Lupus affects each patient differently

Lupus is a chronic and complex autoimmune disorder in which the immune system attacks different parts of the body and affects each patient differently, said Falmouth rheumatologist Kelsey Rigby, DO. She has many patients with the condition and, while there is a “classic” version of lupus, each case is unique, she explained.

“If I saw twenty patients with lupus, they will all present with different manifestations,” she said. “Lupus can attack any organ system in the body, which can make it difficult to diagnose. There is no lab test that is 100 percent. You have to look at both the patient’s symptoms and their lab tests and put it together.”

The classic symptoms include joint pain and what’s known as a butterfly rash over the cheeks that worsens in the sun. A lot of people get joint pain as they get older, but the type of pain caused by lupus is different.

“With autoimmune joint pain, you see swelling of the joints,” Dr. Rigby said. “They are unable to make a fist because their joints are so swollen. People who have ‘wear and tear’ osteoarthritis have stiffness and pain with use and at the end of the day it’s worse, but you don’t see a lot of swelling with it.”

Diagnosing Lupus

Lupus that attacks organs like kidneys, liver and lungs is more serious. That is more common in Hispanic and young African American women.

The body automatically makes millions of antibodies to fight infection, but with autoimmune disorders like lupus, there is a defect that causes the body to make antibodies against the body. That only becomes a problem when the antibodies start attacking different tissues like the joints and skin, she explained.

In lab tests, Dr. Rigby looks for high titers of auto-antibodies like the ANA (anti-nuclear antibody) and double-stranded DNA antibody and inflammatory markers in the blood. There can also be low white blood cell counts, low hemoglobin and platelet counts. Doctors also look for any kidney malfunctioning.

“A lot of times, people have lab abnormalities and I see antibodies in the blood that suggest possible lupus. But without clinical symptoms, you don’t make that diagnosis,” she said. “Just because you have antibodies doesn’t mean you’re going to have lupus. In some patients, you will see low titers of lupus antibodies but there are not always harmful. The problem with lupus is that your body is not able to destroy those autoantibodies that are injuring you.”

Treatment

Treatment depends on which symptoms a patient has. If there is major organ involvement, the treatment is high-dose steroids to suppress their immune system and lower their inflammation. The trick is to get them into remission and then put them on steroid-sparing medication, because people can’t stay on steroids for long periods of time because of the negative side effects, she explained.

The mainstay medication for lupus is Plaquenil (hydroxychloroquine), which reduces flare-ups and lowers mortality over time, Dr. Rigby said.

“Everyone is different, and everyone responds differently to different medications, so it can be tough to treat,” she said.

A Promising Drug

There are some new studies that show that CAR-T therapy can help. It is basically like an immune system transplant that can cure lupus. Even though it sounds great in theory, it also has dangers, Dr. Rigby said. Immunotherapy basically wipes out the patient’s immune system which predisposes them to infection which can be deadly.

Lupus has a genetic component. It runs in families, but not every person in the family is destined to get it. There is some sort of environmental trigger that activates it. Dr. Rigby has even seen drug-induced lupus, where a medication can stimulate the immune system and cause a lupus-like illness with high inflammatory markers. These patients will have high antibodies, the butterfly rash and joint pain, but usually when they stop taking the medication that caused it, their symptoms go away.

Patients with lupus can overlap with other autoimmune disorders like rheumatoid arthritis.

“The thing about autoimmune diseases is a lot of the meds work for multiple diseases because the problem is the immune system is overreacting, so suppressing the immune system works well for multiple diseases,” Dr. Rigby said.