SAN DIEGO — Although an estimated 80% of patients with systemic lupus erythematosus acquire the disease before age 50 years, beware of ruling out the potential for diagnosing new cases in older patients.
“It certainly can happen,” Dr. Bevra H. Hahn said at the annual meeting of the North American Menopause Society. “It's not rare, so it's okay to let it cross your mind.”
The clinical presentation of SLE that develops before the age of 50 differs from that of disease that occurs later in life, said Dr. Hahn, chief of rheumatology at the University of California, Los Angeles, Ronald Reagan Medical Center. SLE that develops before age 50 is marked by development of nephritis, anti-DNA antibodies, malar rash, and/or discoid lupus. This relatively early-onset form of SLE causes less organ damage in general. Mortality in this patient population “is primarily from active lupus or from infections that relate to being sick and having immunosuppressive therapies,” Dr. Hahn said.
SLE that develops after age 50 is marked by cardiac and pulmonary problems. “I see a lot of patients who present with heart failure or with pericarditis, or arrhythmias, and they have a strongly positive antinuclear antibody, so it's fine to screen for ANA in that situation,” she said.
Compared with their younger counterparts, patients who develop SLE after age 50 are also more likely to have arthritis, Sjögren's syndrome, and a high damage index. “Their mortality is more from coronary artery disease or stroke, some from infection, and less of it from antilupus medications,” said Dr. Hahn, who is also a professor of medicine at UCLA. “For this group, preventive care is very important for the coronary artery disease.”
Several clinical studies have shown that the use of the antimalarial drug hydroxychloroquine reduces damage over time, whether the lupus is mild or severe. “We think most people should be on [hydroxychloroquine] if there is not a contraindication,” she said. Hydroxychloroquine use has a slight risk for associated retinal damage, Dr. Hahn added.
Dr. Hahn's approach to treatment involves first determining whether the disease threatens life or organs. If the disease is mild, she will consider a number of different agents to lessen pain, fatigue, and rash, including NSAIDs; topical agents, such as steroids or tacrolimus; sunscreen with SPF 50; antimalarials, such as hydroxychloroquine at a dose of 200-400 mg/day or quinacrine dosed at 100 mg/day; DHEA (dehydroepiandrosterone) dosed at 100-200 mg/day; or low-dose prednisone.
She cautioned that the use of NSAIDs “can bump creatinine levels and cause aseptic meningitis in patients with lupus. It's not common, but it happens.”
“The three phases of treatment for severe SLE are induce improvement, maintain improvement, and prevent damage,” she said. For these patients, high-dose prednisone “saves lives. It causes cataracts, osteoporosis, and diabetes, but it really is life saving.”
Other options to consider for patients with severe lupus include antimalarials and the cytotoxic agents mycophenolate mofetil (CellCept), azathioprine (Imuran), and cyclophosphamide (Cytoxan). Other agents showing promise include rituximab, which is a monoclonal antibody against the protein CD20, and belimumab, an investigational human monoclonal antibody.
One certainty of the disease is that infections are common. Dr. Hahn said that 60% of the time, fever that occurs in SLE is the result of infection; the other 40% result from flare. “If you think these patients have an infection, treat it as early as possible,” she advised.
Survival rates in SLE patients have improved in recent decades. Currently, Dr. Hahn said, the 10-year survival for SLE patients without nephritis stands at about 95%, whereas the 10-year survival for SLE patients with nephritis stands at about 88%.
“This is so different from 20-30 years ago,” she remarked. “We've had tremendous improvement in our therapies and our diagnoses.”
Disclosures: Dr. Hahn had no relevant financial disclosures.