Systemic Lupus Erythematosus Medications Research Articles

Effectively measuring adherence to medications for systemic lupus erythematosus in a clinical setting

To assess the reliability and concurrent validity of the Medication Adherence Self-report Inventory (MASRI) when used in systemic lupus erythematosus (SLE), to investigate the predictive validity of the MASRI using pharmacy refill information as the criterion standard, and to propose a sensible approach to the screening for nonadherence in a clinical setting. Adherence to 2 medications (hydroxychloroquine and prednisone) was measured in 55 patients using the MASRI, pill counts, and physician ratings (MD scale). Adherence based on pharmacy refill information served as a criterion standard with nonadherence defined as adherence rates <80%. To determine test-rest reliability of the MASRI, 20 patients completed the measure twice within a 2-week period. Using pharmacy information, 39% of the patients were nonadherent to prednisone and 51% to hydroxychloroquine. The MASRI had acceptable internal consistency (Cronbach's alpha 0.7) and good reliability. Irrespective of the drug assessed, MASRI ratings were moderately correlated with patient adherence (pharmacy), supporting the concurrent validity of the MASRI. The combination of adherence estimation by MD scale rating at <85% and by MASRI at <90% was 87% sensitive and 86% specific for identifying patients who were nonadherent to prednisone. These cutoff values also appeared suitable for identifying nonadherence to hydroxychloroquine. The MASRI is a reliable measure of adherence to medications in SLE. The measure has concurrent and predictive validity. When combined with the MD scale, the MASRI appears to be a useful screening tool for nonadherence in patients with SLE that could be suitable for clinical practice.

Characteristics of patients with systemic lupus erythematosus (SLE) and non-Hodgkin’s lymphoma (NHL)

Patients with systemic lupus erythematosus (SLE) are at increased risk of developing non-Hodgkin's lymphoma (NHL), but features of SLE associated with NHL are not well described. The objective of this study was to describe SLE characteristics, laboratory serologies, and medication histories in patients who subsequently develop NHL. Two thousand twenty patients with SLE were identified using the online Partners' patient database research tool between October 1992 and June 2005. We confirmed the diagnoses of SLE and NHL and sought details of medical history and treatment by medical record review. Eleven patients with NHL without coexisting rheumatoid arthritis, Sjögren's, or HIV were identified; seven of these (64%) had a diffuse large B cell lymphoma subtype, and 83% of those stained were Epstein-Barr virus (EBV) negative. The mean duration of SLE at NHL diagnosis was 17.8 years (range 1.6-41.8), and the mean Systemic Lupus International Collaborative Clinics/American College of Rheumatology damage index was 1.9. Seven patients (64%) had SLE hematologic involvement, four had anti-dsDNA antibodies, and four had anti-phospholipid antibodies. One patient had significant renal disease. All patients had arthritis and had received antimalarial therapy. Five of 11 patients had received other treatments for SLE, including cyclophosphamide, imuran, methotrexate, and/or sulfasalazine. Diffuse large B cell lymphoma was the most common subtype of NHL, and most were EBV negative. Although disease duration was fairly long and end organ damage moderately severe in this group of patients, renal disease and the use of immunosuppressive chemotherapeutic agents were rare and did not appear to confer an increased risk of NHL development.

Therapy Insight: osteoporosis and osteonecrosis in systemic lupus erythematosus

Survival of patients with systemic lupus erythematosus (SLE) has improved over the past decade, thanks to improved treatment of the disease, which now results in fewer fatal complications. This improvement has allowed physicians to focus their attention on the prevention of organ damage caused by this chronic, inflammatory disease, and by the medications used to control the disease. Osteoporosis is common in SLE patients; risk factors for osteoporosis include prolonged use of glucocorticoids, cyclophosphamide and possibly gonadotropin-releasing-hormone agonists. In premenopausal women with SLE, inflammation or SLE-related medications can increase bone turnover, which eventually weakens bone architecture, then reduces bone strength and increases the risk of fracture. Prevention and treatment of osteoporosis in SLE patients should entail a multifaceted approach. Levels of calcium, vitamin D and homocysteine should be evaluated, and age-appropriate supplementation instituted. The bone loss that results from systemic inflammation should be treated by reduction of the inflammation with glucocorticoids, potent anti-inflammatory agents or antiresorptive agents. The efficacy of this therapy can be monitored using bone mineral density scans. This Review briefly discusses the pathophysiology of the localized and generalized osteoporosis and osteonecrosis in SLE patients and recommends therapies to both prevent and treat these unfortunate complications of this disease.

Assessment of strategies for identifying diagnosed cases of systemic lupus erythematosus through self-report.

The objective of this work was to assess the optimal way to identify potential systemic lupus erythematosus (SLE) cases in large epidemiologic studies through self-reported information about diagnosis of SLE, symptoms and medications, and to investigate the utility of a criteria checklist sent directly to participants' physicians. We used data collected in 1997 from 53322 participants in a study of African-American women, the Black Women's Health Study, including a lupus screening questionnaire (LSQ) and questions about SLE diagnosis and medications. We confirmed self-reported SLE through medical records and criteria checklists sent to participants' physicians. Among those for whom we received medical records and/or criteria checklists, we compared the predictive value and proportion of missed cases of several algorithms using combinations of self-reported SLE diagnosis, LSQ score and medication use to self-reported SLE diagnosis alone. We obtained a physician checklist or medical chart for 251 individuals who reported SLE, of whom 212 (84%) fulfilled ACR criteria for definite or probable SLE, or had clinical lupus (SLE diagnosis recorded in medical charts plus appropriate medication use). The use of LSQ score or medication use in addition to self-report of SLE tended to decrease the false positive rate but also to reduce the proportion of true cases identified. Checklists of ACR criteria completed by subjects' physicians documented more criteria than medical records. In conclusion, among participants who consented to medical record review, SLE prediction algorithms using questions about lupus symptoms and medications offered slightly higher predictive value for detecting cases than self-reported diagnosis alone, but at the cost of case detection. SLE case confirmation strategies can be complemented by the use of criteria checklists sent directly to participants' physicians.

Xylohypha bantianaMultiple Brain Abscesses in a Patient with Systemic Lupus Erythematosus

Xylohypha bantiana is a rare cause of cerebral fungal infection (phaeohyphomycosis). We report on a 72-year-old man who, while taking several immunosuppressive medications for systemic lupus erythematosus, presented with multiple bilateral cerebral abscesses caused by X bantiana. The lesions were not surgically amenable and the patient died two months after discontinuing antifungal therapy.

Outpatient management of systemic lupus erythematosus.

Systemic lupus erythematosus (SLE) is often managed by primary care practitioners, who must coordinate the care with the support of subspecialists. The management of patients with such a serious and chronic disease can be both rewarding and challenging. This article reviews common problems and suggests management strategies. Measurement of serum antinuclear antibodies can lead to an erroneous diagnosis if used as the sole basis for diagnosis. Infections are the leading cause of death in lupus patients, and immunizations and antibiotic prophylaxis need to be considered. Acute cutaneous SLE is exacerbated by exposure to ultraviolet light. Patients should avoid sun exposure. Specific treatment of cutaneous SLE includes topical corticosteroids and antimalarial agents. Some of the most perplexing problems seen in SLE relate to neuropsychiatric features. NSAIDs, corticosteroids, and antimalarials are the most commonly used medications for SLE.

The clinicopatholocical significance of cytomegalovirus (CMV) inclusions demonstrated on endocervical biopsy

The detection of CMV inclusions in an endocervical biopsy from an otherwise healthy 20 y.o. woman with confirmatory immunoperoxidase staining, <i>in silu</i> hybridization and electron microscopy, prompted review of the literature to ascertain the clinicopathological significance of this finding. Case report : A 20 y.o. woman presented for evaluation following a cervical smear which showed viral affects. Colposcopy showed changes of cervicitis and histological examination of biopsy material revealed an acute and chronic cervicitis associated with the CMV infection. The patient was lost to followup for 18 months. Following this, repeat colposcopy again showed inflammation, with cervicitis, mild dysplasia and CMV inclusions on biopsy. Full immunological workup, including human immunodeficiency virus study, was performed and was normal. Eleven other cases with histologic evidence of CMV inclusions on endocervical biopsy were found in the literature. In the 9 cases where information was available, endocervical inflammation was present. One patient was on immunosuppressive medication for systemic lupus erythematosus and 1 was found to have acquired immunodeficiency syndrome (17% of total). These cases demonstrate that: 1) CMV may be associated with acute and chronic cervicitis and 2) although histological evidence of endocervical CMV may be a marker of disseminated disease or impaired immunological function, this is more often not the case, and the prognosis is usually excellent. Immunologic testing is still, however, advisable so that occult immunodeficiency states will not be overlooked.

The clinicopathological significance of cytomegalovirus inclusions demonstrated by endocervical biopsy

A healthy 20 yr old woman presented for evaluation following a cervical smear which showed viral effects typical of human papilloma virus. Colposcopy showed changes of cervicitis with the main finding on histologic examination of biopsy material being an acute and chronic cervicitis associated with typical features of cytomegalovirus (CMV) infection. Viral identification was confirmed by immunoperoxidase staining, in situ hybridization and electron microscopy. The patient was lost to follow up for 18 mths. Following this, a repeat colposcopy again showed inflammation, with cervicitis, mild dysplasia and CMV inclusions on biopsy. Full immunological work-up, including human immunodeficiency virus (HIV) study, was performed and was normal. Only 11 other cases of endocervical biopsies with histological evidence of CMV inclusions were found in the literature, although the reported rate of detection of genital CMV in women on culture is 4-12%. In the 9 cases where information was available, endocervical inflammation was present. One patient was on immunosuppressive medication for systemic lupus erythematosus and another was found to have Acquired Immune Deficiency Syndrome (17% of total). These cases demonstrate that although histologic examination is an insensitive marker for CMV within the cervix, its presence may signify immunodeficiency and so immunological assessment of a patient with this finding is advisable.