Patient education: Systemic lupus erythematosus (SLE) (Beyond the Basics)
- Daniel J Wallace, MD
Daniel J Wallace, MD
- Clinical Professor of Medicine
- Cedars-Sinai Medical Center
- The David Geffen School of Medicine at UCLA
SYSTEMIC LUPUS ERYTHEMATOSUS OVERVIEW
Systemic lupus erythematosus (also known as lupus or SLE) is a chronic inflammatory disease that can affect various parts of the body. Lupus is an autoimmune condition, meaning that your body's immune system attacks your own tissues, thinking that they are foreign. This can lead to pain, swelling, and damage to organs such as the kidneys. The cause of lupus is not clear.
People with lupus often have disease flares, in which symptoms worsen, followed by a period of remission, in which symptoms improve. Lupus is mild in some people and is life-threatening in others. However, treatments are available to reduce symptoms, reverse inflammation, and minimize organ damage.
This article discusses the symptoms, diagnosis, and treatments for lupus in adults. The treatment of lupus in pregnant women is discussed in a separate article. (See "Patient education: Systemic lupus erythematosus and pregnancy (Beyond the Basics)".)
The exact cause of lupus is not known. A person who develops lupus probably inherits the risk from one or both parents and then develops the disease when exposed to a trigger. Triggers may include being exposed to sunlight, being ill with an infection, having surgery, or being pregnant.
SYMPTOMS OF SYSTEMIC LUPUS ERYTHEMATOSUS
Symptoms of systemic lupus erythematosus (lupus, SLE) can be caused by inflammation, which can affect the whole or parts of the body. Other lupus symptoms are caused by inflammation and/or damage to a particular organ system.
●Whole body symptoms can include fatigue and weight loss.
●Organ-related symptoms include skin rash following sun exposure and easy bruising due to decreased numbers of platelets in the blood.
Whole body symptoms — Most people with lupus develop fatigue, fever, and weight changes at some point in their illness.
Fatigue — Fatigue is the most common symptom of lupus, and it is occasionally the most debilitating. Fatigue can occur in almost everyone, even when there are no other symptoms of lupus.
Fatigue may be caused by lupus itself or by underlying issues, such as depression, unhealthy habits (smoking, unhealthy diet, drug abuse), stress, anemia, use of certain medications, underlying health problems, lack of exercise, and, in particular, difficulty sleeping.
Problems with sleep are usually treated with medicine, and an exercise program can improve energy levels. (See 'Exercise' below.)
Weight changes — SLE can lead to both weight loss and weight gain. Unintentional weight loss is often due to:
●The side effects of medications
Weight gain is usually due to one of two factors:
●Salt and water retention associated with kidney disease (see 'Kidneys' below)
●Increased appetite associated with the use of glucocorticoids (steroids)
Fever — Most people with SLE have fevers. Fever is defined as a temperature over 100°F (37.8°C). Fever related to active lupus usually responds to nonsteroidal antiinflammatory drugs (NSAIDs) (eg, naproxen, ibuprofen) and/or acetaminophen. If fever does not improve with these treatments, call your healthcare provider.
Specific organ symptoms — SLE can affect many organs of the body and can result in a variety of symptoms.
Joint pain and stiffness — Joint pain and stiffness occur in almost all patients with lupus, and these are often the earliest symptom of lupus. The pain and stiffness tends to move from one part of the body to another and does not usually affect both sides of the body in the same way. Only a few joints are affected at any time. (See "Musculoskeletal manifestations of systemic lupus erythematosus".) Typical joints include the fingers, wrists, and knees. Joints may be swollen and warm (“arthritis”).
Skin changes — Most people with SLE have skin abnormalities at some time. The most common is a rash, known as the “butterfly rash”; this appears as redness over the cheeks and nose after being in the sun (picture 1). The rash usually lasts only a few days but often comes back. (See "Overview of cutaneous lupus erythematosus".)
Some people develop circular patches of raised, scaly skin (called discoid lesions), which have a tendency to scar (picture 2). Hair loss (alopecia) is common, but baldness is not. Many people develop ulcers in the mouth, which are usually painless.
The Raynaud phenomenon causes blood vessels in the fingers and toes to narrow in response to cold temperatures, emotional stress, cigarette smoking, and/or caffeine (figure 1). As the blood vessels narrow, less blood flows to the area, causing the fingers or toes to become pale and then blue, purple, and/or red. Raynaud is a frequent problem in patients with SLE. However, most people who have Raynaud do not have lupus. (See "Patient education: Raynaud phenomenon (Beyond the Basics)".)
●Light sensitivity – Between 60 and 100 percent of people with lupus are sensitive to ultraviolet (UV) light. This “photosensitivity” causes the person to develop a rash after exposure to ultraviolet light from the sun or fluorescent lights. Some people are also sensitive to UVA radiation (from sunlight). Glass protects individuals sensitive to UVB (from sunlight or fluorescent light) but only partially protects those sensitive to UVA. Blonde, blue-eyed, fair-skinned individuals are much more photosensitive than brunettes or individuals with darker skin.
Those who are photosensitive should do the following to minimize UV exposure:
●Avoid areas of high sun exposure (beaches, snow, lakes), especially between 10 AM and 3 PM.
●Avoid medications that may cause photosensitivity.
●Use a sunscreen with a sun-protection factor (SPF) of 50 or greater daily. The sunscreen should be applied 30 to 60 minutes before going outside and should be reapplied every four to six hours.
More information about ways to minimize UV exposure is available separately. (See "Patient education: Sunburn prevention (Beyond the Basics)".)
Kidneys — Changes in kidney function are common in people with lupus. These changes usually develop during the first few years of the illness. Monitoring for changes in kidney function with urine and blood tests can help to detect these changes.
●Lupus can cause inflammation of the filtering device in the kidneys (the glomerulus); this is called glomerulonephritis or lupus nephritis. Damage to the glomeruli can prevent the kidneys from filtering wastes from the bloodstream. (See "Patient education: Glomerular disease overview (Beyond the Basics)" and "Diagnosis and classification of renal disease in systemic lupus erythematosus".)
●Initially, the kidneys may “leak” protein from the blood into the urine. When severe, this can cause water retention, swelling in the feet and lower legs, and other changes referred to as the nephrotic syndrome. (See "Patient education: The nephrotic syndrome (Beyond the Basics)".)
Left untreated, lupus nephritis can lead to permanent scarring in the kidneys. If the kidneys are too damaged to filter the blood properly, you will need dialysis or a kidney transplant. Fortunately, treatments to prevent or minimize lupus-related kidney disease are available.
Digestive system — The digestive system can be affected by medications often used to treat lupus, including glucocorticoids and NSAIDs. These medicines can cause upset stomach, or, less commonly, stomach ulcers. (See "Patient education: Nonsteroidal antiinflammatory drugs (NSAIDs) (Beyond the Basics)".)
However, severe abdominal pain, nausea, and vomiting can occur if lupus affects the pancreas (pancreatitis), the lining of the abdomen (peritonitis), or the large intestine (colitis).
Lungs — A number of lung diseases can occur in people with lupus (see "Pulmonary manifestations of systemic lupus erythematosus in adults"):
●Pain with breathing – Pleurisy is a type of chest pain that is worsened by taking a deep breath. Pleurisy can occur if there is inflammation of the lining covering the lungs and inside of the chest.
●Shortness of breath – Shortness of breath can occur due to several different problems. Collection of fluid in the space around the lungs (called pleural effusion) can interfere with expansion of the lung. Inflammation of the air sacs of the lung (pneumonitis) or dysfunction and scarring of the supporting tissues between the air sacs (interstitial lung disease) can cause difficulty breathing.
Heart — There are a variety of symptoms that can develop if lupus affects the heart or blood vessels:
●Chest pain with exercise – As mentioned above, people with lupus can develop chest pain as a result of pleurisy. In addition, lupus can increase the risk of developing coronary artery disease. Symptoms of coronary artery disease can include chest pain with exercise or emotional stress that resolves with rest (angina pectoris). Sudden severe chest pain or pressure that does not go away within a few minutes may be a sign of a heart attack (myocardial infarction).
●Chest pain due inflammation around the heart – Chest pain can also occur if lupus causes inflammation of the sac that surrounds the heart, a condition known as pericarditis.
●Shortness of breath due to heart valve disease – Shortness of breath can be caused by heart as well as lung involvement. The heart valves can become leaky or narrowed as a result of damage to the lining of the heart cavity and surfaces of the normally smooth valves (endocardium).
Nervous system — Lupus can affect the nervous system in many ways. These problems may be related to lupus itself, to treatments used for lupus, or to unknown causes. Some of the most common problems affecting the nervous system include:
●Difficulty concentrating and thinking clearly
●Confusion or memory loss
●Depression and anxiety
●Pain in the hands or feet (called peripheral neuropathy)
●Weakness or numbness
Treatments are available for lupus-related nervous system problems. (See "Neurologic manifestations of systemic lupus erythematosus" and "Neuropsychiatric manifestations of systemic lupus erythematosus".)
Eye — The eye is sometimes affected by lupus. The most common symptom is dryness of the eyes with a feeling of grittiness or a lack of tearing (called keratoconjunctivitis sicca). This can be treated by using artificial tears.
SYSTEMIC LUPUS ERYTHEMATOSUS DIAGNOSIS
The American College of Rheumatology has created criteria to classify patients with systemic lupus erythematosus (lupus, SLE). While these criteria were developed to aid in research, they are often used in medical practice to help with the diagnostic process. These criteria are shown in the table (table 1) . (See "Diagnosis and differential diagnosis of systemic lupus erythematosus in adults".)
SYSTEMIC LUPUS ERYTHEMATOSUS TREATMENT
Although there is no cure for systemic lupus erythematosus (lupus, SLE), a variety of treatments can reduce symptoms, limit damage to vital organs, and reduce the risk of recurrence.
Diet and nutrition — Most people with lupus do not require a special diet but should instead eat a well-balanced diet. A well-balanced diet is one that is low in fat; high in fruits, vegetables, and whole grains; and contains a moderate amount of meat, poultry, and fish.
However, you may need to make changes to your diet, depending upon how lupus has affected your body. If you have questions about your diet, discuss these with your healthcare provider. In general:
●People with active lupus and fever may require more calories.
●Glucocorticoids (prednisone) increase appetite, potentially causing you to gain a lot of weight. Try to control your appetite and to stay active. Weigh yourself daily while taking prednisone, and talk to your healthcare provider if you gain more than five pounds.
●If your cholesterol or triglyceride levels become elevated, you may be advised to eat a special diet. (See "Patient education: High cholesterol and lipids (hyperlipidemia) (Beyond the Basics)".)
●If you have swelling (edema) in your feet or lower legs, decrease the amount of salt and sodium in your diet. (See "Patient education: Low-sodium diet (Beyond the Basics)".)
●Extra vitamins are rarely needed if you eat a balanced diet. If you are not able to eat a balanced diet or are dieting to lose weight, you should take a multivitamin.
●If you take glucocorticoids every day or are a postmenopausal woman, you should take 1000 to 1500 mg of calcium and 400 to 800 units of vitamin D per day to minimize bone loss. (See "Patient education: Calcium and vitamin D for bone health (Beyond the Basics)".)
●Drinking a moderate amount of alcohol (one drink or less for women and two drinks or less per day for men) is usually safe for people with lupus. However, alcohol can interact with medications used to treat lupus. Talk to your healthcare provider if you have questions.
●Herbal and other dietary supplements are not recommended and may even cause harm.
Exercise — Being inactive while ill can cause you to lose muscle and energy quickly. A separate article discusses how to incorporate exercise into your life. (See "Patient education: Arthritis and exercise (Beyond the Basics)".)
Immunizations — Vaccines to prevent pneumonia and the flu are recommended for people with lupus.
In contrast, vaccines that contain live viruses (eg, measles, mumps, rubella, polio, varicella, and smallpox) are not recommended for people with lupus, especially if you currently take prednisone. (See "Patient education: Adult vaccines (Beyond the Basics)".)
Medication precautions — A number of medications are known to worsen lupus. You should not take these medications if there is an acceptable alternative. Sulfa-containing antibiotics are examples of medicines that should be avoided.
Pregnancy and birth control — Women with lupus are at increased risk of miscarriage; however, the majority of women with lupus who get pregnant are able to carry to term. Miscarriage occurs more often in women with active disease, especially if there has been related organ damage; other issues sometimes associated with lupus, such as the presence of certain proteins in the body (called “antiphospholipid antibodies”), also increase the risk of miscarriage. Your doctors can guide you on how to maximize your chances of having a healthy pregnancy and baby. In most cases, women should wait until their lupus has been under control (ie, no flares) for at least six months before trying to get pregnant. (See "Patient education: Systemic lupus erythematosus and pregnancy (Beyond the Basics)".)
There are several options for women with lupus who want long-term birth control. The best choice depends on your symptoms, risk factors, and personal preference. Your gynecologist and rheumatologist can help you find something that works for you. Options may include:
●An intrauterine device (IUD) – An IUD is a small device that is placed in the uterus to prevent pregnancy. While a number of IUDs are available, those that release the hormone progestin are often recommended for women with lupus who want a long-term method of birth control. (See "Patient education: Long-acting methods of birth control (Beyond the Basics)".)
●Birth control pills – Most birth control pills contain two hormones, estrogen and progestin. These are safe for many women with mild forms of lupus. However, some women (eg, those at an increased risk of blood clots) probably should not take any medicines that contain estrogen. For these women, the progestin-only birth control pill may be a good option. (See "Patient education: Hormonal methods of birth control (Beyond the Basics)".)
●Injectable birth control – The birth control shot (brand name: Depo-Provera) contains progestin and is injected into a muscle (usually the buttock or upper arm). It may be an option for some women with lupus, although it should not be used long-term in women who have osteoporosis or are taking glucocorticoids. (See "Patient education: Hormonal methods of birth control (Beyond the Basics)" and 'Glucocorticoids and immunosuppressives' below.)
Certain other birth control methods, including the patch, implant, and vaginal ring, are not usually recommended for women with lupus because the amount of estrogen they contain may increase the risk of blood clots.
Many medications often used to treat lupus can interfere with birth control, making one or both medications less effective. Your doctors can review your current medications with you in order to help you choose a birth control option that will be safe and effective.
General treatment concepts — A number of different medications are used in the treatment of lupus, including nonsteroidal antiinflammatory drugs (NSAIDs), hydroxychloroquine or chloroquine, glucocorticoids (also called steroids), and immunosuppressive agents.
The choice of medication therapy for lupus is highly individualized and is typically guided by the specific organs that are affected. However, there are some measures that should be taken in all people with lupus. All people should be treated with hydroxychloroquine (brand name: Plaquenil) or chloroquine unless these medications are otherwise contraindicated. The benefits of hydroxychloroquine or chloroquine in SLE are broad and include relief of whole-body symptoms (such as fatigue and fever), musculoskeletal symptoms, and skin symptoms, as well as a reduction in the number of flares. People with internal organ lupus (eg, involvement of the kidney, heart, lungs, or central nervous system) usually require glucocorticoids alone or in combination with medications that suppress the immune system (called immunosuppressive medications). (See 'Glucocorticoids and immunosuppressives' below.)
Joint pain — NSAIDs can usually relieve joint pain caused by lupus-related arthritis and inflammation. NSAIDs include ibuprofen (sample brand names: Advil, Motrin) and naproxen (sample brand names: Aleve, Naprosyn).
Skin symptoms — Hydroxychloroquine or chloroquine may be especially helpful for people with skin symptoms and joint pain that have not fully responded to NSAIDs. These drugs may also help to protect the body from lupus-related organ damage .
Glucocorticoids and immunosuppressives — Glucocorticoids may be used alone or in combination with medications that suppress the immune system. Examples of immunosuppressive medicines include mycophenolate, cyclophosphamide, azathioprine, rituximab, and belimumab. These treatments are generally reserved for people with significant organ damage, particularly of the kidneys, blood, lungs, or central nervous system, or for those needing high doses of glucocorticoids to treat their condition.
The benefit of glucocorticoids and immunosuppressive medications must be weighed against the risks because these treatments have potentially serious side effects. Glucocorticoids can cause weight gain, worsened diabetes, thinning of bones (osteopenia and osteoporosis), and an increased risk of infection.
Other options — A number of other treatment approaches for lupus have been tried or are under investigation.
HOW WILL SYSTEMIC LUPUS ERYTHEMATOSUS AFFECT MY LIFE?
Systemic lupus erythematosus (lupus, SLE) can cause a wide spectrum of symptoms; in some people, it is relatively mild while, in others, it is a severe, debilitating illness.
The survival rate of people with SLE has dramatically increased over the last several decades from approximately 40 percent still alive at five years in the 1950s to survival rates of approximately 90 percent at 10 years. The improvement in survival is probably due to multiple factors, including the ability to recognize the disease earlier with more sensitive diagnostic tests, to begin treatment earlier, and to promptly treat complications.
Many people go into remission and require no treatment. In one study, approximately 25 percent of patients had remission lasting for at least a year. Remission occurred in 50 percent of those with disease over 18 years’ duration and in 75 percent of those with disease over 30 years’ duration. Remission was even seen in some patients who had had severe kidney disease .
Researchers are continually conducting clinical trials of systemic lupus erythematosus (lupus, SLE) treatments to find better ways of treating the disease. A clinical trial is a carefully controlled way to study the effectiveness of new treatments or new combinations of known therapies. For more information about clinical trials, visit http://clinicaltrials.gov or http://clinicalstudies.info.nih.gov.
WHERE TO GET MORE INFORMATION
Your healthcare provider is the best source of information for questions and concerns related to your medical problem.
This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.
Patient level information — UpToDate offers two types of patient education materials.
The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Patient education: Lupus (The Basics)
Patient education: Lupus and pregnancy (The Basics)
Patient education: Pericarditis in children (The Basics)
Patient education: Lupus and kidney disease (The Basics)
Patient education: Antinuclear antibodies (The Basics)
Patient education: Disease modifying antirheumatic drugs (DMARDs) (The Basics)
Patient education: Interstitial lung disease (The Basics)
Patient education: Discoid lupus (The Basics)
Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Patient education: Systemic lupus erythematosus and pregnancy (Beyond the Basics)
Patient education: Raynaud phenomenon (Beyond the Basics)
Patient education: Sunburn prevention (Beyond the Basics)
Patient education: Glomerular disease overview (Beyond the Basics)
Patient education: The nephrotic syndrome (Beyond the Basics)
Patient education: Nonsteroidal antiinflammatory drugs (NSAIDs) (Beyond the Basics)
Patient education: High cholesterol and lipids (hyperlipidemia) (Beyond the Basics)
Patient education: Low-sodium diet (Beyond the Basics)
Patient education: Calcium and vitamin D for bone health (Beyond the Basics)
Patient education: Arthritis and exercise (Beyond the Basics)
Patient education: Adult vaccines (Beyond the Basics)
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.
Antibodies to double-stranded (ds)DNA, Sm, and U1 RNP
Approach to the patient with macular skin lesions
Clinical features and therapy of lupus membranous nephropathy
Coronary heart disease in systemic lupus erythematosus
Diagnosis and differential diagnosis of systemic lupus erythematosus in adults
Diagnostic approach to the neuropsychiatric manifestations of systemic lupus erythematosus
End-stage renal disease due to lupus nephritis
Epidemiology and pathogenesis of systemic lupus erythematosus
Gastrointestinal manifestations of systemic lupus erythematosus
Hematologic manifestations of systemic lupus erythematosus
Menstrual function, menopause, and hormone replacement therapy in women with systemic lupus erythematosus
Overview of cutaneous lupus erythematosus
Musculoskeletal manifestations of systemic lupus erythematosus
Neonatal lupus: Epidemiology, pathogenesis, clinical manifestations, and diagnosis
Neurologic manifestations of systemic lupus erythematosus
Neuropsychiatric manifestations of systemic lupus erythematosus
Non-coronary cardiac manifestations of systemic lupus erythematosus in adults
Overview of the clinical manifestations of systemic lupus erythematosus in adults
Overview of the management and prognosis of systemic lupus erythematosus in adults
Pregnancy in women with systemic lupus erythematosus
Pulmonary manifestations of systemic lupus erythematosus in adults
Treatment and prognosis of diffuse or focal proliferative lupus nephritis
Therapy of resistant or relapsing diffuse or focal proliferative lupus nephritis
Diagnosis and classification of renal disease in systemic lupus erythematosus
The following organizations also provide reliable health information.
●National Library of Medicine
●National Institute of Arthritis and Musculoskeletal and Skin Disease
●American College of Rheumatology
●Lupus Foundation of America
●Lupus Research Alliance
- Hochberg MC. Updating the American College of Rheumatology revised criteria for the classification of systemic lupus erythematosus. Arthritis Rheum 1997; 40:1725.
- Fessler BJ, Alarcón GS, McGwin G Jr, et al. Systemic lupus erythematosus in three ethnic groups: XVI. Association of hydroxychloroquine use with reduced risk of damage accrual. Arthritis Rheum 2005; 52:1473.
- Urowitz MB, Feletar M, Bruce IN, et al. Prolonged remission in systemic lupus erythematosus. J Rheumatol 2005; 32:1467.
- Chambers SA, Rahman A, Isenberg DA. Treatment adherence and clinical outcome in systemic lupus erythematosus. Rheumatology (Oxford) 2007; 46:895.
- Smith KG, Jones RB, Burns SM, Jayne DR. Long-term comparison of rituximab treatment for refractory systemic lupus erythematosus and vasculitis: Remission, relapse, and re-treatment. Arthritis Rheum 2006; 54:2970.
All topics are updated as new information becomes available. Our peer review process typically takes one to six weeks depending on the issue.