Chemotherapy and Lupus

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Many of you who see this will think, what do these two have in common? The truth is, quite a lot. I personally have been on chemotherapy several times due to my lupus. Many of my lupie friends have as well. It is not well known to those outside of the lupus world though.

You see, lupus is an autoimmune disease, which means, that our bodies create antibodies against our own body and its cells. In effect, our body attacks itself. Antibodies are great when you are sick and need to fight an infection. When they go into hyper mode, you are now into the realm of autoimmune diseases.

Where does the chemotherapy come in, you ask? In an effort to slow down the autoimmune disease from being in hyper mode, we are given chemotherapy agents to shut it down, or at least attempt to take it down to a more normal level. Sometimes it works, sometimes it goes too far. It is a fine line on therapeutic effect and overkill.

I actually was on chemotherapy when I was “let go” from my last job. I had been told that my job would still be there while I was out on paid sick leave. The truth is, they fired me by email. They gathered my things up and federal expressed them to me too. How lovely. Ok, sorry, I am digressing into the land of the past and I need to let it go.

This information is from the Lupus Foundation of America website about chemotherapy:

“chemotherapy, is generally reserved for those individuals who have the most severe flares of lupus; or to enable the steroid dose to be reduced. A severe flare is one that affects an organ to the degree that the function is impaired. When this happens something has to be done to preserve the function of the organ and that’s when immunosuppressive or chemotherapy medications are prescribed. These actually suppress the over activity of the immune system brought on by the lupus, and help limit the damage and preserve the function of the involved organ. (Lupus is NOT a form of cancer).”

There are many types of chemotherapy agents used in treating lupus. I have looked them up and here are a few of them (from the Lupus Foundation of America website):

Imuran, Cytoxan And Related Drugs

Although immunosuppressive drugs can have serious side effects, they can be of great value in the treatment of systemic lupus erythematosus (SLE). They may help to:

  • prolong life
  • preserve kidney function
  • reduce disease symptoms
  • reduce damage to vital organs, such as the kidneys and lungs.
  • sometimes even serve to put the disease into remission.

Steroids used alone to treat major organ involvement in lupus must sometimes be given in high doses. This increases the risk of short-term and long-term side effects, which may sometimes be worse than the disease itself. Immunosuppressive drugs can be used either in addition to, or instead of, steroids to spare the patient some of the undesirable side effects of steroid therapy.

Thus, immunosuppressive and cytotoxic drugs are used in the treatment of lupus for two major reasons:

  1. They are potent drugs which help to control disease activity in major organs, including the kidney, brain, cardiovascular system, and lungs.
  2. They may reduce or eliminate the need for steroids (cortisone derivatives such as prednisone).

How Do They Work?

Cells in the body divide and grow at varying rates. Examples of rapidly dividing cells include:

Cytotoxic (cyto=cell, toxic=damage) drugs work by targeting these cells which grow at a rapid rate. In lupus, the immune system produces autoantibodies at a rapid rate of growth. Cytotoxic medicines can suppress the cells involved in the hyperactive immune response.

Possible Risks

There are risks associated with the use of cytotoxic drugs.

  • The immune system may be suppressed too much, which causes an increased susceptibility to infection, particularly shingles (a painful, blistering skin condition) and pneumonia.
  • The bone marrow can be suppressed as well, which results in reductions in red blood cells, white blood cells, or clot-forming platelets.
  • Suppression of hair cell growth may lead to overall loss of hair.
  • The cytotoxic effects on gonadal cells can lead to sterility.

Imuran (generic name: azathioprine)

Imuran is less potent and less effective than Cytoxan, but has fewer side effects. Imuran is well tolerated in most cases. Imuran is steroid-sparing and studies have shown that it clearly improves liver and kidney lupus.

Side effects can include:

  • nausea
  • decreases in white blood cell count, platelet count, or red blood cell count
  • increased risk of developing lymphoma (cancer involving the lymph glands, liver and spleen), with long-term Imuran use

Blood tests to determine the white blood cell, platelet, and red blood cell count should be done regularly in patients receiving this drug. Adjustments in dosage are made if the tests indicate a serious decrease in blood counts.

Cytoxan (generic name: cyclophosphamide)

Cytoxan is well tolerated by most patients. Like Imuran, it may cause an upset stomach, and its use may decrease the white blood cell count, platelet count, or red blood cell count

Side effects can include:

  • an increased risk of developing malignancies, including leukemia and bladder cancer, with long-term Cytoxan use
  • temporary or permanent sterility in both women and men, preventing them from having children
  • leading to damage of a developing fetus if a woman gets pregnant while being treated with the drug
  • bleeding from the bladder-this usually can be prevented by drinking large amounts of water
  • causing a predisposition to develop shingles
  • hair loss
  • like Imuran, causing a predisposition to develop unusual infections, particularly when given in combination with high doses of steroids

Blood tests to determine these blood counts should be done regularly for those receiving Cytoxan. If the blood count is seriously decreased, the dosage is adjusted and the blood counts will generally return toward normal.

How Is Cytoxan Administered?

Cytoxan can be given as oral tablets, but more often is given through the vein (intravenously, or IV).

  • This procedure generally takes between 15 and 60 minutes.
  • Large amounts of intravenous fluids are also given to dilute the concentration of Cytoxan in the bladder.
  • Pre-medication for nausea is sometimes given, but treatment with Cytoxan is generally well tolerated.
  • IV Cytoxan seems to be associated with fewer malignancies and many fewer bladder problems, while being equally effective.
  • Controlled studies also show that it improves kidney and autoimmune lung disease.

 

Related Drugs

Leukeran (generic name: chlorambucil) and Mustargen (generic name: nitrogen mustard)

  • These two cytotoxic drugs are related to cyclophosphamide.
  • Both have similar side effects to Cytoxan.

Methotrexate

This drug is usually given orally on a weekly basis, although it may be given by injection.

  • The dosage is generally 7.5 to 25 milligrams per week.
  • Methotrexate is well tolerated by most patients.
  • Its use in lupus has not been thoroughly tested, but it is given commonly for rheumatoid arthritis and has been shown to produce improvement of joint pain and stiffness.
  • It is only modestly effective for organ-threatening lupus.
  • Liver disease and lung reactions can occasionally occur with the use of methotrexate.
  • Blood counts and blood liver enzyme tests should be monitored regularly in patients receiving this drug, and the dosage modified if side effects are detected.

CellCept (generic name: mycophenolate mofetil) and Neoral (generic name: cyclosporine)

  • These two medications modify the immune system, which, in lupus, appears to be both overactive and misdirected.
  • Both of these medications are used to prevent rejection of the donated organ in kidney, liver, heart and lung transplants.
  • CellCept can cause nausea and diarrhea.
  • Cyclosporin may elevate blood pressure and reduce kidney function.

Conclusion

All of these agents are steroid-sparing. While cytotoxic medications should not be used in cases of mild lupus, these medications can be very helpful and even life-saving when major organs are involved, or in cases where the lupus is quite active and symptomatic.

Sometimes a kidney biopsy or other tissue biopsy is necessary before deciding whether to use these drugs. Even in more serious cases of major organ involvement, cytotoxic drugs should not be used indefinitely without good reason.

It is important to weigh the beneficial effects as well as the risks involved in cytotoxic drug therapy. Doctors use the term “risk-benefit ratio” to describe the comparison of side effects to beneficial effects of medication. While these cytotoxic drugs are not FDA-approved for use in SLE, they are commonly used and accepted as standard practice. People with lupus should discuss the risk-benefit ratio of these medications with their physician.

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