur in a person with a chronic illness such as lupus. can be difficult to diagnose. chronic illness has a gradual onset. She was given an appointment to follow-up in one month and lab work was ordered prior to that appointment. fatigue. and there is rarely a cure.

Use "I" messages. We will discuss each of these. Next Tuesday at 1:30 p. and decisions about medical and alternative health care options. Communication Communication includes all the different people and situations an individual may encounter on a daily basis. The patient needs to get his/her message across to the health care professional in the limited time available. If clarification is needed.. alternative health measures. For a person with a chronic illness such as lupus a typical day may include family. Some simple tips may help Mrs. Knowing when to use humor is important. This plan should be something the patient wants to do and it should answer important points he/she want to make during the appointment with the health care professional. employer and health care team. and self-management are examples of interventions aimed at stopping the continuous cycle. physical activity and exercise. ask the person to rephrase what was said or rephrase what the person said. It is necessary to find interventions that stop the cycle and help the person live successfully with his/her chronic illness. nutrition. Humor is sometimes useful when a conversation goes in the wrong direction. Self-management skills refer to all the daily decisions a person makes to attain the greatest possible physical functioning and mental outlook to positively manage his/her chronic illness:       communication.. The patient can practice this by using a Communication Action Plan." Acknowledge the other person and his/her message. Evan in her daily encounters. friends.m. A patient should learn to communicate effectively with members of the health care team.        Effective communication involves more than one person. coping strategies and stress reduction.his/her interests and vocation. Be clear and concise. Medical treatment. managing medications. Non-verbal communication sends an important message. One day each week I will summarize how I feel and concerns I need to . It is helpful and possible to prevent this cycle from occurring. "I feel. Example Communication Action Plan Where (location): When (time of day): How often (days of At my next appointment with my physician.

Another coping theme is the use of stress management [scroll down] techniques such as meditation. There are many ways to manage stress. A form of this plan can be used for any area of self-management in which a person has a desire to improve his/her skills.. If your score is 7 or above.. and the second is exercise for physical fitness. The patient should know what resources are available. 0 = I cannot do this plan and 10 = I am sure I can do this plan. with 0 being totally uncertain and 10 being totally certain. joining a support group or self-help course. . or counselor.): morning. Biofeedback involves equipment that measures heart rate and muscle tension. We will address only physical activity to improve general health. psychologist. What (message do I To narrow my information to give to the doctor to my three most want to communicate): important issues to be addressed during my appointment. How sure (0 .week): communicate at my next appointment. If I am unable to complete my list on Friday each week. Some insurance plans will pay for biofeedback equipment when it is ordered by a physician. The first is physical activity to improve general health. how sure am I that I can accomplish this plan?" If your score is below 7. This support may be emotional. financial. "On a scale of 0 to 10. ask yourself how you can change the plan to make it achievable. distraction. physical. this represents a realistic plan.10 see scale below*): 8 * This rating scale helps you determine how certain you are that you can accomplish your plan. writing a journal. Other stress management techniques involve talking with a trusted friend. or talking with a professional such as a social worker. Coping Strategies and Stress Reduction One coping theme is finding more information about the person's own chronic illness(es). there are two main reasons to exercise. but a person must be willing to learn the selected technique well enough to use regularly. Educate the patient and his/her family about the chronic illness. and biofeedback. Other stress reduction techniques include muscle relaxation. guided imagery. spiritual. Physical Activity Physical activity and exercise are important in the self-management of chronic illness. I will jot a Fall back plan (what to reminder on my appointment calendar for the following Monday do if . and so on. Generally. Family and friends provide ongoing support important to success in managing a chronic illness.

Check the expiration date on all medications and discard any unused portion. Managing Medications Managing medications is an important self-management skill. and any special tests needed to monitor the use of the medication. Lupus is a good example where the accumulation of 30 minutes is important since fatigue can be an issue. Nutrition It is especially important for a person with a chronic illness like lupus to eat a balanced diet. If you take any over-the-counter medication(s). In summary. and the amount of exercise can be accumulated to reach total 30 minutes during the day. set an alarm on your watch. the guidelines for improving health include participating in physical activity four or more days a week. and suggestions for exercise are available for people of any age to get started. One type of physical activity that has been found especially helpful is aquatics. Medications can be harmful when used incorrectly. When a new medication is prescribed. including suggestions for physical activity. any interactions with food or other medications. the activity should be of moderate intensity measured by achieving maximal heart rate (220 minus age in years). or have a family member ask if you have taken your medication. . It is also important not to put too much strain on the joints.In 2010 the Surgeon General issued a vision for a healthy and fit nation. Physical activity helps keep you healthy. time(s) of day to take it. physician or nurse if they are unclear about any aspect of taking their medication(s) or if they have questions about effectiveness or side effects. Some tips for patients to manage them sensibly include:       Know about the medication(s) you are taking: name of the drug. Get your refill a few days before you take your last dose. Do not let your medications run out. use a medication chart. A warm water pool is the key to aquatics for anyone with arthritis. Patients should ask their pharmacist. how to take it (with food or on an empty stomach). dosage. The Arthritis Foundation recommends the water temperature be 83°--88°F. Ways to remember to take your medication: set it next to a reminder like your toothbrush or coffee cup. what it is supposed to do. Anyone with a chronic illness should check with his/her doctor before beginning a new exercise program. possible side effects. use a medication organizer. ask the pharmacist to check for any possible drug interactions. Patients should be well-informed shoppers by reading labels and comparing the nutritional value of the food they eat. Consider the patient's food allergies and the current literature. check the safety of taking them with prescribed medication. reason for taking it.

and herbs. 1996. Exercise improves daily energy level ( Gecht. "Once I received the diagnosis I went to the library to find out everything I could about lupus. complementary therapy. from a self-help course. 2000). attends a support group.and longterm) of any type of treatment suggested by her health care team or that she feels may benefit her. Minor & Lane. et al. Patient's Perspective Deb O'Neal was diagnosed with lupus six years ago.Alternative Health Care Alternative health care. These different terms comprise a vast array of therapies including exercise. The person feels valued as an active participant in his/her health care.. Lorig et al.. She does gentle exercise. increased functional abilities and a reduced number of hospitalizations and physician visits ( Braden. Deb remains active and educated herself about every aspect of lupus. massage. 1991. Benefits and Evidence for Self-Management in Chronic Illness What are the benefits and evidence to support the use of self-management skills?    The person feels more in control of his/her situation ( Braden. Wallace. The information on self-management skills discussed in this case is only a small portion of what is available from the literature. or from the internet. She states. 2000). or integrative health care.. 1996). 1996. Aquatics in a warm water pool have been found to promote flexibility and movement ( Ferrell. 1998. biofeedback." One resource she mentioned is The Lupus Book. 1991. Deb states that over the years she has carefully weighed the benefits and risks (short. also called alternative therapy. Lorig. Ferrell. and decreased feelings of depression as well as improved mood and sleep. Participating in a self-help or self-management course demonstrated decreased reports of pain. Sierpina. 1998. acupuncture. Minor & Lane. keeps up with any new research. Particular types of self-management skills have been examined for the benefits received: Physical activity has been found to promote general health. She noted her first symptoms 30 years ago. diet. Fully research any alternative health care option and consider the potential impact it may have on a prescribed treatment. has become big business over the past decade. Many health care providers have become open to discussing this issue with patients as the number of people using these therapies has increased as well as some of the documented dangers ( Horstman. goes for . 1999. 2000). 2001). decrease pain and stiffness. et al.

and taking medicines. Although these things can trigger lupus. or blood cells. drug-induced systemic lupus. She uses alternative health options including massage and acupuncture. They do this by seeing their doctors often for checkups. heart. the most common and most serious type of lupus. getting enough rest and exercise. This topic focuses on systemic lupus erythematosus (SLE). including the virus that causes mononucleosis. The signs and symptoms can be vague and are suggestive of other forms of arthritis as well as other disease processes. and subacute cutaneous lupus.regular appointments with her health care team. What causes lupus? The exact cause of lupus is not known. and sunlight. These include viral infections. which means that the body's natural defense system (immune system) attacks its own tissues instead of attacking foreign substances like bacteria and viruses. Topic Overview What is systemic lupus erythematosus. Then a number of other factors can trigger lupus attacks. If you develop severe lupus. But most people can control their symptoms and prevent severe damage to their organs. Review Systemic lupus erythematous (SLE or lupus) is a complex form of arthritis that is an autoimmune disease. nervous system. pain. we have presented information to help distinguish lupus as well as provide treatment information. Experts believe that some people are born with certain genes that affect how the immune system works and that they are more likely to get lupus. also called SLE. they may affect one person but not another person. But there are four other types of lupus: discoid or cutaneous lupus. Although some people with lupus have only mild symptoms. neonatal lupus. In this case. and regularly asks questions. Lupus is the common name for systemic lupus erythematosus. Since lupus is a chronic illness. or lupus? Lupus is an autoimmune disease. What are the symptoms? . you may have problems with your kidneys. This causes inflammation. we also presented self-management skills because of their importance in the overall treatment plan. lungs. the disease is lifelong and can become severe. Inflammation causes swelling. and tissue damage throughout the body.

and take steps to control them. Common symptoms include feeling very tired and having joint pain or swelling (arthritis). How is it treated? Lupus is treated by:     Applying corticosteroid cream for rashes. the doctor will recommend the lowest dose that will give the most benefit. some people with lupus have problems with the heart. Some of the other things you can do include:      Rest to reduce stress.Lupus symptoms vary widely. Stop smoking. Mouth sores and hair loss may occur. lungs. or flares. Because corticosteroids are powerful medicines and can cause serious side effects. and a skin rash . The times when symptoms get worse are called relapses. blood cells. so doctors will use blood tests and other tests to find out if you have lupus. Exercise regularly to prevent fatigue and joint stiffness. It is easier for your doctor to diagnose lupus if you have the most common symptoms and your blood has certain proteins. joint pain. Learn the warning signs of a symptoms flare. pain. The times when symptoms are under control are called remissions. Taking nonsteroidal anti-inflammatory drugs (NSAIDs) for mild joint or muscle pain and fever. The doctor may also recommend other medicines that slow down the immune system. Over time. Avoid the sun. Wear sunscreen and protective clothing when you are outside. The rash often happens after you have been in the sun. asking you questions about your medical history and common symptoms. or ANAs. Taking antimalarial medicines to treat fatigue. or nervous system. These proteins are called antinuclear antibodies. How can you manage lupus? One of the goals of controlling mild to moderate lupus symptoms is to prevent flares. and they come and go. How is lupus diagnosed? There is no single test for lupus. . Taking corticosteroids if other medicines are not controlling your symptoms. and skin rashes. the times when your symptoms are worse. it can be hard to diagnose. and doing some urine and blood tests. such as fatigue. and rash. But other problems can cause your body to make ANAs. Because lupus affects different people in different ways. kidneys. a fever. Your doctor will check for lupus by examining you.

The booklet describes the disease and its symptoms and contains information about diagnosis and treatment. friends. Department of Health and Human Services‘ National Institutes of Health (NIH). Lupus Online version updated August 2011 Handout on Health: Systemic Lupus Erythematosus This booklet is for people who have systemic lupus erythematosus. you may wish to discuss them with your doctor. In autoimmune diseases.With good self-care. the immune system turns against parts of the body it is designed to protect. Develop a support system of family. commonly called SLE or lupus. If you have further questions after reading this booklet.S. and health professionals. as well as current research efforts supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) and other components of the U. help your family and friends understand your limitations and needs when your symptoms flare. Also. This leads to inflammation and damage to various body tissues. Lupus can affect many parts of . It also discusses issues such as health care.           Defining Lupus Understanding What Causes Lupus Symptoms of Lupus Diagnosing Lupus Treating Lupus Lupus and Quality of Life Pregnancy and Contraception for Women With Lupus Current Research Hope for the Future For More Information Information Boxes      Common Symptoms of Lupus Diagnostic Tools for Lupus Warning Signs of a Flare Preventing a Flare Tips for Working With Your Doctor Defining Lupus Lupus is one of many disorders of the immune system known as autoimmune diseases. pregnancy. as well as for their families and friends and others who want to better understand the disease. It is important to learn about lupus so that you can understand how it might affect your life and how you can best cope with it. and quality of life for people with lupus. most people with lupus can keep doing their regular daily activities.

heart. They include some antiseizure medications. In addition. Many different drugs can cause drug-induced lupus. some of the most common ones include extreme fatigue. raised rash appears on the face. and periods of wellness. or elsewhere. painful or swollen joints (arthritis). However. The kidneys and brain are rarely involved. babies with neonatal lupus may have congenital heart block. Although people with the disease may have many different symptoms. Asian. Neonatal lupus is a rare disease that can occur in newborn babies of women with SLE. a serious heart problem in which the formation of fibrous tissue in the baby’s heart interferes with the electrical impulses that affect heart rhythm. and brain. There are several kinds of lupus:      Systemic lupus erythematosus (SLE) is the form of the disease that most people are referring to when they say “lupus. Sjögren’s syndrome. lungs. or remission. unexplained fever. The rash may last for days or years and may recur. scalp. and low blood counts. In rare instances. and scientists funded by NIH are continuing to make great strides in understanding the disease. These symptoms gradually go away over several months. It is difficult to estimate how many people in the United States have the disease. including the joints. Lupus is two to three times more common in African American women than in Caucasian women and is also more common in women of Hispanic. and they typically go away completely when the drug is stopped. called flares. lupus can run in families. The raised areas may become thick and scaly and may cause scarring. high blood pressure medications. antibiotics and antifungals. Understanding how to prevent flares and how to treat them when they do occur helps people with lupus maintain better health. and kidney problems. This booklet focuses on SLE. A small percentage of people with discoid lupus have or develop SLE later. We know that many more women than men have lupus. At birth. lupus can be effectively treated with drugs. Scientists suspect that neonatal lupus is caused in part by autoantibodies in the mother’s blood called anti-Ro (SSA) and anti-La (SSB). or no disease at all. Drug-induced lupus is a form of lupus caused by medications. liver problems. Discoid lupus erythematosus is a chronic skin disorder in which a red. thyroid medications. healthy lives. because its symptoms vary widely and its onset is often hard to pinpoint. and most people with the disease can lead active.” The word “systemic” means the disease can affect many parts of the body. and most infants of . blood vessels. skin. but the risk that a child or a brother or sister of a patient will also have lupus is still quite low. kidneys. Two of the major questions researchers are studying are who gets lupus and why. The symptoms of SLE may be mild or serious. rash. Although SLE usually first affects people between the ages of 15 and 45 years. Lupus is characterized by periods of illness. and chest pain). fever. and Native American descent. skin rashes. African American and Hispanic women are also more likely to have active disease and serious organ system involvement.the body. Symptoms are similar to those of SLE (arthritis. which may ultimately lead to a cure. there is no cure for lupus. Autoantibodies (“auto” means self) are blood proteins that act against the body’s own parts. Subacute cutaneous lupus erythematosus refers to skin lesions that appear on parts of the body exposed to sun. At present. the babies have a skin rash. Neonatal lupus is rare. and oral contraceptive pills. The lesions do not cause scarring. it can occur in childhood or later in life as well. Intense research is underway.

SLE can also flare during pregnancy. studies suggest that a number of different genes may be involved in determining a person‘s likelihood of developing the disease. and prompt treatment can keep the mother healthier longer. the body‘s immune system does not work as it should. as described here and in the ―Current Research‖ section of this booklet. but it also shows that genes alone do not determine who gets lupus. Rather. It is important for women with SLE or other related autoimmune disorders to be under a doctor’s care during pregnancy. Recent research has confirmed that one virus. Scientists believe there is no single gene that predisposes people to lupus. In lupus. and other foreign substances that invade the body. Doctors and scientists do not yet understand all of the factors that cause inflammation and tissue damage in lupus. most commonly on the face Chest pain upon deep breathing Unusual loss of hair Pale or purple fingers or toes from cold or stress (Raynaud's phenomenon) Sensitivity to the sun Swelling (edema) in legs or around eyes . Epstein-Barr virus (EBV). the immune system produces antibodies against the body‘s healthy cells and tissues. All women who are pregnant and known to have anti-Ro (SSA) or anti-La (SSB) antibodies should be monitored by echocardiograms (a test that monitors the heart and surrounding blood vessels) during the 16th and 30th weeks of pregnancy. cigarette smoke. Doctors can now identify mothers at highest risk for complications. These antibodies. which causes mononucleosis.mothers with SLE are entirely healthy. A healthy immune system produces proteins called antibodies and specific cells called lymphocytes that help fight and destroy viruses. hormones. Understanding What Causes Lupus Lupus is a complex disease. Common Symptoms of Lupus         Painful or swollen joints and muscle pain Unexplained fever Red rashes. Researchers have begun to make headway in identifying some of those genes. and infectious agents such as viruses. and its cause is unknown. certain drugs. In lupus. which tissues and organs are affected. and researchers are actively exploring them. the other twin has a 24-percent chance of developing it. This and other research suggests that genetics plays an important role. Scientists are making progress in understanding lupus. bacteria. is a cause of lupus in genetically susceptible people. allowing for prompt treatment of the infant at or before birth. which could eventually lead to better ways to treat and perhaps even prevent lupus. and that other factors play a role. and the severity of disease. Some of the factors scientists are studying include sunlight. contribute to the inflammation of various parts of the body and can cause damage to organs and tissues. stress. called autoantibodies. In studies of identical twins—who are born with the exact same genes—when one twin has lupus. The most common type of autoantibody that develops in people with lupus is called an antinuclear antibody (ANA) because it reacts with parts of the cell‘s nucleus (command center).

Some people also experience headaches. upper arms. People with lupus who have a type of autoantibody called antiphospholipid antibodies have an increased risk of blood clots. chest. Rashes may also occur on the face and ears.       Kidneys: Inflammation of the kidneys (nephritis) can impair their ability to get rid of waste products and other toxins from the body effectively. mouth ulcers. skin rashes often first develop or worsen after sun exposure. unexplained fever. causing the valve surface to thicken and . confusion. dizziness. depression. New symptoms may continue to appear years after the initial diagnosis. which assist in clotting). particularly with breathing. People with lupus are also at increased risk for atherosclerosis (hardening of the arteries). Endocarditis can damage the heart valves. inflammation can occur in the heart itself (myocarditis and endocarditis) or the membrane that surrounds it (pericarditis). an inflammation of the lining of the chest cavity that causes chest pain. and pale or purple fingers and toes from cold and stress. although some patients may notice dark urine and swelling around their eyes. the only indication of kidney disease is an abnormal urine or blood test. lupus affecting the kidneys generally requires intensive drug treatment to prevent permanent damage. Because the kidneys are so important to overall health. This can cause headaches. some of the most common symptoms of lupus include painful or swollen joints (arthritis). dizziness. The inflammation may be mild and may not require treatment or may be severe and require immediate attention. legs. affecting the way blood circulates through the body. Blood: People with lupus may develop anemia. such as the skin or joints. or changes in behavior. A characteristic red skin rash—the so-called butterfly or malar rash—may appear across the nose and cheeks. Other symptoms of lupus include chest pain. Blood vessels: Blood vessels may become inflamed (vasculitis). or thrombocytopenia (a decrease in the number of platelets in the blood. depression. Lungs: Some people with lupus develop pleuritis. leukopenia (a decreased number of white blood cells). Most often. hair loss. and hands and other areas exposed to the sun. vision problems. Heart: In some people with lupus.   Mouth ulcers Swollen glands Extreme fatigue Symptoms of Lupus Each person with lupus has slightly different symptoms that can range from mild to severe and may come and go over time. shoulders. Patients with lupus also may get pneumonia. or fingers. memory disturbances. or seizures. Because many people with lupus are sensitive to sunlight (called photosensitivity). Other people experience symptoms in many parts of their body. seizures. However. ankles. anemia (a decrease in red blood cells). causing chest pains or other symptoms. and extreme fatigue. stroke. In some people with lupus. and different symptoms can occur at different times. There is usually no pain associated with kidney involvement. Central nervous system: In some patients. lupus affects the brain or central nervous system. The following systems in the body also can be affected by lupus. only one system of the body. Just how seriously a body system is affected varies from person to person. is affected.

or determine if you truly have the disease. Diagnosing Lupus Diagnosing lupus can be difficult. The presence of this antibody may indicate increased risk for blood clotting and increased risk for miscarriage in pregnant women with lupus. This information. However. this usually doesn’t affect the valves’ function. Reaching a diagnosis may take time as new symptoms appear. and anti-La (SSB). all these tests merely serve as tools to give the doctor clues and information in making a diagnosis. anti-RNP. symptoms. The most useful tests identify certain autoantibodies often present in the blood of people with lupus. helps the doctor consider other diseases that may mimic lupus. which can cause heart murmurs. It may take months or even years for doctors to piece together the symptoms to diagnose this complex disease accurately. For example. The doctor will look at the entire picture— medical history. anti-RNP. The doctor may order a biopsy of the skin or kidneys if those body systems are affected. what health problems you have had and for how long) is critical to the process of diagnosis. anti-Sm. and test results—to determine if a person has lupus. but several laboratory tests may help the doctor to confirm a diagnosis of lupus or rule out other causes for a person‘s symptoms. and occasionally it is found in healthy people. there are a number of other causes of a positive ANA besides lupus.develop growths. the antinuclear antibody (ANA) test is commonly used to look for autoantibodies that react against components of the nucleus. The doctor may use these antibody tests to help make a diagnosis of lupus. anti-La [SSB]) . Again. accurate medical history (for example. The ANA test simply provides another clue for the doctor to consider in making a diagnosis. including infections and other autoimmune diseases. Making a correct diagnosis of lupus requires knowledge and awareness on the part of the doctor and good communication on the part of the patient. anti-Ro [SSA]. Giving the doctor a complete. anti-Ro (SSA). however. In addition. anti-Sm. No single test can determine whether a person has lupus. or ―command center. although not all people with lupus test positive for these and not all people with these antibodies have lupus. Diagnostic Tools for Lupus    Medical history Complete physical examination Laboratory tests: o Complete blood count (CBC) o Erythrocyte sedimentation rate (ESR) o Urinalysis o Blood chemistries o Complement levels o Antinuclear antibody test (ANA) o Other autoantibody tests (anti-DNA. Most people with lupus test positive for ANA. These antibodies include anti-DNA. along with a physical examination and the results of laboratory tests. Some doctors may order a test for anticardiolipin (or antiphospholipid) antibody. there are blood tests for individual types of autoantibodies that are more specific to people with lupus.‖ of the body‘s cells. Some tests are used less frequently but may be helpful if the cause of a person‘s symptoms remains unclear.

hematologists (doctors specializing in blood disorders). As treatment progresses. kidney. A complete blood count. other professionals often help. Common side effects of NSAIDs can include stomach upset. to treat them when they do occur. dermatologists (doctors who treat skin disease). drugs that decrease inflammation. These may include nurses. NSAIDs may be used alone or in combination with other types of drugs to control pain. diarrhea. making it especially important to stay in close contact with the doctor while taking these medications. Once lupus has been diagnosed. nephrologists (doctors who treat kidney disease). or can visit a rheumatologist. Even though some NSAIDs may be purchased without a prescription. or even neurological complications. In developing a treatment plan. The range and effectiveness of treatments for lupus have increased dramatically in recent decades. Another common test measures the blood level of a group of substances called complement. urinalysis. the doctor will develop a treatment plan based on the patient‘s age. which help antibodies fight invaders. A person with lupus can go to his or her family doctor or internist. The doctor and patient should reevaluate the plan regularly to ensure it is as effective as possible. called nonsteroidal anti-inflammatory drugs (NSAIDs). heartburn. giving doctors more choices in how to manage the disease.  o Anticardiolipin antibody test Skin biopsy Kidney biopsy Other laboratory tests are used to monitor the progress of the disease once it has been diagnosed. sex. Although some NSAIDs. and lifestyle. Treatment plans are tailored to the individual‘s needs and may change over time. enodocrinologists (doctors specializing in problems related to the glands and hormones). and fluid retention. X rays and other imaging tests can help doctors see the organs affected by SLE. and neurologists (doctors specializing in disorders of the nervous system). cardiologists (doctors specializing in the heart and blood vessels). are often used. and fever. A rheumatologist is a doctor who specializes in rheumatic diseases (arthritis and other inflammatory disorders. It is important for the patient to work closely with the doctor and take an active role in managing the disease. it is important that they be taken under a doctor‘s direction. NSAIDs: For people with joint or chest pain or fever. blood chemistries. a doctor‘s prescription is necessary for others. such as that which occurs during a flare of lupus. social workers. often involving the immune system). and the erythrocyte sedimentation rate test (a test to measure inflammation) can provide valuable information. Clinical immunologists (doctors specializing in immune system disorders) may also treat people with lupus. the doctor has several goals: to prevent flares. psychologists. health. swelling. symptoms. . such as ibuprofen and naproxen. and to minimize organ damage and complications. are available over the counter. A low level of complement could mean the substance is being used up because of an immune response in the body. Some people with lupus also develop liver. Treating Lupus Diagnosing and treating lupus often require a team effort between the patient and several types of health care professionals.

and inflammation of the lungs. Hexadrol). These drugs may be given by mouth or by IV infusion. such as cyclophosphamide (Cytoxan) and mycophenolate mofetil (CellCept). the typical side effects are less likely and slow withdrawal is unnecessary. there is a risk of relapse after the immunosuppressives have been stopped. increased appetite. Corticosteroids are related to cortisol. Also. and their inclusion does not mean that these products are endorsed by the National Institutes of Health or any other Government agency. damage to the arteries. methylprednisolone (Medrol). Side effects may include nausea. high blood pressure. restrain the overactive immune system by blocking the production of immune cells. skin rashes. and cataracts. by injection or by intravenous (IV) infusion (dripping the drug into the vein through a small tube). Typically. in creams applied to the skin. extremely rarely. such as prednisone (Deltasone). The risk for side effects increases with the length of treatment. infections. . Corticosteroids can be given by mouth. Immunosuppressives: For some patients whose kidneys or central nervous systems are affected by lupus. They work by rapidly suppressing inflammation. the higher the dose and the longer they are taken. These drugs were originally used to treat malaria. bladder problems. Researchers are working to develop ways to limit or offset the use of corticosteroids. but doctors have found that they also are useful for lupus. and increased risk of cancer and infection. With this treatment. joint pain. vomiting. this does not mean or imply that the product is unsatisfactory. Short-term side effects of corticosteroids include swelling. damage to the retina of the eye. It may be used alone or in combination with other drugs and generally is used to treat fatigue. if a particular brand name is not mentioned. Long-term side effects of corticosteroids can include stretch marks on the skin. the doctor will seek the lowest dose with the greatest benefit. Because they are potent drugs. a type of drug called an immunosuppressive may be used. Side effects of antimalarials can include stomach upset and. so it is very important that the doctor and patient work together in changing the corticosteroid dose. and weight gain. hydrocortisone. People with lupus who are using corticosteroids should talk to their doctors about taking supplemental calcium and vitamin D or other drugs to reduce the risk of osteoporosis (weakened. As with other treatments for lupus. Clinical studies have found that continuous treatment with antimalarials may prevent flares from recurring.Antimalarials: Antimalarials are another type of drug commonly used to treat lupus. or the doctor may try to slowly decrease the dose once the disease is under control. A common antimalarial used to treat lupus is hydroxychloroquine (Plaquenil1). less potent drugs. hair loss. the greater the risk and severity of side effects. weakened or damaged bones (osteoporosis and osteonecrosis). It is dangerous to stop taking corticosteroids suddenly. 1 Brand names included in this publication are provided as examples only. which is a natural anti-inflammatory hormone. high blood sugar (diabetes). decreased fertility. Sometimes doctors give very large amounts of corticosteroid by IV infusion over a brief period of time (days) (―bolus‖ or ―pulse‖ therapy). Immunosuppressives. For example. These side effects generally stop when the drug is stopped. Corticosteroids: The mainstay of lupus treatment involves the use of corticosteroid hormones. and dexamethasone (Decadron. corticosteroids may be used in combination with other. fragile bones).

An open dialogue between the patient and doctor about the relative values of complementary and alternative therapies allows the patient to make an informed choice about treatment options. ointments and creams. a B-lymphocyte stimulator (BLyS) protein inhibitor. and homeopathy. Other therapies: In some patients. Less commonly. funded in part by NIAMS. Because some treatments may cause harmful side effects. may be used to help control the disease.BLyS-specific inhibitors: Belimumab (Benlysta®). this difference in response to a treatment may be another indicator of the various ways that the disease affects different patients. If the doctor feels the approach has value and will not be harmful. Although these methods may not be harmful in and of themselves and may be associated with symptomatic or psychosocial benefit. high blood pressure. Mexate. Patients may also experience reactions at the infusion site. fish oils. or infection. no research to date shows that they affect the disease process or prevent organ damage. in many cases it may be necessary to take additional medications to treat problems related to lupus such as high cholesterol. serious infections may result. was approved by the U. Food and Drug Administration (FDA) in March 2011 for patients with lupus who are receiving other standard therapies. methotrexate (Folex. However. In studies conducted so far. An additional study of this patient population will be conducted to further evaluate belimumab in this subgroup of lupus patients. and fever. Lupus and Quality of Life A diagnosis of lupus can have a significant impact on quality of life. diarrhea. it may reduce the number of abnormal B cells thought to be a problem in lupus. Some alternative approaches people have tried include special diets. for which antihistamines can be given in advance. a diseasemodifying antirheumatic drug. it is important to report any new symptoms to the doctor promptly. it is important not to neglect regular health care or treatment of serious symptoms. African American patients and patients of African heritage did not appear to respond to belimumab. including those listed above. The most common side effects include nausea. Working closely with the doctor helps ensure that treatments for lupus are as successful as possible. In addition to medications for lupus itself. many patients seek other ways of treating the disease. Rheumatrex). Recent research on work loss associated with lupus. which may be useful for controlling lupus when other treatments haven‘t worked. chiropractic treatment. nutritional supplements. it can be incorporated into the patient‘s treatment plan. including the ability to work. estimated that almost three-quarters of the study‘s 982 participants would stop working before the usual . Other treatments may include hormonal therapies such as dehydroepiandrosterone (DHEA) and intravenous immunoglobulin (proteins derived from human blood). Some alternative or complementary approaches may help the patient cope or reduce some of the stress associated with living with a chronic illness. However. Given by IV infusion. It is also important not to stop or change treatments without talking to the doctor first. Alternative and complementary therapies: Because of the nature and cost of the medications used to treat lupus and the potential for serious side effects.S.

headache. pain. The researchers determined that demographics and work characteristics (the physical and psychological demands of jobs and the degree of control over assignments and work environment) had the most impact on work loss.age of retirement. on average) would no longer be working by the age of 50. and not smoking particularly important for people with lupus. Women with lupus should receive regular preventive health care. If new symptoms are identified early. Men with lupus should have the prostate-specific antigen (PSA) test. If a person is taking corticosteroids or antimalarial medications. Many people with lupus experience increased fatigue. Because people with lupus can be more susceptible to infections. and the importance of structured exercise and rest. Despite the symptoms of lupus and the potential side effects of treatment. as well as birth control and family planning. people with lupus can maintain a high quality of life overall. fever. can be adjusted accordingly. One key to managing lupus is to understand the disease and its impact. The treatment plan. treatments may be more effective. stress reduction. such as learning to recognize your warning signals and maintaining good communication with your doctor. Both men and women need to have their blood pressure and cholesterol checked on a regular basis. such as gynecological and breast examinations. an eye exam should be done at least yearly to screen for and treat eye problems. which is tailored to the individual‘s specific needs and circumstances. exercising regularly. instead of seeking help only when symptoms worsen. Developing strategies to prevent flares can also be helpful. This makes healthy lifestyle choices such as eating well. The doctor can provide guidance about such issues as the use of sunscreens. Learning to recognize the warning signs of a flare can help the patient take steps to ward it off or reduce its intensity. abdominal discomfort. the doctor may recommend yearly influenza vaccinations or pneumococcal vaccinations for some patients. It is also important for people with lupus to receive regular health care. People with lupus should also be aware of their increased risk of premature cardiovascular disease. and that half of those who had jobs when they were diagnosed (during their mid-thirties. Results from a medical exam and laboratory work on a regular basis allows the doctor to note any changes and to identify and treat flares early. a rash. or dizziness just before a flare. Other concerns also can be addressed at regular checkups. Warning Signs of a Flare        Increased fatigue Pain Rash Fever Abdominal discomfort Headache Dizziness Preventing a Flare .

others do not. such as nurses.  Learn to recognize your warning signals. women who have antiphospholipid antibodies are at a greater risk of miscarriage in the second trimester because of their increased risk of blood clotting in the placenta. A support system may include family. diabetes. and remain more active.) Tips for Working With Your Doctor         Seek a health care provider who is familiar with SLE and who will listen to and address your concerns. Do not hesitate to discuss sensitive subjects (for example. Ask for clarification or further explanation if you need it. and setting priorities for spending time and energy. Pregnancy counseling and planning before pregnancy are important. accurate medical information. Make a list of your questions and concerns in advance. Learning more about lupus may also help. especially those taking corticosteroids. Studies have shown that patients who are wellinformed and participate actively in their own care experience less pain. a woman should have no signs or symptoms of lupus and be taking no medications for at least 6 months before she becomes pregnant. and kidney complications. make fewer visits to the doctor. Lupus patients with a history of kidney disease have a higher risk of preeclampsia (hypertension with a buildup of excess watery fluid in cells or tissues of the body). relaxation techniques such as meditation. friends. Discuss any treatment changes with your doctor before making them. build self-confidence. Pregnant women with lupus. Ideally. Some approaches that may help include exercise. Staying healthy requires extra effort and care for people with lupus. Be honest and share your point of view with the health care provider. Some women may experience a mild to moderate flare during or after their pregnancy. Participating in a support group can provide emotional help. also are more likely to develop high blood pressure. Women with lupus in general have a higher rate of miscarriage and premature births compared with the general population. Talk to other members of the health care team. Maintain good communication with your doctor. see the ―For More Information‖ section at the end of this booklet. or pharmacists. and spirit. (For more information on support groups. most women with lupus carry their babies safely to the end of their pregnancy. so regular care and good nutrition during pregnancy are essential. Provide complete. birth control. In addition. so it becomes especially important to develop strategies for maintaining wellness. Wellness involves close attention to the body. community organizations. Effective stress management varies from person to person. intimacy) with your doctor. therapists. boost self-esteem and morale. medical professionals. One of the primary goals of wellness for people with lupus is coping with the stress of having a chronic disorder. hyperglycemia (high blood sugar). mind. and support groups. Developing and maintaining a good support system is also important. It is also . Pregnancy and Contraception for Women With Lupus Although pregnancy in women with lupus is considered high risk. and help develop or improve coping skills.

Another NIAMS-funded registry is collecting information and blood samples from children affected by neonatal lupus and their mothers. By evaluating patients with lupus and their relatives. Previously. For women with lupus who do not wish to become pregnant or who are taking drugs that could be harmful to an unborn baby. They are doing laboratory studies that compare various aspects of the immune systems of people with lupus with those of other people both with and without lupus. published in 2005. This gives researchers across the country access to information and materials they can use to help identify genes that determine susceptibility to the disease. has a major focus on lupus research in its on-campus program in Bethesda. oral contraceptives (birth control pills) were not an option for women with lupus because doctors feared the hormones in the pill would cause a flare of the disease. NIAMS is funding a Lupus Registry and Repository that gathers medical information. Information from the registry forms the basis of family counseling and tracks important data such as recurrence rates in subsequent pregnancies. Maryland. In addition. as well as blood and tissue samples from patients and their relatives. To help scientists gain new knowledge. NIAMS also funds many lupus researchers across the United States. NIAMS also has established a Specialized Center of Research at the University of Virginia School of Medicine in Charlottesville devoted specifically to lupus research. scientists are developing new and better ways to study the disease. The National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS). Department of Health and Human Services‘ National Institutes of Health (NIH). . Current Research Lupus is the focus of intense research as scientists try to determine what causes the disease and how it can best be treated. doctors are increasingly prescribing oral contraceptives to women with inactive or stable disease.advisable to have access to a neonatal (newborn) intensive care unit at the time of delivery in case the baby requires special medical attention. a component of the U.S. and why are cases in these groups often more severe? What goes wrong in the immune system and why? How can we correct the way the immune system functions once something goes wrong? What treatment approaches will work best to lessen lupus symptoms? How do we cure lupus? To help answer these questions. researchers at NIH are learning more about how lupus develops and changes over time. However. reliable birth control is important. As a result of this study. They also use mice with disorders resembling lupus to better understand the abnormalities of the immune system that occur in lupus and to identify possible new therapies. a large NIH-supported study called Safety of Estrogens in Lupus Erythematosus National Assessment (SELENA) found that severe flares were no more common among women with lupus taking oral contraceptives than those taking a placebo (inactive pill). Some of the questions they are working to answer include: Why are women more likely than men to have the disease? Why are there more cases of lupus in some racial and ethnic groups.

Simply put. a collaboration among the NIH Institutes. NIAMS intramural and extramural investigators have established that a variant in a gene called STAT4. voluntary and professional organizations. as well as the extent of damage to the kidney. is more specifically associated with disease characterized by severe symptoms such as disorders of the kidney. This finding may allow doctors to determine which patients are at risk of more severe disease and may lead to the development of new treatment for patients at greatest risk of complications.The hope is that the registry will facilitate improved methods of diagnosis. consequence of a process. or a response to a therapeutic intervention. other Federal agencies. In separate research. meaning they can predict that a flare will occur. Further studies are needed to determine whether urine protein analysis could replace the use of biopsies to assess kidney damage in lupus. Biomarkers Biomarkers are another significant area of lupus research. They also showed that moderate doses of prednisone can prevent flares in people having these biomarkers. They have shown that having an alternative form of the gene Ly108 may impair the body‘s ability to keep selfdestructive B cells in check. These biomarkers can be used to indicate the type and severity of renal disease in these patients. Here are some recent major advances in different areas of lupus research: Genetics Identifying genes that play a role in the development of lupus or lupus severity is an active area of research. Biomarkers are defined as molecules that reflect a specific biological or pathological process. and industries with an interest in lupus. The Working Group is led by NIAMS and includes representatives from all relevant U. Department of Health and Human Services (HHS) agencies and other Federal departments having an interest in lupus. Scientists have also found a gene that may confer susceptibility to lupus. which is associated with lupus susceptibility.S. they can let the doctor know what is happening in the body—or predict what is going to happen—based on something reliably measurable in tissues. as well as prevention and treatment for this rare condition. NIAMS-supported investigators identified a list of proteins in the urine of people with renal disease caused by lupus. This gene is part of a gene family (SLAM) that has been linked to lupus-like disease in mice. NIH established the Lupus Federal Working Group (LFWG). Such biomarkers could form the basis of clinical tests to help doctors establish an effective treatment plan for these patients without putting them through repeated kidney biopsies. In 2003. The Disease Process One recent NIAMS-supported study found that the disease process of lupus—including the . cells. NIAMS-supported researchers have identified anti-double-stranded DNA antibodies and complement C3a—both of which can be found in blood tests—as biomarkers for flares. or fluids.

development of certain autoantibodies and some symptoms of the disease—begin before the disease is diagnosed. Because lupus is different in different people and is characterized by autoimmunity in various systems of the body, the initial presentation can be unpredictable. Many symptoms wax and wane over time, often delaying diagnosis and the start of therapy. Seeking to identify patterns among early clinical events in lupus, as well as to assess whether the presence of lupus-associated autoantibodies precedes clinical manifestations, investigators looked back at the charts of 130 lupus patients, analyzing 633 serum samples taken at different times and noting when the criteria for a lupus diagnosis were fulfilled. To be classified as having lupus, a person needs to meet at least 4 of 11 criteria. They found that in 80 percent of the patients, at least one clinical criterion for SLE appeared before SLE was diagnosed. Eighty-four percent developed antinuclear antibodies (ANAs). Discoid rashes and seizures were the earliest observed symptoms, with a mean onset of 1.74 years and 1.70 years prior to diagnosis, respectively. Oral ulcers tended to appear only after diagnosis, making this a less useful diagnostic tool. Among SLE patients with renal disease, anti-double-stranded DNA antibodies appeared before or at the same time as American College of Rheumatology (ACR)-defined renal disorder in the majority of patients who had both the autoantibodies and the renal disorder. Researchers are also making strides in understanding how the disease process affects different organs. One NIAMS investigator reported that a subset of antibodies to DNA can be found in the blood and the brain of lupus patients with cognitive problems. These anti-DNA antibodies bind to specific receptors (NMDA [N-methyl-D-aspartate] receptors) on nerve cells in the brain. In the culture dish, binding of these anti-DNA antibodies to nerve cells results in the death of the cells. In subsequent studies involving mice, the researchers found that these antibodies affect the nervous system only when the blood-brain barrier was broken, allowing the antibodies access to the brain. Where the blood-brain barrier was broken, antibodies bound to the neurons in a specific area of the brain that helps regulate emotion and memory. Tests for cell death in that area of the brain were positive. Behavioral tests on the mice also revealed impaired cognitive function and memory. Perhaps more important was the finding that the nerve cell binding and its damage could be prevented with a drug that inhibits the NMDA receptor. Researchers say the findings suggest that such drugs may eventually be a useful therapy for people with lupus. Treatment Understandably, identifying and developing better treatments for lupus—and ensuring that patients receive the best treatments—are among the primary goals of lupus research. A 2005 study of 17 adults with lupus that was clinically active despite treatment, found that just one injection of the cancer drug rituximab (Rituxan) eased symptoms for up to a year or more. Several participants were able to reduce or completely stop their regular lupus medications. Rituximab works by lowering the number of B cells—white blood cells that produce antibodies—in the body. It is approved by the U.S. Food and Drug Administration (FDA) for a type of cancer called lymphoma, as well as for rheumatoid arthritis. Further research is needed to better understand its effectiveness and safety and to better determine its role in lupus treatment. Other research is examining barriers that keep certain populations from complying with their prescribed medical treatment, which could contribute to worse disease outcomes, including disability and death in those populations. One NIAMS-supported study of economically

disadvantaged and ethnically diverse people with rheumatoid arthritis or lupus identified fear of side effects, including long-term damage, as a major reason people failed to take prescribed medications for their disease. Other factors identified included belief that medicines are not working, problems with health system such as navigating Medicaid requirements and a lack of continuity with the same doctor, and medication cost. Hope for the Future With research advances and a better understanding of lupus, the prognosis for people with lupus today is far brighter than it was in the past. It is possible to have lupus and remain active and involved with life, family, and work. As current research efforts unfold, there is continued hope for new treatments, improvements in quality of life, and, ultimately, a way to prevent or cure the disease. The research efforts of today may yield the answers of tomorrow, as scientists continue to unravel the mysteries of lupus. For More Information

National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) Information Clearinghouse National Institutes of Health

1 AMS Circle Bethesda, MD 20892-3675 Phone: 301-495-4484 Toll Free: 877-22-NIAMS (877-226-4267) TTY: 301-565-2966 Fax: 301-718-6366 Email: Website: NIAMS, a component of the National Institutes of Health (NIH) within the U.S. Department of Health and Human Services, conducts and supports medical research on the causes, treatment, and prevention of diseases of bones, joints, muscles, and skin; trains scientists to carry out this research; and disseminates information on research progress to improve public health.

American College of Rheumatology (ACR)

2200 Lake Boulevard NE Atlanta, GA 30319 Phone: 404-633-3777 Fax: 404-633-1870 Website: The American College of Rheumatology (ACR) is an organization of doctors and associated health professionals who specialize in arthritis and related diseases of the bones, joints, and muscles. The Association of Rheumatology Health Professionals, a

division of ACR, aims to enhance the knowledge and skills of rheumatology health professionals and to promote their involvement in rheumatology research, education, and quality patient care. The association also works to advance and promote basic and continuing education in rheumatology for health professionals who provide care to people with rheumatic diseases.

Alliance for Lupus Research, Inc.

28 West 44th Street, Suite 501 New York, NY 10036 Phone: 212-218-2840 Toll Free: (800) 867-1743 Website: The Alliance for Lupus Research, Inc. (ALR), is a nonprofit organization devoted exclusively to the support of promising research for the prevention, treatment, and cure of lupus. Through accelerated, focused, goal-oriented research programs, the ALR aims to promote basic and clinical sciences to achieve major advances leading to a better understanding of the causes of lupus.

American Autoimmune-Related Diseases Association, Inc. (AARDA)

22100 Gratiot Ave. East Detroit, MI 48021 Phone: 586-776-3900 Toll Free: 800-598-4668 Fax: 586-776-3903 Email: Website: The American Autoimmune-Related Diseases Association (AARDA) is a nonprofit voluntary health agency dedicated to bringing a national focus and collaborative effort to the more than 100 known autoimmune diseases through education, awareness, research, and patient services. By collaborating with the National Coalition of Autoimmune Patient Groups (NCAPG), AARDA supports legislative advocacy for autoimmune disease patients. AARDA provides free patient education information, physician and agency referrals, forums and symposia, and a quarterly newsletter.

Arthritis Foundation

P.O. Box 7669 Atlanta, GA 30357-0669 Phone: 404-872-7100 Toll Free: 800-283-7800 Website:

The Arthritis Foundation is devoted to supporting arthritis research and providing educational and other services to individuals with arthritis. The foundation publishes a free pamphlet on rheumatoid arthritis and a magazine for members on all types of arthritis. It also provides up-to-date information on research and treatment, nutrition, alternative therapies, and self-management strategies. Chapters nationwide offer exercise programs, classes, support groups, physician referral services, and free literature. The foundation also has free information about lupus, scleroderma, and other autoimmune and rheumatic conditions on its Web site.

Lupus Clinical Trials Consortium, Inc. (LCTC)

142 West 57th Street, Suite 15A New York, NY 10019 Phone: 212-593-7227 Fax: 212-593-3133 Email: Website: The LCTC is a nonprofit organization that encourages the identification and testing of promising new therapies for lupus. It provides infrastructure support grants to certain academic institutions to support their clinical research activities; encourages lupus clinical researchers from those institutions to share their expertise; supports and conducts educational efforts to show the need for lupus clinical research; and disseminates scientific insights to advance the discovery of new lupus therapies.

Lupus Foundation of America (LFA)

2000 L Street, N.W., Suite 410 Washington, DC 20036 Phone: 202-349-1155 Toll Free: 800-558-0121 Fax: 202-349-1156 Website: The Lupus Foundation of America is a national nonprofit voluntary health organization dedicated to finding the causes of and cure for lupus; and to providing support, services and hope to all people with this condition. The LFA and its network of nearly 300 chapters and support groups conduct programs of research, education, and advocacy.

Lupus Research Institute

330 Seventh Ave, Suite 1701 New York, NY 10001 Phone: 212-812-9881 Fax: 212-545-1843 Email: Website:

New Rheuminations is a private. Hospital for Joint The SLE Foundation supports and encourages medical research to find the cause and cure of lupus. Uniformed Services University of the Health Sciences. Buyon. Rosalind Ramsey-Goldman..D.D. An earlier version of this booklet was written by Debbie Novak of Johnson. Bethesda. and improve its diagnosis and treatment. George Tsokos. Barbara Volcker Center for Women and Rheumatic Disease.. Lockshin. The Arthritis Foundation. nonprofit foundation committed to funding excellence in medical research. Inc. NIAMS.. Barbara Mittleman. and Elizabeth Gretz.. NY 10001 Phone: 212-685-4118 Toll Free: 800-74-LUPUS (745-8787) Fax: 212-545-1843 Email: lupus@lupusny. M. M. Maryland. in the preparation and review of this and earlier versions of this publication. It also provides a wide variety of services to help people with lupus and their families. preventing. M.dxlupus. Illinois. Dr. Boston. Acknowledgments NIAMS gratefully acknowledges the assistance of Jill P. Atlanta. and increase understanding of this serious chronic autoimmune disease. Patricia A. and establish a higher level of public awareness about the disease.. and Peter E. Ph. New York.D.P. Website: http://www.. M. Hospital for Special Surgery.D. M. and Shaw. Suite 1701 New York...D. this voluntary organization conducts a broad-based public education program to raise awareness of lupus.  Rheuminations. New York. Massachusetts.D. John H. . M. M. Brigham and Women‘s Hospital. Fraser. Northwestern University Medical School.D. NIH. Michael D. M. 142 West 57th Street. M. educate and empower those who live with lupus and those who care for them. which will foster a better understanding of the causes of lupus and bring new treatments to market. Inc. Bassin.The Lupus Research Institute provides funds for promising new ideas for curing.H.D. Suite 15A New York.D.  SLE Lupus Foundation 330 Seventh Avenue. Chicago. Lipsky..lupusny. In addition.D.. New York. Special thanks also go to the many patients who reviewed this publication and provided valuable input. Susana Serrate-Sztein. and treating lupus. NY 10019 Phone: 212-593-5180 Fax: 212-803-0059 Website: http://www..

gov/nchs Immune: Systemic lupus erythematosus by Paul Bergner Medical Herbalism 9(4): 1. and prevention of arthritis and musculoskeletal and skin diseases. Systemic lupus erythematosus (SLE) is one of the most serious autoimmune diseases.The mission of the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS). the training of basic and clinical scientists to carry out this research. and lupusinduced kidney damage can cause death. treatment. and the dissemination of information on research progress in these diseases. Occasionally. For updates and for any questions about any medications you are taking. for a list of the symptomatic manifestations of lupus. 3-13 This article is based on a review of the medical literature. we included the most up-to-date (accurate) information available. new information on medication is released. Food and Drug Administration Toll Free: 888–INFO–FDA (888–463–6332) Website: For updates and questions about statistics. When this booklet was The National Institute of Arthritis and Musculoskeletal and Skin Diseases Information Clearinghouse is a public service sponsored by NIAMS that provides health information and information sources. Unlike other autoimmune conditions.S. both alternative and conventional. Conventional medicine lists lupus as a disease of unknown etiology. Hyattsville. Additional information can be found on the NIAMS Web site at www.cdc. SLE attacks a wide variety of tissues. please contact Centers for Disease Control and Prevention's National Center for Health Statistics 3311 Toledo Rd. Exacerbations and remissions of symptoms are typical. please contact U. is to support research into the causes.S. although a likely genetic component .niams.fda. and on the histories of five cases treated by the author from 1996-1998. For Your Information This booklet contains information about medications used to treat the health condition discussed here.nih. Department of Health and Human Services‘ National Institutes of Health (NIH). See Table 1 at the end of this article. which may arise as the immune system attacks various tissues. a part of the U. MD 20782 Toll Free: 800-232-4636 Website: http://www.

and the rationale for their inclusion. A dose of 12-24 grams of the dry herb. uremia. although they begin to appear in those societies when Western diet and stresses are introduced (Trowell and Burkitt). During remissions. Natural treatment Natural and herbal treatment of SLE is controversial from a scientific point of view. In emergency conditions or SLE complicated with myocarditis. or on emerging concepts of pathology which have not been definitively proven in the literature. During exacerbations. Heat-clearing herbs The application of traditional Asian terms such as ―heating‖ and ―cooling‖ to Western herbs is in its infancy. Conventional treatment is symptomatic only. produced by the Institute for Traditional Medicine in Portland.‖ and mild bitters may be useful in lupus.has been identified. and systemic lupus and other autoimmune diseases are rare in primitive societies following traditional lifestyle and dietary habits. conventional treatment should be initiated without delay. Table 1 shows the herbs in Lithospermum 15. the principle of using mild tonic herbs combined with cooling herbs is applicable. TCM syndromes The underlying syndromes for systemic lupus in traditional Chinese medicine involve Deficiency patterns and Heat syndromes (especially Deficiency Heat or False Fire). the stronger artemisia species might be used following the same ―heatclearing‖ strategy that conventional medicine applies with antimalarial drugs. In general. If the disease were entirely due to genetics. decocted in a quart of water. Whatever paradigm of herbalism is used to treat SLE. burdock (Arctium lappa). and also used for exacerbations of SLE. Thus. Tonics in the formula are mild. ascites. heat-clearing herbs. and drunk in . Incidence is much higher in the developed countries. The therapeutic challenge with herbal medicines (regardless of the medical paradigm) is how to tonify to increase strength in SLE patients without simultaneously increasing heat and inflammation. or agrimony (A. however. A. pilosa) might be included in formulas. OR. natural therapies involving diet and lifestyle may be effective at modifying or removing the cause of SLE.). The most important Chinese organ system for therapy is the Kidney. Sweet Annie (Artemisia annua) is used in China as an antimalarial. gentle bitters such as dandelion (taraxacum off. A window into the therapeutic balance necessary for treating lupus might be seen in the commercial formula Lithospermum 15. eupatoria. and in clinical practice drug side effects commonly complicate the symptom picture and make natural treatments more difficult. bitter herbs are viewed as ―cooling. and potentially overstimulating tonics such as deer antler or Asian ginseng (Panax ginseng) are avoided. About 20% of the volume of the formula is composed of cooling. which in Western terms most closely fits the hypothalamic-pituitary-adrenal axis. and thus classification may be imprecise or subject to debate. traditional Asian herbalism. or cerebral edema. we would expect to find equal rates among primitive people and those living in the developed countries. usually based on empirical approaches.

She had tried it several times with rechallenge before stopping its use. whereas American ginseng root may cost several hundred dollars. or meat broth. antiinflammatory. to modify their course or severity.three doses throughout the day. Immunomodulating herbs Contemporary American herbalists classify a group of herbs. The herbs might be administered in a ―tonic soup‖ which the patient can prepare in large quantities every few days. with differences of opinion among practicing herbalists around the world. Yoshida et al. The use of echinacea in lupus is controversial. including reishi mushroom (Ganoderma lucidum). The herbs tend to have a neutral ―temperature‖ or mild action in traditional usage. and autoimmunity‖ in this volume] explains the possible connection between loss of efficiency of the gut barrier and autoimmune conditions. microchimerism. M. shiitake mushroom (Lentinus edodes). astragalus. The herbs may be given in decoction or powdered. Nutrients and herbs that support liver detoxification may be appropriate as addition either . Restoration of the integrity of the barrier may be the most important herbal therapy for autoimmune diseases. chamomila).) These herbs have complex actions on the immune system when measured in in-vitro and in-vivo trials. Asian ginseng leaf costs only a few dollars a pound.‖ The term is common is the journal articles of Asian scientists researching traditional Asian herbs and medicinal mushrooms (Chang. If powdered. Demulcents might best be given separately in order to provide more of the herb than would be available in dose. 1992. One possible basic formula might include equal parts of chamomile (Matricaria recutita. He J et al. He Y et al. maitake mushrooms (xxx). A gut-healing strategy might include demulcent. American ginseng (Panax quinquefolius) also has cooling properties. can be given as a simple. shiitake mushroom. and licorice (Glycyrrhiza glabra). grains as tolerated. decocted in a nourishing soup with vegetables. Slippery elm powder (Ulmus fulva) can be given with applesauce or added to oatmeal. and are traditionally taken for long periods of time in food quantities. Amounts might be modified and other herbs added to the formula. Wang and Lin. Gut-healing herbs The article on the ―leaky gut‖ syndrome [see ―Gastrointestinal: Leaky gut. fennel (Foeniculum vulgare). Peony root is a cooling tonic which can offset the tendency of astragalus to aggravate inflammation. and carminative herbs. Marshmallow (Althea off). and astragalus root (Astragalus membranaceus) as ―immunomodulating. may be appropriate. meat. they should be given in warm water. A possible complication of ―leaky gut‖ is an overload of gut pathogens on the liver. Among herbalists the term is used to indicate herbs that have traditionally been used to restore balance to the immune system rather than to stimulate it. depending on the presenting picture. and peony root (Paeonia lactiflora). especially as soups or decoctions. as do the leaves of Asian ginseng (Panax ginseng). peppermint (Mentha piperita). An example might be reishi mushroom. One of the five patients in this study reported that taking echinacea would make her lupus symptoms worse. molecular mimicry.

Refined omega-six oils and margarine combined with a relative deficiency of omega-3 oils. Diet/Supplements/Exercise Food allergies may be either a cause or a consequence of the leaky gut syndrome. Stress management . and soy. An ionic liquid mineral supplement high in magnesium is available from Trace Minerals Research in Utah. such as dandelion. Abandonment of the modern diet in favor of a whole foods diet is essential in the treatment of lupus. Wild salmon (not farmed) and/or sardines added to the diet on a regular basis can produce dramatic clinical results with reduced inflammation. These two conditions argue for the value of homeopathic remedies or flower essences. or agrimony might be preferred. The chief offenders appear to be dairy. wheat. and margarine. even if they are currently refusing recommended steroids or chemotherapy agents. essential to the process of liver detoxification. refined flour. and refined oils. such as appear in fish and wild game. The foods most likely implicated in the Western diseases (see introduction) are sugar.[see ―Gastrointestinal: Leaky gut. Nutrition supplements administered must be selected for easy assimilation. along with the hepatoprotectant milk thistle seed (Silybum marianum). The gentler cleansing herbs. despite their popularity among customers of health foods stores. An easily assimilable form of magnesium is essential. traditionally used to treat deep seated emotional conditions or the ill effects of suppression of symptoms with drugs. can lead to prostaglandin imbalances that favor the inflammatory response. may be helpful. Homeopathy. and may also reduce elevated estrogen levels which promote hyperactivity of the immune system. burdock. with the outbreak following by 1236 hours. flower essences A history of suppression of symptoms with pharmaceutical drugs is the rule in lupus patients. because impaired digestion or intestinal absorption may otherwise render supplementation useless. molecular mimicry. Fasting and reintroduction of suspected foods may dramatically demonstrate to both practitioner and patient the importance of food allergies to the presenting symptom picture. Nutrients such as magnesium and vitamin B6. microchimerism. It is the author‘s experience that flax oil and other omega-3 oils from vegetable sources are usually ineffective in treating inflammatory a leaky gut formula or to tonic soups. The author has seen dramatic changes in energy-level and/or inflammation in each of the patients above given this supplement. confirmed by removal from the diet and rechallenge. Underlying emotional complexes either predating the illness or in response to it are also common. and autoimmunity‖ in this volume. Two of the patients could trigger full-blown lupus flareups with joint pain and/or kidney involvement by eating a single cookie made of wheat. All five SLE patients in this demonstrated severe allergies to dairy and/or wheat. for a full discussion of possible mechanisms].

TCM treatment of the Kidney organ system (see discussion above) is consistent with restoring proper adrenal function. while all tonics should be discontinued during such a period. prayer. may be useful. Raynauds phenomenon. Fasting on water and lemon juice and resting during fever or severe inflammation can reduce the antigenic load on the gut and promote elimination of immune complexes. For milder outbreaks. Painful swelling of all the lymph glands in the body . and not relied on to ―cure‖ the illness. The loss of the antiinflammatory effects of the cortisol can exacerbate the autoimmunity. group support. or war. according to DSM IV criteria. following major childhood traumas. including NSAID and steroids. might be useful. extended vacations. DHEA supplementation should be given only in conjunction with treatments that address the cause. Dosages of up to 100 mg of DHEA have been reported in the alternative treatment of lupus (Pizzorno). such as professional lives characterized by deadline pressures or pressure to overwork. but therapeutic doses should normally be limited to 10-20 mg per day. Birth control pills may also induce leaky gut syndrome. sexual or physical abuse. Removal of medications The drugs commonly used to treat lupus. Dihydroepiandrosterone (DHEA) production by the adrenal glands may also be depleted. healing is unlikely without their removal. especially from potentially allergenic foods. 5‘5" 120 lbs.o. DHEA supplementation may be helpful in severe cases of lupus. may themselves cause leaky gut syndrome. with separate treatments for outbreaks and remissions. Each also had unusual stress in their current situation. Overall health self-assessment: 7 of 10 Chief complaint: Lupus-like autoimmune outbreaks. especially with kidney involvement. spa therapy. and the full array of possibilities might be explored. Case 1: Early Stage Lupus Patient: 25 y. meditation. and will not heal the leaky gut or remove food allergens.Each of the lupus patients in this review has suffered from mild to severe post-traumatic stress disorder. In the author‘s opinion. further contributing to immune imbalances and reduced tissue repair. While they may have their place in treatment. abusive marital situations. or to break the cycle of stress and adrenal depletion. etc. DHEA does not address the cause of the disease. a light diet or modified fast. Chronic stress may lead to exhaustion of cortisol secretion by the adrenal glands (which might be measured by a simple salivary cortisol test). Mild heat-clearing herbs might also be appropriate. including psychotherapy. female. The patient was told she had ―pre-lupus‖ by her physician. Reducing stress is no simple matter clinically. Two-phase strategy A dual strategy. or poverty.

Lifestyle: 6-8 beers per week. in two sittings. Discontinued all conventional meds eight months prior.during attacks. Meditates regularly. easy bruising. allergy Great grandparents: Emphysema. Joint inflammation. arthritis. liver damage secondary to alcoholism. headaches. bone cancer. Most recent outbreak three weeks prior. Drinks 2-3 quarts water a day. Minor symptoms. 2-3 cups coffee per week Exercise (walk. jog. Possible kidney pain. Sleeps 6-9 hours per night. osteoporosis.I. Ending long-term relationship. About four outbreaks a year. ―Could set the calendar by them‖ Mild hair loss. especially past 3-6 months. Family History: Father: Stomach ulcer. High stress job.. Great aunts and uncles: enlarged thyroid. hypothyroid. Maternal grandmother: allergy. bike. stomach ―upsets‖ . hair loss. esophageal cancer. Daily meds: 1000 mg Vitamin C. Deceased Paternal grandfather: allergy. One positive “anti-DNA antibody” test. angina. with dairy binges. Low grade fever. allergies Great aunts and uncles: heart disease. etc) 60 minutes per day seven days a week. M. Maternal grandfather: stomach ulcer. Raynauds. goiter. spaced at regular three-month intervals. Diet: Diet diary revealed possible dairy allergy. heart disease Paternal grandmother: enlarged heart. arthritis Mother: symptoms of lupus without clear diagnosis.

repeated antibiotics. Sulfur-salicylic acid shampoo prescribed for eczema. Second DPT shot 4 months (March 8) 3rd DPT shot. hypertension. Meds for cold. Fungus infection still present 9 months (August 6). Put on bc pills. Eczema on scalp. Mother says developed Raynauds phenomenon in teens. ―bad‖ periods. 6 months. Treated with ―mycolog cream‖ — combination of nyastatin and corticosteroid. Client says first Raynauds symptoms (See mother‘s comments above). Eventual surgery to ―stretch tubes‖ Doctor says ureters were congenitally too narrow — i. Age 13: Menarche. Tongue developed ―raw spots‖ Unspecified medication. Age 12: Tonsillectomy for recurrent strep Teens: sulfa allergy. Menstruation stopped for next 2 ½ years . with yeast infections as side effect. 3 months (Feb 8) Put on cow‘s milk. diaper rash. prostate cancer. 2nd oral polio vaccine. Received multiple prescriptions and antibiotics with simultaneous antifungals. but then put on soy formula. Age 22: March: Norplant. middle. thumb — in symmetrical pattern. Corticosteroid cream for scalp eczema. head cold. incomplete and slow draining of bladder. Tegopen (cloxacillin) for recurrence of infection on finger. Hospitalized with pyelonephritis. Breast fed for two weeks. Client History Fungal infection on bottom shortly after birth. Doctor says ―may eat anything‖. ovarian cysts. oral polio vaccine. Age 6-12 Recurrent strep throat infections. Age 22: January. Introduced solid baby food. No obvious adverse reactions to any immunizations. Continuous until Norplant at age 23 Age 12-17: Repeated urinary tract infections. 2 months: first DPT shot. (March 29) fungus on 3 fingers of each hand — index. thyroid problems in extended family. developed seasonal allergies to grasses. osteoporosis.Great grandparents: arthritis. 13 months. Fungal infection cleared.e. Treated with repeated antibiotics.

Prodromal insomnia. All glands in body. Fatigue. Brain ―shuts off‖.‖ Breast pain makes her cry. Constant gas. better with hot tea. frustration. Current outbreaks Swollen glands. Lasts 1-2 weeks. Can‘t wear bra or tight clothes. promoting urinary retention. Hair loss is getting worse with latest outbreak (started 2-3 months ago) . Age 24: September. which doctor said was too narrow. Emotional: expressed these verbally but does not show strong emotions: sadness. ―nice‖ deep red color. Morning-evening fever pattern. preceded by flu. Worse in breasts ―don‘t want them there. Female BC pills since age thirteen after ovarian cysts and ‗bad" periods. better with warm blankets. every four weeks. Norplant at age 22-25. no clots. tender to touch. no cramps. Low grade fever: 100 degrees. Can‘t sleep on side. Suppressed periods completely. *Possible ―leaky gut‖ syndrome. Main trigger is stress. Removed nine months ago. Systems Urogenital: repeated uti and kidney infection in teens. forgetful. Surgery to ―stretch‖ the tubes. anger. Discontinued Norplant. ―happy to have it back. Doctors thought it was mononucleosis. Can‘t fully extend elbows. *Suppression of fertility and feminine psychological development *Stress and adrenal exhaustion. Better with hot bath. confused. Assessment: *Congenital immune weakness and tendency to allergy *Probable dairy allergy. Bloating. *Post-traumatic stress disorder (events confidential) . Two outbreaks ago. stress.‖ Digestive: Upper GI pain after meals. 5-6 days.Age 22: July: first lupus outbreak. Aggravation. Not ―a lot‖ of blood. Periods now normal. *Severe antibiotic suppression. Cramping in small intestine.

Let come to room temperature. and leaky gut. 3 days a week. Diet: Increase fruits and vegetables. Rest in natural setting as often as possible. Equal parts.) Digestive tea. Equal parts. Place three handfuls in a 2 quart pot and simmer for two hours. chamomile (Matricaria recutita).Treatments: Intensive education about the issues involved: food allergy. and did not) Diet for outbreaks (Client had no further outbreaks) Diluted citrus juice fast for duration of fever. (Glycyrrhiza glabra). . If too ―heating‖ add equal part of peony root (Paeonia lactiflora) and reduce astragalus by one-half part. astragalus (Astragalus membranaceus). on empty stomach. rewarmed to taste. stress. (The tea was not heating and was well-tolerated by the patient. fennel (Foeniculum vulgare). No dairy whatsoever. (Client was reluctant to comply. Complete rest. marshmallow (Althea officinalis). Peppermint (Mentha piperita). Strain and store in refrigerator. Stress management around work. Consider short stay at nearby spa. Chinese immunodulating soup Red reishi mushroom (Ganoderma lucidum). Castor oil packs. licorice (Glycyrrhiza glabra). licorice. Stress: Reduce heavy exercise to a moderate level. shiitake mushroom (Lentinus edodes). Decoct 1 ounce per pint of tea for 20-30 minutes. Eliminate dairy Increase vitamin C to 2-4 grams/day and add equal parts bioflavonoids. 3 cups per day. Take three cups per day. poria (Poria cocos).

Five-month follow-up. No further followups. and asked if the herbs could cause this. and the formula above to be taken t. indigestion. she ‗felt bad‘ for a day and a half. female Diagnosed with SLE at age 40. Drug-induced (methotrexate) cervical cancer at age 43. The patient received a dose of the flower essence at the end of second visit. Chronic lifelong PMS: bloating. Compliance with herbal treatments and elimination of dairy was good. History . with a happy resolution involving forgiveness. Hair loss stopped. irritability. Three month follow-up. with a one-hour educational follow-up. Her lupus outbreaks had previously happened ―like clockwork‖ every three months. breast tenderness.d. victimization Celery — immune support during stress Psycho-spiritual To local Wise Woman practitioner for a ―blood rites‖ ceremony to celebrate the psychospiritual passage that had been suppressed at menarche. Referred to MD-homeopath for constitutional homeopathy and ongoing monitoring of immune status. Case 2: Advanced Systemic Lupus with severe drug side effects Patient: 45 y. bloating. and reported better overall energy and improved digestive symptoms. Over the next few weeks. Patient called and said she had borderline diastolic hypertension. During this period she eliminated dairy completely. Results The visits included a two-hour intake. weight-gain. I suggested she remove the licorice from all formulas.o. At the anticipated three-month point. mild depression. but had no further symptoms. a healing crisis ensued around abuse issues. Chronic constipation since childhood: BM (dry) once in 5-7 days.i. Chronic gas.Flower essences Salvia — extreme stress Dill — releasing power to others.

Ran car into tree. 20 y. emergency room treatment for one incident. Prednisone 10 mg for two years.Almost died at age 2-3 from unidentified illness. Bleeding and convulsions. . Measles. Blackout spells as teenager. Married at 35 to chronic addict-alcoholic Extreme fatigue. Chills.o. First diagnosis: ―transient arthritis‖ Prednisone 60 mg plus NSAID. Could not move neck.o. No medical treatments Menses at 14 y. Peripheral neurological symptoms. Severe headaches.o. Chronic fatigue in twenties. Crying with pain. Right little finger ballooned. Arthritic pains during PMS. Followed by strep throat in twenties on three occasions. Age eight: Adverse reaction to multiple immunizations for travel: nausea.. and swelling of arm lasted two weeks. Onset symptoms: Major itching all over body for one month. One month later: joint pain throughout body. Chronic fatigue in teenage years. 38 y. Physically immobilized. History of physical and sexual abuse. mumps. Bladder infections. Lupus onset was after last miscarriage. Major PMS in teens and all adult life. and Darvocet for sleep. Four miscarriages. chicken pox during childhood. Diagnosed as hypoglycemic in thirties. which coincided with family financial crisis. deep pain in both arms. Severe PMS. Worse after marriage. dizziness. oral gold. Treated with short-term antibiotics.

Second diagnosis: rheumatoid arthritis.o. watercress. Hands crippled. Patient was told she would die of cancer unless she stopped taking the drugs. Was drug-free by September 1995. Pain in eyes.5 mg/week. Fourth diagnosis: SLE. Blurry vision. astragalus. or of kidney failure if she stopped taking them. Cortisone 60 mg plus gold shots. Bronchitis (treated with antibiotics). 42 y.5 mg/wk. meat. poria.‖ Major juice fast (three months). No joint pain. CNS involvement with seizures. Mixed NSAID. prednisone 10 mg. Healing crisis with acne. folic acid 1 mg. Methotrexate 7. brown rice. Chinese tonic soup. Caused lupus flareup. Plaquenil 200 mg. September 1995.‖ Plaquenil (hydroxychroloquine) 200 mg day and methotrexate 12. Major juice fast (three months). discoid rash. Diagnosis: SLE and fibromyalgia. Plaquenil-induced photosensitivity. coix. Had to wear sunglasses in house.Moved to rental home after losing house. Prednisone 10 mg. Ocular side effects to Plaquenil. burdock. ―Never felt better. December 1995. Adverse (rash) reaction to gold. Hysterectomy recommended. Bitten by dog and had tetanus shot. Methotrexate 12. Multiple infections. Temporary paralysis of right arm. .o. Methotrexate 10 mg/wk. memory loss. major regression: low back pain. 40 y. Plaquenil 200 mg. methotrexate 10 mg/wk. NSAID-induced ulcers. Excessive bleeding (clotting disorder). and mucous discharge. Rash. vegetables. 43 y. and millet. and wheat allergies. NSAID. 41 y. Treatments faced with a likely fatal diagnosis. Third diagnosis: ―Mixed connective tissue arthritis. Gradually tapered cortisone to 5 mg. Green juice and carrot. Severe squamous cell cervical dysplasia and cervical carcinoma in-situ with endocervical gland involvement. Over six months she started taking herbs and weaned herself from all drugs. and identified dairy.5 weekly dose and cortisone (10-12 mg) and NSAID. Energy good.o. The exact components have varied somewhat but include such items as: Shiitake and reishi mushrooms. Cortisone injection in wrists. the patient began to pray and study herbalism and natural healing.o. Collapsed with stress and slept for most of a week. Proteinuria — upped cortisone to 30-50 mg. Weight loss in spite of prednisone. Reintroduced foods. boils.

Deglycyrrhizinated licorice (DGL) for NSAID-induced ulcers. Soy protein. sesame and sunflower seeds. Vitamin C 5-6 grams. Juice in AM: carrot. Pantothenic acid 500 mg bid. argyi) as ―Plaquenil substitute‖ (antimalarial) 19 grams in three cups of water boil ten minutes. Pleurisy: Treated successfully with Asclepias tuberosa Proteinuria: Treated successfully with ground flax seeds and flax seed oil.Diet Sardines four times a week. cleared in one week. blackstrap molasses. parsley. Bupleurum as a simple for PMS Supplements Bromelain 1800 mcu tid. Organic vegetables.) 800 iu. Treatment She approached the author for herbal advice in Summer 1996. Chamomile for sleep (patient could not tolerate valerian) and antiinflammatory effects. Reduced astragalus and increased burdock in tonic soup to reduce heating effects. fresh-ground in vita-mix. Multivitamin. fresh ground flax. Other herbal treatments Chinese Artemisia (A. ½ clove garlic. . Organic grains. B complex bid Results Patient had normal pap in Fall 1995 and has had four more normal paps since. Curcumin 500 tid (Patient says turmeric powder is more effective than the extracted curcumin for antiinflammatory effects). Possible lupus flareups during herbal treatment: Hives: treated by Chinese practitioner. Reduces heat and joint pain. Vitamin E (mixed toc. Salmon (contain antiinflammatory essential fatty acids).

and slippery elm. white oak bark.Leaky gut formula: Equal parts of peppermint. witch hazel. This illustrates the vague nature of the diagnosis of SLE. Afterwards could manage lupus symptoms with one-fourth the previous dose of tonic herbs and artemisia. licorice. gums bleeding. Feels generally worse. First symptoms were the emergence of suppressed emotions around her marriage. Both had been sexually abused or raped. cheeks puffed up. except for leaky gut formula. and marshmallow. and suffered post-traumatic symptoms from the events. In February 1997 normal bowel movements (1x/day) began for first time in her life. Patient removed the licorice because of increased bloating. and was counseled on stressmanagement strategies. Common elements in both cases Diagnosis: Patient 1 was told she probably had lupus but did not fit all the diagnostic criteria for it. fennel. Self medicated with raspberry. Etiology:   Both patients had experienced stress in childhood also were experiencing it in their current situations. Flower essences Broccoli — balance of personal power Celery — immune support during stress Comfrey — higher vibrational damage or injury Salvia — extreme stress Dill — Victimization (Take several drops three times a day or as desired) Within a week. One outbreak of hives (treated by Chinese herbalist). . Fall 1996-Winter 1997 Patient discontinued most of herbal treatments. chamomile. but is functional. Patient was under unusual stress during this time. shortness of breath. Then bleeding from rectum. Reintroduce the tonic soup and artemisia. the flower essences appeared to provoke a strong healing crisis. Lasted four days. slippery elm. Patient 2 received multiple misdiagnoses before finally being diagnosed with SLE.

initiating inflammation. usually of child-bearing age. Pathogenesis Production of pathogenic auto-antibodies and immune complexes coupled with failure to suppress them.  Both had extreme digestive symptoms Both had food allergies to dairy and/or wheat. o Both had a history of severe and repeated suppression of symptoms with antibiotics and/or steroids. . Antigen-antibody equivalence or mild antigen excess tend to larger complexes. Usually phagocytosed. Specific symptom manifestation is highly variable. Size of complexes may be an important factor C larger cause more tissue damage. Genetic defects in aptosis (natural death) of B and/or T-cells. Antigen-antibody complexes may be deposited in tissues. and depends on which tissues are involved in the autoimmune response. Exacerbations and remissions are typical. Both eliminated food allergens Both experienced relief of both digestive symptoms and experienced improved overall health in response to a gut-healing formula Both complied with treatments in making and regularly consuming a soup of Chinese immunomodulating herbs In both cases. The foods provoked exacerbations of lupus symptoms with rechallenge. Successful treatment: o o o o o o Both patients had a large degree of self-empowerment and self-direction. Both stopped all pharmaceutical medications. Etiology Genetic factors: Abnormal humoral and cell-mediated immune responses. 90% of cases are in women. proven by elimination and rechallenge. Antigen or antibody excesses tend to smaller complexes. a flower essence remedy during later stage of treatment produced healing crisis Table 1: Systemic Lupus Erythematosus Definition and prevalence Tissues and cells damaged by deposition of pathogenic auto-antibodies and immune complexes. but clearance is poor in this and related diseases. More common in Blacks and Hispanics than in whites.

immunizations. and microchimerism@ Hormonal: Estrogen enhances and testosterone reduces antibody responses. sulfa drugs. Butterfly rash across nose and cheeks occurs in less than 50%. Interleukin secretion is diminished. Suggests importance of avoiding xeno-estrogens. molecular mimicry. weight loss Musculoskeletal (95%): Most common are arthralgias/myalagias and polyarthritis (60%) Cutaneous (80%): Most common are rashes. First trimester of pregnancy and first six weeks post-partum may trigger lupus (See accompanying article ALeaky gut. Suggests important role for ALeaky Gut@ syndrome and molecular mimicry. and maximizing hepatic clearance of estrogens.) Systemic (95%): Fatigue. Overall pattern is one of elevated antibody activity with overall immune deficiency. nausea. Infection: Streptococcal or viral infections may trigger or aggravate. Digestive: Phospholipids in cell walls of enteric bacteria may activate B-cells or antibodies and elicit cross-reactivity to ribose-phosphate backbone in DNA. anticonvulsants. fever. molecular mimicry. T-4 and T-cytotoxic cell deficiency during attacks. Immune: B-cell hyperactivity. but miscarriage is high (30-50%). seizures. See accompanying article ALeaky gut. May explain higher incidence in women. Reproductive: Fertility is normal. and pericarditis are most common. oral ulcers. and triggering effect of oral contraceptives. pleural effusions. Cardiopulmonary (60%): Pleurisy. and microchimerism@) Clinical manifestations (only those occurring in a majority of patients are listed. others being possible. Stress: Physical or mental stress may trigger or aggravate. penicillins. Hematologic (85%): Anemia and leukopenia are most common. Neurologic (60%): Possible manifestations are organic brain syndromes. and alopecia. and peripheral neuropathies. malaise. Elevated anti-nuclear and/or anti-DNA antibody titer and decreased serum complement (C3 and C4) during attacks. hydralazine. and oral contraceptives.Pharmaceutical Drugs: SLE may be triggered or aggravated by procainamide. . Slow clearance of immune complexes due to inherited or acquired deficiencies in complement system. Clotting and bleeding disorders may also develop. anorexia. Mild mental dysfunction is most common manifestation.

mild pain. or thrombocytopenia Positive lupus erythematosus cell. leukopenia./day. or excessive cellular casts in the urine Seizures or psychoses Hemolytic anemia. Nephrotic syndrome (25%) and renal failure (5-10%) may occur. Most common cause of death in lupus patients. Gastrointestinal (45%): Nonspecific (anorexia.Renal (50%): Proteinuria and cellular casts are most common. The American Rheumatism Association has issued a list of criteria for diagnosis of SLE as follows.5 g. anti-DNA. exceeding 0. Malar or discoid rash Photosensitivity Oral or nasopharyngeal ulcerations Nonerosive arthritis of two or more peripheral joints Pleuritis or pericarditis Profuse proteinuria. or anti-Sm test or chronic false-positive serologic test for syphilis Abnormal titer of antinuclear antibody. lymphopenia. diarrhea) and ascites are most common. Diagnosis Symptoms overlap with those of related connective tissue autoimmune disease. Four or more of the signs must be present at some time during the course of the disease. Prognosis .

54(11 Pt 2):S91-S93 Dharmananda S. H. Lin ZB The immunomodulatory effect of lentinan. Serious damage to central nervous system is also possible. and Burkitt. Liu JN. cataracts.Death may occur in 10-15% of cases due to kidney failure or autoimmune damage to the heart. California: Prima Publishing. Portland. Oregon: Institute for Traditional Medicine. Total Wellness. Pennsylvania: Springhouse Corporation.19(7):359-370. Eleventh Edition. Shan BE. Western Diseases. Immunomodulating activity of Chinese medicinal herbs and Oldenlandia diffusa in particular Int J Immunopharmacol 1997 Jul. Inflammatory Joint Diseases and rheumatic disorders and Nursing Intervention Lecture February 15th. Cahill References Braunwald. D. Li Y. Cambridge. M. infections.) Karst Chung Kuo Chung Yao Tsa Chih 1992 Apr. irregular menses. Rocklin. Massachusetts: Harvard University Press.C. bone necrosis. 1987 Cahill. Ma L Chemical studies on immunologically active polysaccharides of Ganoderma lucidum(Leyss. Gastrointestinal side effects common. diabetes mellitus. Lin Z. myopathy. Wei S. 1998 Chang R Functional properties of edible mushrooms. glaucoma. weight gain. Conventional treatments Non-steroidal antiinflammatory drugs (NSAID). and psychosis. irritability. 2011 Admin 797 Views .23(4):408411 He Y. New York: McGraw-Hill. 1990 He J. A Bag of Pearls. Fu W. Nephrotoxicity is possible. hypertension. Harrison’s Principles of Internal Medicine. Li R. 1981 Wang GL. 1996 Trowell. Springhouse. Antimalarials. Yamashita U. ex Fr. Sources: Braunwald.31(2):86-90 Yoshida Y. Professional Guide to Diseases. E. Effects of mixture of Astragalus membranaceus.P.17(4):226-228 Pizzorno. insomnia. Nutr Rev 1996 Nov. Full range of side effects common: adrenal disorders. Ocular side effects common. Xia D. J. Chen Q. osteoporosis. Wang MQ. Guo M. Fructus Ligustri lucidi and Eclipta prostrata on immune function in mice Hua Hsi I Ko Ta Hsueh Hsueh Pao 1992 Sep. Corticosteroids. their Emergence and Prevention. Yao Hsueh Hsueh Pao 1996.

Scleroderma– is a chronic autoimmune disease characterized by fibrosis or progressive hardening of skin in patches or diffusely with rigidity of underlying tissues. lymph nodes and GI tract. Rheumatoid arthritis – it is a systemic inflammatory disorder of the connective tissue/joints characterized by chronicity. lungs. Clinical manifestations of OA may include joint pain.Inflammatory Joint Diseases Rheumatic Disorders . locking of joints.More than 100 different disorders that affect muscles. The main goal of treatment is to identify the underlying infectious source with the appropriate antibiotics if still present..Polymyalgia rheumatica (PMR)– is an inflammatory condition of the muscles. creaking. Coming into contact with bacteria and developing an infection can trigger reactive arthritis. PMR is usually treated with long courses of oral steroid Osteoarthritis – is a group of diseases and mechanical abnormalities involving degradation of joints. usually in the neck. bones. The pain can be very sudden. kidney. although treatments and medications are available to reduce symptoms and pain Reiter‘s syndrome – is an autoimmune condition that develops in response to an infection in another part of the body. which causes pain or stiffness. The cause is unknown .so there is no direct cure for scleroderma. or can occur gradually over a period of time. Systemic Lupus Erythematosus (SLE) – A diffuse connective tissue disease affecting multiple body systems – skin. joints. and hips. manual therapy. remissions and exacerbations. tenderness. stiffness. medication and other interventions to alleviate pain Ankylosing spondylitis – chronic connective tissue disorder of spine and surrounding cartilaginous joints such as sacroiliac joints and soft tissues around vetebrae. serous membrane of heart. shoulders. No cure is known for AS. lifestyle modification. tendons and joints. Treatment of OA consists of exercise. . ligaments. PMR usually goes away within a year or two after treatment.

elbows.Autoimmune disease . hormonal and environmental factors. Gout – is a medical condition that usually presents with recurrent attacks of acute inflammatory arthritis (red.Body image disturbance Rheumatoid Arthritis . erythema.Inflammation of arterioles causing lesions and necrosis.Degenerative changes – loss of articular surfaces and joint motion. joint swelling. .Pericarditis and pleural effusions. is inflammation of the synovial membrane that lines joints and tendon sheaths.Functional assessment – gait. wrists.Fever. It is caused by elevated levels of uric acid in the blood. Nursing Diagnosis of SLE: . joint swelling.NSAIDS and corticosteroids . . feet. lungs.Begins in small joints of hands. and stiffness limits their movement . . kidneys.Onset often in childbearing years and may be insidious or acute. warmth.Increased autoantibody production resulting from abnormal suppressor T-cell function. . hot.Immunosuppressive agents.Arthritis. Systemic Lupus Erythematosus SLE . posture.Result of immune response . Affects around 10-30% of people suffering from the chronic skin condition psoriasis.Lymphadenopathy: swollen/enlarged lymph nodes . blood vessels. heart.Skin lesions and butterfly shaped rash on nose and cheeks. fatigue.Acute onset of bilateral and symmetric pain.Impaired skin integrity . tender. tenderness and pain.Antimalarial medications . weight loss SLE Management . .The arthritis of joints known as synovitis.Depression and psychosis . Joints become swollen.Can be life threatening . . Assessment Of Rheumatic Arthritis .Family History – hereditary component Signs and symptoms: . Signs and symptoms: .Fatigue. swollen joint) affects the feet. loss of function. . .Inflammation involves other areas as well as joints.Control acute exacerbations that may damage organs . .Behavioral and cognitive changes .Psoriatic arthritis – a skin disease characterized by reddish marinated patches with profuse silvery scaling on extensor surfaces like knees and elbows. tender and warm. . . ankles and knees.Caused by combination of genetic.

balance of rest and exercise .Corticosteroids .X-ray shows cartilage abnormality.Preventive measures can slow progress . caused by swelling and joint destruction. GI disturbance.Deformity in hands and feet is common.Salicylates. pericarditis. fatigue.Rheumatoid nodules (nontender. Symptoms of Osteoarthritis .Antirheumatic agents .Rheumatoid factor. prevent injuries . Rheumatic Arthritis Tests . spurs. anemia.X-ray: loss of joint cartilage. NSAIDS (anti-inflammatory and analgesic) . elbows. . . NSAIDS .Decreased RBC Management of Rheumatic Arthritis . knee.Early education. neuropathy. shoulders. stiffness in morning relieved with movement . spine) but dinger joints often involved .Weight reduction.Pain.. lymph node enlargement. weight loss. .Inflammation and degeneration of cartilage and bone .Reconstructive surgery when pain unrelieved. .Intraarticular injection of corticosteroids Surgery when pain not manageable or function loss (arthroplasty).Antimalarials. narrowing of joint space. Systemic effects Fever. joint trauma. anemia.Blood studies not useful Management .Apply heat. .Splints and braces to support inflamed joints . methotrexate.Blood tests . spine. . rest the joint .Immunosuppressive agents (methotrexate. . arteritis. heavy physical activity.Functional impairment .Progresses to knees. Osteoarthritis . bone marrow suppression. . some hereditary. splenomegaly.Bony nodules (painless) .Raynaud‘s phenomenon (cold and stress induced vasospasm in fingers and toes causing cyanosis). . joint erosion.Arthrocenteseis (needle aspiration of synovial fluid – cloudy with increased inflammatory cells) .Occurs most often in weight bearing joints (hips.Increased ESR.Acetaminophen.Degenerative joint disease .Antidepressant (amitriptylline) for sleep disturbance . related top obesity. dry eyes and mucous membranes. hips. . movable in subcutaneous tissue over bony prominences).Many types.Tender and enlarged joints. cyclophosphamide) for advanced diseaseincreased – toxicity. .

dieting. increase in rest requirements. sustained sense of exhaustion and decreased capacity for physical and mental work at usual level Characteristics: Inability to restore energy even after sleep.NSAIDS to decrease inflammation .com/2011/02/inflammatory-joint-diseases-and. abdominal pain).Causes : severe diet.Colchicine lowers deposits of uric acid . increase in physical complaints. compromised concentration. lethargic or listless. drowsy. excessive intake of high purine foods (shellfish. June 18. Signs and symptoms of Gout . starvation. stress. perceived need for additional energy to accomplish routine tasks. .Acute gouty arthritis (recurrent. temperature . .Repeated attacks cause accumulations of sodium urate crystals (Tophi) to be deposited in greater toe. vomiting. multiple myeloma. compromised libido. severe attacks of inflammation) triggered by trauma. 2010 Labels: NURSING DIAGNOSIS Nursing Definition for Nursing Diagnosis Fatigue An overwhelming.Abrupt onset at night of severe pain. lights.Tophi is a deposit of monosodium urate crystals in people with longstanding high levels of uric acid in the blood . swelling and warmth. June 18. decreased performance. organ meats) heredity.Oversecretion of uric acid or decreased excretion. alcohol ingestion. illness.Defect in purine metabolism resulting in hyperuricemia . tired.html Nursing Diagnosis Fatigue Posted by d. inability to maintain usual routines. ASA. stress. verbalization of an unremitting and overwhelming lack of energy. anxiety. redness. .Uricosuric agents (probenecid) to correct hyperuricemia and dissolve deposited urate. Management Of Gout . leukemia. 2010 . ear.nurisna at Friday. Friday. introspection. medications. lack of energy or inability to maintain usual level of physical activity. depression Humidity. hands. disinterest in surroundings.Urate crystals precipitate within the joint causing inflammatory response .Urate deposits in kidneys cause kidney stones .Allopurinol prevents uric acid formation (side effects of bone marrow suppression. ethanol). Read more http://www. noise.Gout .nursing-lectures. feelings of guilt for not keeping up with responsibilities Related Factors: Boring lifestyle. altered renal function (caused by diuretics. or combination . .Renal impairment and kidney stones.

Encourage client to keep a journal of activities. . malnutrition. Assist client with ADLs as necessary. or medication effect. Work with the physician to determine if the client has chronic fatigue syndrome. hypothyroidism. ability to perform activities of daily living (ADLs). Encourage the client to get adequate rest. anemia NOC • • • • Client Outcomes   Outcomes (Nursing Energy Outcomes Nutritional Status: Classification) Endurance Concentration Conservation Energy Verbalizes increased energy and improved well-being Explains energy conservation plan to offset fatigue NIC Energy Interventions (Nursing Interventions Classification) Management Nursing Interventions             Assess severity of fatigue on a scale of 0 to 10. encourage independence without causing exhaustion. multiple sclerosis). symptoms of fatigue. refer to physical therapy for carefully monitored aerobic exercise program. poor physical condition. disease states (cancer.g.Negative life events. Help client identify essential and nonessential tasks and determine what can be delegated. and usual pattern of activity. such as anemia. pregnancy. activities associated with increased fatigue. Evaluate adequacy of nutrition and sleep.. occupation Sleep deprivation. and feelings. Determine with help from the primary care practitioner whether there is a physiological or psychological cause of fatigue that could be treated. Refer to Imbalanced Nutrition: less than body requirements or Disturbed Sleep pattern if appropriate. use active listening techniques and help identify sources of hope. increased physical exertion. Encourage client to express feelings about fatigue. Help client set small. hire cleaning service). Refer client to diagnosis-appropriate support groups such as National Chronic Fatigue Syndrome Association or Multiple Sclerosis Association. Give client permission to limit social and role demands if needed (e. electrolyte imbalance. assess frequency of fatigue. HIV. With physician's approval. depression. easily achieved short-term goals such as writing two sentences in a journal daily or walking to the end of the hallway twice daily. times of increased energy. switch to parttime employment. mood. ability to concentrate.

make lists of required activities.    Refer client to occupational therapy to learn new energy-conserving ways to perform tasks. and use of music.. anxiety is correlated with increased fatigue. Fatigue may be more pronounced in specific settings for physical or psychological reason. See Anxiety care plan if appropriate. Identify recent losses. . Refer to occupational therapy to accomplish this if necessary. beta-blockers. Assess home for environmental and behavioral triggers of increased fatigue When assisting client with adapting to home and daily patterns. If client is very weak.g. Teach strategies for energy conservation Teach client to carry a pocket calendar. and post reminders around the house. avoid activities of high energy output. a room with familiar. Assist client with identifying or creating a safe.. monitor for depression as a possible contributing factor to fatigue. antihistamines. imagery. Certain medications (e. Teach stress-reduction techniques such as controlled breathing.g. nonthreatening. refer to physical therapy for prescription and use of a mobility aid such as a walker. pain relief. Review medications for side effects. Teach the importance of following a healthy lifestyle with adequate nutrition and rest. or nonfrightening belongings). pain medications) may cause fatigue in the elderly. restful place within the home that can be used routinely (e. Client/Family Teaching      Share information about fatigue and how to live with it. including need for positive selftalk. Home Care Interventions     Assess client's history and current patterns of fatigue as they relate to the home environment. and appropriate exercise to decrease fatigue.

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