Lupus Medications

Your provider will likely prescribe certain medications to manage your lupus and prevent tissue and internal organ damage related to the course of this disease. This guide provides an overview of the medications used to treat lupus as well as their uses and side effects so you’re as informed as possible about your disease and treatment plan.

Over-the-counter medications

Whenever possible, over-the-counter treatments are used to reduce the pain and inflammation associated with lupus. Anti-inflammatories serve as a first line of treatment because they don’t produce serious side effects like prescription medications, they interact with fewer medications, they’re affordable, and they’re often highly effective in patients with milder forms of lupus.

The most common over-the-counter medications used to treat lupus include: 

• Non-Steroidal Anti-Inflammatories (NSAIDs). This class of medications includes naproxen (Naprosyn) and ibuprofen (Motrin) as well as some prescription NSAIDs addressed later. NSAIDs reduce inflammation throughout the body, addressing the primary underlying issue for most patients with lupus. NSAIDs can irritate the lining of the stomach, so those with acid reflux or stomach ulcers should visit their provider before adding over-the-counter NSAIDs to their daily regimen.
• Acetaminophen (Tylenol). Acetaminophen relieves pain but doesn’t address inflammation. Unlike many other OTC meds used for lupus, acetaminophen doesn’t cause stomach problems. Side effects are rare, but it’s imperative to limit the amount of tylenol you take in a 24-hour period to prevent liver toxicity.
• Aspirin. Aspirin provides both anticoagulant and anti-inflammatory benefits, making it ideal for patients who can benefit from both (typically patients with co-existing conditions). While aspirin can control some of the symptoms of lupus, it can also be hard on the stomach, which means it isn’t a viable treatment option for everybody. 

Prescription NSAIDs

Prescription NSAIDs like indomethacin (Indocin), celecoxib (Celebrex), and nabumetone (Relafen) can provide stronger reduction in pain and inflammation than over-the-counter options. Like over-the counter options, you and your provider will take into consideration the benefits and the risks. Over-the-counter NSAIDs can irritate the stomach, leading to unwanted side effects or more serious complications like stomach ulcer, if taken long-term. To avoid stomach irritation, you can take NSAIDs with milk, food, or antacid medications like omeprazole or misoprostol. Ask your doctor if you need to take these medications with your prescription NSAID.

Appropriate dosing is also crucial for protecting your kidneys; too much can restrict blood flow to the kidneys and impact their function, causing serious complications.

Antimalarials (AMs)

The most universal medications used in the treatment of lupus are antimalarials, drugs that were originally developed for use in the treatment of malaria. After many years of off-label use treating lupus, the US Food and Drug Administration approved antimalarials for use in treating lupus in 1954.

While there are several antimalarial drugs on the market, those most commonly prescribed to patients with lupus are hydroxychloroquine (Plaquenil) and chloroquine (Aralen). These medications work by reducing the production of autoantibodies, which attack healthy tissues in the same way they attack foreign invaders. One disadvantage of antimalarials is that it takes months for the drug to build up in your system and produce any noticeable change. 

The most common side effects include skin color changes and upset stomach, and most side effects begin to alleviate as your body adjusts to the medication. The most serious complication that occurs as a result of antimalarial use is retinal toxicity, which can cause permanent vision problems if not caught early. While this complication is extremely rare, it’s still essential that anyone taking antimalarials long-term takes precautionary measures to promote early detection and intervention in the case of retinal toxicity. This includes getting an ophthalmic examination within the first year of treatment and then annual ophthalmic examinations thereafter. 

Antimalarials do cross the placenta, but the risk to the fetus is so low that studies indicate it’s safer for a pregnant mother with lupus to take antimalarials than not to.

Immunosuppressives

People with lupus are victimized by their own immune system, which attacks health tissue in the same way it would attack invaders like viruses and bacteria. Immunosuppressive medications weaken the immune system, leaving it unable to attack healthy tissue. Subsequently, the immune system is also unable to attack foreign invaders, leaving you at higher risk of becoming seriously ill in response to a bacteria, virus, or other foreign invaders. For this reason, use of immunosuppressives is limited and reserved for cases in which the benefits outweigh the risks.

Those who are taking immunosuppressives must closely monitor for signs of infection and notify their healthcare provider immediately if they notice changes. For example, shingles, a chest cold, or a new wound could quickly become very serious without medical intervention if you’re taking medications that suppress your immune system.

Side effects vary from one medication to the next and will be considered carefully by your doctor before prescribing. Be sure to ask questions about common side effects and when you should seek medical treatment before starting any new medication.

The most common immunosuppressives used to battle lupus include methotrexate, voclosporin, cyclophosphamide, and azathioprine. Here’s what you need to know about each.

Methotrexate (Rheumatrex)

Methotrexate was developed to treat cancer and later used as an immunosuppressive drug for lupus and rheumatoid arthritis. This medication can be very effective in treating pleuritis, arthritis, and skin lesions in patients with lupus, but not without side effects. Most common side effects include mouth sores, headaches, and nausea. In rare cases, methotrexate can cause sensitivity to the sun, liver damage, and lung infections. It’s important to note that you may not be able to drink alcohol or take NSAIDs while you’re on this medication.

Voclosporin (Lupkynis)

Voclosporin was developed specifically to treat lupus nephritis by preventing an autoimmune response damaging the kidneys. This medication is available by prescription only and can be taken orally at home, providing convenience for patients with lupus. The most common side effect is infection because it can also prevent immune response to foreign invaders, so carefully monitoring signs and symptoms of infection is important.

Cyclophosphamide (Cytoxan)

Like methotrexate, cyclophosphamide was originally developed as a treatment for cancer and later used in the treatment of autoimmune diseases like lupus. Cyclophosphamide is taken intravenously only. Studies show that this medication can improve lung and kidney disease associated with lupus, but it’s accompanied by some side effects: bladder problems, hair loss, sterility, and problems with your menstrual cycle for female patients.

Azathioprine (Imuran)

Originally developed to prevent kidney transplant rejection, azathioprine blocks inflammation pathways to improve kidney and liver disease in patients with lupus. It may also be effective in lowering the dose of steroids required, limiting side effects and long-term issues related to steroid use. Common side effects include fatigue, stomach irritation, changes in hair color, bloody stool or urine, mouth sores, appetite loss, and unusual bruising. Serious adverse events include pancreatitis and hepatitis, so blood work is required routinely during treatment.

Corticosteroids

Corticosteroids like prednisone and prednisolone are available only with a prescription and provide the same benefits as the hormone, cortisol. Cortisol, and therefore corticosteroids, regulate your immune system and blood pressure while providing powerful anti-inflammatory properties. The corticosteroids that patients with lupus take are not the same thing as anabolic steroids, which are often taken by athletes and weightlifters to help them build strength and bulk quickly.

The most impactful benefit of corticosteroids in the patient with lupus is reduction in inflammation throughout the body. These medications can quickly reduce swelling, tenderness, and warmth caused by inflammation by limiting the immune system’s response against healthy tissue. 

Steroids produce a myriad of undesirable side effects, so your doctor will only prescribe them if there is no safer, more effective medication to utilize. Side effects of steroids include acne, moon-face, hair growth, bruising, stunted growth in children, insomnia, depression, irritability, agitation, fluid retention, and more. The longer you take steroids, the more likely you are to suffer from more serious effects, like: 

• Avascular necrosis in the hip, which is the death of the bone due to restricted blood supply. Avascular necrosis in the hip typically requires a total hip replacement.
• Osteoporosis, which refers to decreased bone density and increased fragility, leading to higher risk of fractures.
• Higher risk of infections. Long-term steroid use can leave you vulnerable to minor and life-threatening infections. Taking vitamins, washing your hands, and keeping wounds clean and protected can help prevent infections.
• Muscle weakness. 
• Cataracts. 

Monoclonal Antibodies

There is only one monoclonal antibody approved for use in treating lupus – Benlysta. Benlysta has In clinic studies, Benlysta lowered autoantibody levels and better-controlled disease activity in patients with lupus. This medication is administered intravenously or subcutaneously but is not available in oral pill form, which means you’ll have to go to your doctor’s office to receive medication.

The most common side effects associated with Benlysta are sore throat, runny nose, persistent cough, nausea, diarrhea, trouble sleeping, fever, arm or leg pain, headache, and depression. Additionally, a reaction at the site of injection is common and may include itching, redness, and swelling. 

Rare but serious side effects include progressive multifocal leukoencephalopathy (PML) and cancer. Visit with your primary care provider about the risks and benefits of treatment before moving forward.

Anticoagulants

While anticoagulants aren’t an approved treatment for lupus, they can prevent the formation of life-threatening blood clots, a complication that patients with lupus are at higher risk of experience. The most common anticoagulants used in patients with lupus include aspirin (over-the-counter), heparin, and warfarin. When you take prescription anticoagulants, you may need routine blood tests to ensure your blood isn’t too thin as a result of the medication. Potential side effects of blood thinners include severe bleeding (including heavy menstrual periods), bloody stool, red urine, coughing up blood, vomiting blood, and joint pain. 

H.P. Acthar Gel

Adrenocorticotropic hormone (ACTH) found in Acthar stimulates the production of cortisol in the body, and if you recall from earlier in this guide, cortisol serves as a powerful, natural anti-inflammatory in the body, which can help reduce the inflammation caused by lupus. The most common side effects associated with Acthar include infections, changes in mood and behaviors, stomach ulcers, acne, dry or thinning skin, trouble sleeping, and bruising and discoloration.

All treatment options pose benefits and risks, and the treatments that are right for you will depend on your medical history, the seriousness of your disease, and the organs and systems impacted. Your lupus doctor will review your signs of lupus, history of lupus diagnosis, current medications, and overlapping conditions to develop a safe and effective treatment plan.