Apr 23, 2019
Lupus can affect a person’s immune system and cause damage to the skin, joints, blood cells and organs. The key to treatment? Knowing what symptoms to look out for and seeking medical attention when necessary.
Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.
Host: Thanks for joining us today. We’re speaking with Dr. Konstantinos Loupasakis, a rheumatologist at MedStar Washington Hospital Center. Thanks for joining us today, Dr. Loupasakis.
Dr. Konstantinos Loupasakis: Thank you for having me.
Host: Today we’re discussing systemic lupus erythematosus, which is also known as SLE or simply lupus. This autoimmune disease can affect the joints, blood cells, and vital organs of the body. Dr. Loupasakis, what does autoimmune disease mean when it comes to lupus?
Dr. Loupasakis: Autoimmune means that the immune system, which is the defense mechanisms that our body is equipped with to fight infections or to heal injury, for reasons that are not entirely understood, goes out of control. When the immune system goes out of control, it can become very active for no obvious reason, as if there were an infection or as if there were an injury, even in the absence of either. When that happens, structures of the body, which can include the joints, the skin, but also vital organs such as the heart, the kidneys, and the brain, can be targeted by the immune system, which otherwise is supposed to be there to protect us. And that can lead to very significant complications.
Host: What are some of the most common symptoms of lupus?
Dr. Loupasakis: The most common symptoms of lupus include joint pain and inflammation of the joints, which we call arthritis. It’s usually affects the joints of the hands, the wrists, but also the feet and the ankles. And it can affect also the larger joints of the body. In addition to that, it can affect the skin. Some very typical rashes happen on the face. The most known one is the one that has been described as a butterfly rash because of its shape. These rashes are usually photosensitive, which means that they get worse by sun exposure. Other symptoms that can also happen at the same time include patchy areas of hair loss, inflammation of the kidneys or the heart, inflammation of the eyes - depending on each individual, patients can have a very different presentation.
Host: What should a patient do if they notice a strange rash on their face?
Dr. Loupasakis: They should definitely consult with their rheumatologist because it may or may not be related to their lupus. There are certain criteria and certain characteristics that a rheumatologist can recognize when they examine the skin rash, that can suggest whether the rash is related to the lupus. Usually, the classic butterfly rash is very red. It can be itchy or burning, and it’s very photosensitive, which means that it’s usually triggered by sun exposure or it can get worse by sun exposure. However, not every rash that happens on the face is a lupus skin rash, and that’s why it’s very important to consult with a rheumatologist and, oftentimes, with a dermatologist, a skin specialist, because it’s not always very clear and there are other conditions that can manifest with a very similar presentation. So, it’s very important to distinguish those conditions from lupus. Oftentimes, a skin biopsy performed by a dermatologist is a necessary test that we end up getting in order to confirm the diagnosis.
Host: Do these symptoms tend to present slowly, quickly, in bursts - or how do they usually make a patient feel?
Dr. Loupasakis: The onset of those symptoms can be very gradual. But occasionally we see patients that have very acute presentations. For example, the skin and the joint manifestations oftentimes happen more gradually. Oftentimes, with a trigger. After a sunny day, patients can present with a skin rash that is really prominent that was not there before. The joint symptoms are usually more gradual, over a period of weeks or even months. However, there are other complications. For example, inflammation of the brain or the kidneys that can present more suddenly. Or, they might have been happening for a long period of time, but the patient sometimes only realizes that something is wrong suddenly, or more acutely.
Host: Could you describe your patient population for lupus and who’s most at risk?
Dr. Loupasakis: Sure. Lupus affects women more than men. In fact, nine times more, women compared to men. When men are affected, the disease is usually a little bit more severe, and usually it starts at an earlier age. For reasons that are not entirely understood, it affects African Americans more than Caucasians. And, there are many research studies that have been focusing on that question. It’s a very complex issue but we think that there might be some genetic component. But also, at the same time, social disparities come in to play and may affect the outcomes and why African American patients may seem to suffer more from lupus. Maybe their disease seems to be more severe. But it’s not entirely understood whether that is because they truly have a different version of lupus or because their access to care might be more limited, at times.
Host: Around what age is a patient typically diagnosed with lupus?
Dr. Loupasakis: Lupus predominantly affects females at the age of 20s and 30s. However, we have had patients that were diagnosed when they were children. And, even though that’s not a classic presentation, it can happen and, obviously, it can be very devastating sometimes for the families. But I would say that the majority of our patients are usually diagnosed in their 20s and 30s.
Host: Is there anything patients can do to reduce their risk for lupus?
Dr. Loupasakis: There are no known risk factors that can be modified by the patients. Sun exposure is a trigger of active disease and patients who have lupus they know that they should avoid sun exposure and that they should definitely use a good sunscreen with an SPF of at least 30. That could be one of the modifiable risk factors for triggers. But not...we don’t really have any modifiable risk factors for the development of the disease. There is some genetic predisposition and some environmental risk factors that are not entirely understood, that, in combination, can lead to the development of lupus in some predisposed individuals. Usually, there is a family history of the disease, usually in the first-degree relatives, but we don’t really have any other risk factors that have been recognized to lead to the development of lupus.
Host: It has to be very frustrating for patients and their families.
Dr. Loupasakis: It is very frustrating because they want to know if there’s anything that they did wrong. They want to know if there’s anything that they can do to prevent it from getting worse. And, the answer is that there’s nothing that they did wrong. Unfortunately, that’s...a lot of our diseases have that kind of course. And, what our patients can do to prevent it from getting worse, to prevent their lupus from flaring, is really to maintain a good relationship with their rheumatologists, to have frequent follow-up with us, with the rheumatologists, and have frequent blood checks and report any new symptoms that they may develop over the time in order to catch it early and treat it accordingly, if they have a flare.
Host: What complications can happen if a person has lupus but doesn’t get treatment for it?
Dr. Loupasakis: Lupus is a multisystemic disease, which means that it can potentially affect many different parts of the body. Even though most of the patients that we see usually have arthritis - so joint inflammation and also inflammation of the skin - there is a significant percentage of patients that can develop more severe disease, which can affect the kidneys and other vital organs, such as the heart and the brain. That’s why it’s very important that the disease is treated early so that it doesn’t lead to the development of those complications. Not everybody is going to develop those unfortunate complications, but a very significant percentage that can reach up to 50 percent of patients can have kidney involvement. And, this is a manifestation of the disease that can be very severe, and it can lead to significant problems in the future. That’s why it’s very important that we treat it very aggressively and very early. The most important thing is that some of these manifestations may not be very easy for the patients to realize that are happening. For example, kidney inflammation doesn’t really cause pain, but it can manifest itself with symptoms such as swelling of their ankles or swelling of their face or changes with their urination - they might see blood in the urine, or their urine might become very foamy. So, sometimes subtle changes in their symptoms may reflect some more severe disease. That’s why it’s very important that patients with lupus follow-up very closely with their rheumatologists in order to be able to identify those subtle changes and do the appropriate lab testing.
Host: How is lupus diagnosed?
Dr. Loupasakis: Lupus is diagnosed by combining a number of blood and urine tests with a very thorough examination in the office, a very thorough history-taking, and also, occasionally, with x-rays of the affected joints. Other imaging studies such as CAT scans or MRIs - these are studies that are done in radiology - they can give us some more information and sometimes we order those tests, as appropriate.
Host: What treatments are available for lupus?
Dr. Loupasakis: We have many medications that can modify the course of the disease, in addition to the corticosteroids, in addition to the cortisone, which we usually reserve only for patients that have very acute worsening of their disease activity. We have medications that patients can take by mouth, in tablet forms. We have some injectable medications. In fact, we have a medication that can be administered by the patient at home. And, we also have some infusions that can be taken through the IV, intravenously, at the infusion center. The combination of different medications, depending on the severity of the manifestations, can lead to cooling down the inflammation and preventing the affected organs from getting damaged.
Host: How long does it take for those medications to take effect for a patient?
Dr. Loupasakis: That’s a very good question. Oftentimes, these medications can take up to three months to kick in and that’s very important for our patients to understand because sometimes, our patients think that the medication is not working and they may end up stopping it, whereas the truth is that the medication might be, in fact, working but it just needs some more time to exert its effect. So, I would say from a few weeks up to three months for some of our medications.
Host: During that time frame, where you’re waiting for the medications to really kick in for a patient, how can you tell that they’re beginning to work?
Dr. Loupasakis: We always bring our patients back, especially when we have newly diagnosed them with possible lupus. We want to see them very frequently in the beginning and re-examine them and get blood and urine tests. We want to make sure that after the initiation of the new treatment, their labs and their symptoms are improving. So, even though I said that the maximum effect of some of our medications can be achieved in a period of weeks or months, it is important to note that we want to make sure that their patient’s labs or symptoms are at least improving during the course of that period of time.
Host: In that probably very frustrating timeframe, how do you help patients remain positive and control their symptoms and their pain as they’re going through treatment?
Dr. Loupasakis: We try to take care of the symptoms with other medications. If they’re in a lot of pain, we try to take care of the pain with pain killers. Depending on the manifestation that they have, we try to treat the symptoms while we’re waiting for the actual lupus medication to kick in. Emotionally and psychologically, we provide them with resources such as instructions of how to participate in a support group or referrals to psychiatry or psychotherapy because, oftentimes, patients might be depressed because the burden of the disease can be quite significant. I would say that I’m very optimistic with the majority of our patients and they do very well, if they stay in touch with us and take their medications consistently. It takes time for the improvement to happen so, during that period of time, it’s very important that we provide a good support to the patients and their families who suffer through this process.
Host: What sort of outcomes can a patient with lupus expect once their treatment has kicked in to full effect?
Dr. Loupasakis: That really depends on the severity of their disease. Lupus is a disease that has a very variable course. I would say that the majority of our patients have a very good outcome. They might have a minor disease, which usually affects the joints and the skin. And, usually with a regular follow-up, usually every three to six months, some blood and urine tests, taking their medications as instructed, they can have a very good quality of life. They can be completely asymptomatic, they can be functional, and they can have a normal life, maybe with some brief periods of flares of more active disease, which, whenever they happen, we try to treat them promptly in order to get our patients back to their life. There is a minority of patients that they may suffer more severe complications. And, in these unfortunate cases, we really try to be aggressive early on and we really try to do the best we can to prevent them from having long-term damage. And I would say that, in a great majority of them, we succeed.
Host: Could you share a success story from your patient population?
Dr. Loupasakis: I will never forget that young lady in her 20s who had lupus for a very long time. She essentially grew up with lupus. And, her disease had been fairly controlled until the time when she was about to go to college. At that time, her lupus became very, very active. She was admitted to the hospital. And, she had inflammation in multiple organs, including her joints, her skin, her brain. She wasn’t even able to recognize me at the time. That was really shocking to me. I had never seen her like that before. And, I recognized that this was a part of the disease, that this was her lupus that was really acting up. Very promptly, our team did the work-up the way we were supposed to do - the blood and urine tests, the imaging studies. We figured out what was going on, and we treated her very aggressively early on with the medications that we usually use in these cases. And, within 24 to 48 hours, she really improved, and she was able to recognize me. And, of course, her recovery took longer, took weeks to months for her to go back to her baseline. But, we were able to bring her back to her normal life and, with regular follow-ups and with the right medications, she was able to become functional again. She went back to college. And, now she’s enjoying her life with her peers.
Host: Why is MedStar Washington Hospital Center the best place to seek care for lupus?
Dr. Loupasakis: We have the largest group of patients with lupus, so we have had a great experience treating patients with this disease. And, we follow a very multidisciplinary approach. We work closely with other subspecialties such as the kidney doctors, the neurologists, the heart specialists. And, this is very important for a disease such as lupus because it is a condition that can affect many different parts of the body. So, working closely with all of these different subspecialties can really make a difference in patient’s outcome. And, we refer these patients to our colleagues, whom we stay in touch with during the course of a flare but also during the course of the follow-up with our patients.
Host: Thanks for joining us today, Dr. Loupasakis.
Dr. Loupasakis: It was my pleasure. Thank you for having me.
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