NSAIDS, calcium supplements may exacerbate SLE comorbidities
BOSTON — Although nonsteroidal anti-inflammatory drugs and calcium supplements are often used to treat patients with systemic lupus erythematosus, physicians — and rheumatologists specifically — should be mindful of the potential complications and complexities that sometimes accompany them, a presenter warned at the 2018 Interdisciplinary Autoimmune Summit.
“I want you to think about the lupus patient in total,” Michelle A. Petri, MD, MPH, a professor at the Johns Hopkins School of Medicine, said. “They are on so many drugs, and I have learned that some of their drugs are contributing to their damage.”
According to Petri, this involves being aware of the cardiovascular risks involved with NSAIDs, and that proton pump inhibitors can increase the risk for osteoporotic fractures, renal damage, dementia and cardiovascular events among patients with SLE. In addition, Petri warned physicians to avoid calcium supplements, as they do not help with bone health but can increase coronary calcium.
Petri noted patients with SLE should use histamine 2 blockers instead of NSAIDs, and receive their calcium through natural sources.
Regarding current treatment approaches to SLE, Petria said hydroxychloroquine should be a background therapy in all patients with SLE. In addition, increasing 25-hydroxyvitamin D could help with disease activity and urine protein-to-creatinine ratios, as well as impart cardiovascular and hematologic benefits. Immunosuppressive approaches to SLE include mycophenolate mofetil for nephritis and skin symptoms, methotrexate for joint symptoms and skin, and azathioprine for nephritis, skin and joint symptoms, she said.
Petri added that post-hoc analyses have shown that both the skin and joints respond to belimumab (Benlysta, GlaxoSmithKline) in patients with SLE, and that reduce severe flares.
However, although an initial “burst” of steroids can be rapidly affective in treating lupus flares, Petri stressed that “prednisone is poison.” According to Petri, is the maintenance dose of prednisone is 6 mg or more, the patient will have a 50% increase in permanent organ damage. In addition, if the prednisone dose is 10 mg, the risk for the patient experiencing a cardiovascular event increases 2.4-fold, and if the maintenance dose is 20 mg, the risk grows more than 5-fold.
According to Petri, the major cause of death among patients with SLE is a cardiovascular event.
“Lupus doesn’t have to kill anymore,” Petri said. “However, with cardiovascular risks, end-stage renal disease and opportunistic infections, our lupus patients have so much comorbidity that they are a little bit like the Dutch boy with the finger in the dike. Let’s plug up those holes.” – by Jason Laday
Petri MA. SLE Chronic Disease Management Pathogenesis, Assessment, Targeted Biological Therapies, Prevention and Long-Term Care. Presented at: IAS 2018; April 27-29, 2018; Boston.
Disclosure: Petri reports consulting fees from Amgen, AstraZeneca, Decision Resources, Eli Lilly, Exagen, GlaxoSmithKline, Inova Diagnostics, IQVIA, Janssen, Medscape, Merck EMD, Novartis and Serono.