Podcast Spotlight – Lupus & Biologics with Dr. Vicky Nahra
Dr. Vicky Nahra, MD, Rheumatologist at University Hospitals of Cleveland Medical Center and Associate Professor at Case Western Reserve University, recently sat down with Suzanne Tierney, CEO at the Lupus Foundation of America, Greater Ohio Chapter, to answer some questions about biologics. Here are some of those questions and answers:
ST: This was one of my big questions, and I still ask this question, with a variety of medications now – I know the pharmaceuticals really wanna get in front of all the physicians and it’s harder for them to get in front of everybody, these days, everyone’s so busy – but, how does a physician decide which of these biologic medications is best? And I don’t know, do we use ’em alongside the traditional medicine or do we let go of the traditional medicines?
VN: Okay, so it basically depends on the patient. So, it’s like a case by case. There’s not one scenario that fits everyone. So depending on the patient’s symptoms, the patient’s preferences, because some of them are available as, for example, injections versus others that are only infusions, others that are pills.
So, it basically depends on a whole cluster of things. So it has to be a shared decision making between the provider and between the patient, depending on what they prefer and their active symptoms. Usually they are used in conjunction with conventional medications. So for example, Plaquenil, we consider it to be the building block of lupus.
So, unless contraindicated or somebody has an allergic reaction to it, or side effects with it, like retinal toxicity, for example, every single patient with lupus needs to be on Plaquenil. We can always add other medications to it, like mycophenolate or azathioprine, depending also if the patients tolerate them.
And then we upgrade to the biologics, and we do use them in conjunction with these medications. So we rarely take out the pills or like the initial meds just because we’re adding the biologics. So it has to work together, it’s more like a synergistic effect. And, usually when the patient is well controlled, like their lupus has been inactive for at least a year and a half, we can consider going down a bit on the medications. And it’s also, again, a discussion with the patient, depending on which one they prefer to get rid of first. But, usually we try to keep the  Plaquenil as the basis for the treatments.
ST: What would any type of side effect look like? Because you deal with so much when you have lupus to begin with. The thought of bringing on more misery, it’s scary. So can we expect any type of side effects from these medications?
VN: Yes. So, with medications that we use, we do know that biologics are more immunosuppressive than the other medications that we use. So, we are putting the immune system more at danger or the risk of getting infections, but that’s gonna be at the expense of controlling the disease. So it’s always gonna be a risk versus benefit. If the risk outweighs the benefit, we don’t use it. If the benefit outweighs the risk, then we do use it.
The most common side effects that we do expect with the biologic therapies are gonna be – increased risk of infections, the most common ones being upper respiratory infections. And, we do tell the patients to be careful, for example, in crowded places, people who are around them who are known to be sick. Personal hygiene, for example. Washing your hands, not touching doorknobs, things like that. Wearing a mask in public. Try it as much as you can to avoid infections. We also have more specific side effects that are specific to each medication. Like for example, the ones that we use as injections, we can have site reactions.
These are the most common as well. So they can have redness, itchiness, or swelling where they do the injection, which is more of a subcutaneous injection. We can have infusion reactions, which with medications that are infused that are given as IV or intravenously. So it could be anything from being feverish, fatigue, dizziness – things like that. So, just like infusion-related reactions. Allergies or anaphylaxis are also a big thing that we look out for, especially with infusions. So whenever a patient develops an anaphylactic reaction, which means a severe allergic reaction to the medication, that means that we can never use it again.
We have to switch to something else. And, also specific medications might have GI side effects, like nausea vomiting, some diarrhea. And some of them also affect neuropsychiatric issues. Like for example, belimumab can cause sometimes like depression and anxiety and suicide thoughts, things like that.
ST: And clarify subcutaneous.
VN: So subcutaneous is an injection that they have to do themselves. It’s like an insulin pen. The medication comes in a pen. It’s not, you’re gonna see the injection, but it’s more like a pen that you give yourself, and you use certain areas in the body where you have the subcutaneous tissue to help you with the absorption. So they can either do it in their belly fat. So they actually expose their belly and give the injection at least one inch away from the umbilicus (belly button). And, we tell them to alternate the site. So every time they do it, they give themselves the injection in a different location. So for example, if they use the right side of the belly button this week, they will use the left side the following week.
Or they can do it below or above the belly button, or behind the upper arm. Or, they can use the front of their thigh, which is also a convenient site. It usually takes a few seconds for the medication to be administered. So most applicators make a clicking noise. It tells you that medication is going in. Then there’s another click when the medication is already administered, so it’s finished and then you can take it off.
You can listen to the entire episode on My Lupus Living room on Spotify, https://bit.ly/4vifhiG, or watch on our YouTube channel, https://youtu.be/iz8E23456dU