Decoding Lupus: How to Overcome Complexities in Diagnosis and Treatment

Dr. Walker:
This is Living Rheum on ReachMD, and I’m Dr. Robert Walker. Joining me to discuss challenges in diagnosing and treating patients with lupus is Dr. Daniel Wallace. Dr. Wallace is based at Cedars-Sinai Medical Center, where he is the Associate Director of the Rheumatology Fellowship Program, Director of the Lupus and Sjogren’s Clinic, and a member of the Board of Governors. He’s also a Professor of Medicine at UCLA’s David Geffen School of Medicine. Dr. Wallace, welcome to the program.

Dr. Wallace:
It’s a pleasure to be here.

Dr. Walker:
So let’s just dive right in, Dr. Wallace. What are the main challenges in diagnosing lupus, particularly in patients with atypical or overlapping symptoms?

Dr. Wallace:
One of the major challenges is if it’s really lupus. Studies have shown that only 12 percent of self-reported lupus patients actually meet the criteria. There’s also a lupus spectrum where one has features of lupus without meeting established criteria for lupus. So there is lupus defined by, let’s say, a biopsy and lupus from blood tests and lupus from established criteria, but there’s also a lot of individuals who don’t feel well, have autoantibodies, respond to certain medications, and have a lupus-related disorder.

Dr. Walker:
And how do you distinguish between flares of lupus and other conditions that can mimic its symptoms, like infections or drug reactions?

Dr. Wallace:
The best way to differentiate lupus flares is by looking at the blood tests. Certain blood tests would suggest inflammation, whereas infections would have positive cultures. And there is also a whole host of other comorbidities, lupus-related disorders, cardiopulmonary issues or hepatic issues, endocrine issues, and thyroid issues that can mimic lupus. It’s an art form. It’s often very hard to distinguish lupus from other related diseases in people who have it or people who believe they have it.

Dr. Walker:
Now, once you do diagnose a patient, how do you approach treatment, given the variability, severity, and the involvement of multiple organ systems?

Dr. Wallace:
The management of lupus is divided into four categories. The first category is physical measures, the second is medication, the third is surgery, and the fourth is other adjunctive measures. So, for example, if you need to do a biopsy to confirm a diagnosis, that’s one treatment. Physical measures would be avoiding the sun because ultraviolet light from the sun flares lupus and activates lupus cells under the skin. There’s a variety of heat. Moist heat is better than dry heat. There are certain diets for lupus, such as avoiding alfalfa sprouts or having fish or fish oil. Changes in barometric pressure can flare lupus. Certain exercises are good for lupus, such as isometric exercises—Pilates, tai chi, yoga. Certain exercises are bad for lupus, such as isotonic exercises. So there’s a variety of measures that help. Medications are used, and they are divided into several categories. We have sunscreens to protect one from the sun. We have nonsteroidal anti-inflammatory drugs, which include over-the-counter, let’s say, ibuprofen. And they do not treat the underlying process, but they also help some of the symptoms. In addition to that, there’s our antimalarial drugs, such as hydroxychloroquine. Also, we use corticosteroids.

We tend to divide lupus into whether it’s organ threatening or non-organ threatening. If it’s organ threatening, such as involving the heart, lung, kidney, liver, brain, or bone marrow, that is usually treated with corticosteroids, biologics and immunosuppressants. These drugs might include methotrexate, azathioprine or mycophenolate, biologics such as belimumab or anifrolumab, or other agents that are proved for specific subsets, such as voclosporin. People with non-organ-threatening disease who are tired and achy and have swollen joints, fatigue, and rashes often respond to antimalarial drugs, such as hydroxychloroquine, low doses of prednisone, and sometimes other adjunctive measures.

Dr. Walker:
For those just tuning in, you’re listening to Living Rheum on ReachMD. I’m Dr. Robert Walker, and I’m speaking with Dr. Daniel Wallace about challenges in managing patients with lupus.

So, Dr. Wallace, considering the broad spectrum of therapeutic options like immunosuppressants and biologics, how do you individualize treatments for patients?

Dr. Wallace:
It’s a matter of what part of the body is involved. Are we talking about skin involvement? Joint involvement? Constitutional symptoms, such as fatigue, fever, or swollen glands? Is the heart, the lung, the kidney, the liver, the brain, or the bone marrow involved? So treatment is individualized. And we want to treat inflammation. We want to treat adjunctive measures, such as hypertension and diabetes. We want to minimize complications from medications, such as corticosteroids.

Dr. Walker:
And what steps do you take to ensure long-term management while also minimizing the risk of treatment-related side effects?

Dr. Wallace:
The first is access to care and being followed on a regular basis. We take a history. Symptoms are important—what bothers you, physical signs, such as swelling or rashes. There’s also a variety of other things we look at, such as laboratory tests. We do a physical exam, and we evaluate the function. We also evaluate the psychological well-being. We try to reduce stress. Counseling helps lupus because the head bone is connected to the immune bone. So we individualize and tailor the medications. First of all, we say, “Is it organ threatening or non-organ threatening?” And then we plug the patient into a focus.

Dr. Walker:
To close out our program, Dr. Wallace, are there any final thoughts you’d like to leave with our audience today?

Dr. Wallace:
The final thought I’d like to say is that the treatment of lupus is changing. There’s lots of new developments. There are now two biologics and an oral molecule that is used for lupus, and these are very important in the management of the disease and have made a huge difference in improving the morbidity and mortality of the disorder.

Dr. Walker:
Those are some great insights for us to think about as we come to the end of today’s program, and I want to thank my guest, Dr. Daniel Wallace, for joining me to discuss common challenges in diagnosing and managing lupus and how we can overcome them. Dr. Wallace, it was great having you on the program.

Dr. Wallace:
Thank you very much. You take care.

Dr. Walker:
For ReachMD, I’m Dr. Robert Walker. To access this and other episodes in our series, visit Living Rheum on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening.