Lupus: Treatment Options
Guest: Dr. Jim Oates – Rheumatology & Immunology
Host: Dr. Linda Austin – Psychiatry
Dr. Linda Austin: I’m Dr. Linda Austin, interviewing Dr. Jim Oates, who is Associate Professor of Rheumatology at the Medical University of South Carolina. Dr. Oates, we talked some in a previous podcast about the symptoms of lupus and the diagnosis of lupus. Once it’s been diagnosed, how do you begin treatment?
Dr. Jim Oates: We try to make the treatment fit a particular patient’s disease course. So, some patients have very mild disease, where they might have a sun-sensitive rash and some joint pain without a lot of swelling or a lot of functional limitations. And the therapy in that case might be a mild therapy, a drug that was once used to treat malaria, called Plaquenil. However, for people who have more significant disease, they’re beginning to have arthritis that doesn’t respond to things like naprosyn and ibuprofen, we’ll use prednisone in small amounts. This is a corticosteroid that we try to use for only a short period of time because of the side effects. And then we may bridge to what we call disease-modifying agents. There is a long list of them with varying side effects. Most of them work by suppressing the immune system.
The goal with our treatment is always to, first of all, never make the drug worse than the disease, but always match our immunosuppressant, or our sort of beating down the immune system, enough to bring the disease into check without destroying the patient’s ability to fight infection, and that’s always sort of a fine line. So, somebody who has mild or moderate disease, we try not to put them at risk with significant immune suppression. But, people who have severe disease, like kidney disease and brain disease, where they can end up on dialysis or have permanent brain damage, then we use more immune-suppressing therapy. There are lots of things being looked at in a research setting that, perhaps, we could talk about later that are very exciting.
Dr. Linda Austin: I would imagine that a rheumatologist and a patient with lupus must have a very long relationship and that the communication must really need to be very important, in both directions. Is that right, because it is a long, chronic illness?
Dr. Jim Oates: Absolutely. Typically, we’ll see our lupus patients every three months. So, often times, we’ll see them more than a primary care physician does, and often times we become the de facto primary care physician. And it’s very important that we communicate back and forth because a lot of our therapies have side effects. And patients may feel shy about telling us when they’re having side effects, and they may stop a drug or reduce the dose on their own, not wanting to bother us with that particular side effect. And I do want to say that we do want to be bothered, because we want to be able to adequately treat the disease and be able to change our medical therapy to meet a patient’s needs or their side effect profile. So, there are multiple options of treatment. And if somebody is having problems with one of those options, we want to switch as quickly as we can to something else.
Dr. Linda Austin: When a patient comes to you early in this illness and they’ve just been diagnosed, let’s say they have some arthritis and they may have a rash, and they look at you and they say, Dr. Oates, what kind of a life am I going to have now with this illness? How do you answer that?
Dr. Jim Oates: That’s difficult because it varies from patient to patient. But, typically, you can tell how somebody is going to do by how they respond to therapy initially. So, if we have a very difficult time bringing their disease under control, they’re more likely to have problems later on. One of the nice things, though, is that we can increase our therapy over time to try to match the severity of their disease. And there are patients who can go back to work and function normally.
There are a good number of patients who suffer some disability related to the disease, some of it, actually, related to fatigue. We may bring the arthritis under control and the inflammation around the heart and lungs, but the fatigue is significant for a lot of patients. And employers and family members have difficulty understanding that. And with our current therapies, we don’t have as much of a handle on that as I would like.
Dr. Linda Austin: I was going to ask if there are any specific treatments for the fatigue of lupus.
Dr. Jim Oates: Unfortunately, there aren’t. We try to bring what we see in their disease, be it arthritis or rash or kidney disease, under control. We do have difficulty treating with significant immune-suppressing therapy for just fatigue, because we always want the drug to be less toxic than the disease. And, sometimes, when there’s a significant amount of fatigue, we may adjust therapy anyway.
Dr. Linda Austin: Can you give kind of a rough estimate of patients who initially present to you that are able to continue to work fulltime on a regular basis and that do have a good response? Is it the majority?
Dr. Jim Oates: I’d say it’s about half and half. One thing that differentiates people who succeed from those who don’t, unfortunately, has to do with their ability to take their medication. A lot of times, the medicine is expensive or the insurance company doesn’t want to pay for it, and we spend time working through the paperwork, or their ability to adapt. So, individuals who may have one particular job but the disease renders them unable to do that job can retrain and do something else. But, I’d say about half my patients are able to go back and work fulltime.
Dr. Linda Austin: You mentioned, in an earlier podcast, that it’s most common in, and actually quite common, I thought you said, 1 in 350 among African-American women of childbearing age. Are those women typically able, subsequently, to become pregnant and become mothers, or is the disease often so debilitating, they can’t do that?
Dr. Jim Oates: We don’t often have difficulty with becoming pregnant and carrying a child, for the most part. The problem we have is if the disease is active. Becoming pregnant can make it more active and it limits our treatment options. A lot of the therapy we use cannot be given to somebody who is pregnant because it will cause damage or harm to the fetus. So, what we ask patients to do is, if they have significant kidney or brain disease, to wait until the disease is quiet and it’s been that way for one or two years before we even think about becoming pregnant.
Dr. Linda Austin: You had said that many of the drugs that are used for lupus suppress the immune system. I would think, then, you would run the risk of, potentially, the patient having other infectious illnesses or disease processes, is that right?
Dr. Jim Oates: Yes. And the most typical are viral infections that are running through our communities every day, particularly in the fall or in the winter months. What we ask patients to do is to stay up to date on their vaccinations, avoid known contacts, and, if you can, have family members vaccinated as well, and wash their hands.
Dr. Linda Austin: Dr. Oates, thank you so much.
Dr. Jim Oates: Thank you.
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