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Managing Infections for Lupus Patients - Highlights from Dr. Curran's Presentation On August 9, 2012, the LSI hosted an educational teleconference “Managing and Preventing Infections for Lupus Patients” presented by Dr. James Curran. The event included a presentation by Dr. Curran followed by Q&A from the callers. The article below is based on information obtained from the teleconference. The entire transcript will be available online in the next few weeks. The second leading cause of death in SLE is infection – making managing and preventing infections a top priority for lupus patients. Lupus patients are at greater risk for many reasons; most are on immunosuppressive therapy at one point or another, pathogen exposure at office visits and lupus itself causes a dysfunction of the normal immune response to name a few. Treatments may also contribute to the high infection rate. The new biologic medications (rituximab, orencia and Benlysta) can increase the risk of infection. Corticosteroids, including prednisone, increase the risk of infection. The higher the dose of corticosteroids you’re on, the longer you’re on the dose, the greater the risk of infection. The incidence of infections in lupus patients – especially life-threatening infections – appears to be highest in the first five years of the disease. One reason for this might be that in the first five years, patients are undergoing treatment that is modifying their immune response. Infections lupus patients should be mindful of include bacterial, viral and fungal. Some common threats to lupus are pneumococcal pneumonia or streptococcus pneumonia, Haemophilus influenza and staphylococcus aureus. Lupus patients have a predilection towards salmonella which in lupus patients frequently causes osteomyelitis or bone infections. Shingles is more common in lupus patients than the general public. Yeast infections are also common in lupus patients. Other non-hospitalized infections include respiratory tract infection, sinusitis, urinary tract infections and skin infections. Usually with aggressive treatment and early diagnosis, these infections do not require hospitalization. What can you do to protect yourself again getting an infection? First, non-live vaccines are recommended. That would include the flu shot (NOT the flu vaccine administered through the nasal passages), Pneumococcal vaccine every 5-10 years, a Bordetella pertussis booster, Hepatitis B (for healthcare workers) and meningococcal to name a few. If you are on a biologic, be aware that the biologic medicine may impair the normal response to a vaccine. If you have lupus, you should be vaccinated before you use any biologic and before taking major immunosuppressant medications. Plaquenil, hydroxychloroquine, decreases the risk of infections. A 2009 study showed that individuals on Plaquenil are 16 times less likely to get a major infection when taking the drug – regardless of whether or not corticosteroids are also taken. So, patients on corticosteroids and Plaquenil had fewer infections than patients on steroids alone. Other things you can do to manage infections are to be sure to get treated with antibiotics if you are sick. Be sure to use bactericidal drugs – drugs that kill the bacteria instead of freeze it. Lupus patient’s immune system needs to kill the bacteria. In conclusion, remember vaccinations are very important – avoid live viruses. Plaquenil reduces risk of infection. Limit your exposure to infection.
Furie discusses SLE pathogenesis April 27, 2016 CHICAGO — At the American College of Rheumatology State-of-the-Art Clinical Symposium, Richard A. Furie, MD, compared the number of “wins” in research into treatments for systemic lupus erythematosus to a losing season for a baseball team. “But, we have had some highlights,” Furie, an investigator at The Feinstein Institute for Medical Research and chief of the Division of Rheumatology at Northwell Health, said. “I think the introduction of mycophenolate mofetil has been great. It has now become pretty much the standard of care for patients with lupus nephritis.” Furie presented a review of data that showed an improvement in response rates with mycophenolate mofetil compared with cyclophosphamide or azathioprine in studies that re-randomized patients to different treatments after showing a response to the first-line treatment. The approval of belimumab was important for patients with systemic lupus erythematosus (SLE), but Furie added resurgence in the use of hydroxychloroquine has improved survival and is effective for many SLE patients with rash or arthritis. In addition, the medication reduces lipid levels and promotes strong bones. “The dogma is now that every lupus patient should be on hydroxychloroquine,” Furie said. However, he argued, “We are not doing a good job if you look at data.” Response rates to new treatments, which include background therapy with corticosteroids, are often 50% or lower, according to Furie. “We are down in the single digits for the abatacept studies,” Furie said. “So we have major unmet needs. I think the biggest need is for lupus nephritis. For those with severe renal disease, we need better drugs. We need safer drugs. We need more efficacious drugs.” Organ damage prevention is key, he said, whether the damage is related to disease progression or side effects of the medication. The pathogenesis of SLE, according to Furie, “starts with a genetically susceptive host, and there has to be an environmental trigger.” For some patients, the environmental trigger may be the sun, according to Furie, which can cause apoptosis of skin cells, the release of RNA and DNA, and activation of toll-like receptor-9 and RNA toll-like receptor-7. “The consequence of toll-like receptor signaling is the elaboration of a variety of cytokines, chief of which is interferon-alpha,” he said. The activation of T cells is a function of the adaptive immune cells involved in SLE, and interactions between B cells and T cells may be responsible for disease activity, according to Furie, and these have been, and will continue to be, targets for treatments of SLE. Reference: Furie RA. Recent advances in SLE treatment. Presented at: American College of Rheumatology State-of-the-Art Clinical Symposium; April 9-10, 2016; Chicago. Disclosures: Furie reports relationships with Pfizer, Amgen, Anthera, Biogenldec, BMS, BoehringerIngelheim, Celgene, Dynavax, Eli Lilly, Exagen, Genetech/Roche, GlaxoSmithKline, Medimmune, Novartis, Pfizer, Mallinckrodt Pharmaceuticals, Sanofi, Takeda, UCB, Abbvie, Alnylam, Biogenldec, BMS, BoehringerIngelheim , Celgene, Chugai, Eli Lilly, Estrela (Janssen), Exagen, Genetech/Roche, GlaxoSmithKline, Medimmune, Pfizer, Onyx, Mallinckrodt Pharmaceuticals, Regeneron, Sanofi, Takeda, UCB, Lupus Foundation of America, Lupus Alliance of America, SLE Foundation, Alliance for Lupus Research and The Lupus Academy.