Steroid Side Effects: How to Reduce Drug Side Effects of Corticosteroids

 

How to reduce drug side effects

How to think about the suggestions below: Any suggestion here which is not clear or which you think may not apply to you should be discussed with the your physician. Note also that the side effects of steroids very much depend on the dose and how long they are taken. If your dose is low, your risk of serious side effect is quite small, especially if precautions, as discussed below, are taken. Reading about these side effects may make you uncomfortable about taking steroids. You should be well aware of the risks before starting these medications. However, please be reassured that many people take steroids with minor or no side effects. Please also remember that steroids are often extremely effective and can be life-saving. If any of the suggestions here is unclear, or seems irrelevant to you, please discuss it with your physician.

Note: Which “steroids” are we talking about: The term “steroids” here refers to anti-inflammatory steroids (corticosteroids) such as prednisone and methylprednisolone (Medrol®) and dexamethasone (Decadron®). The information below does not refer to muscle-building or “androgenic” steroids (such as testosterone), which share some chemical similarities but function quite differently than anti-inflammatory steroids.

Understanding corticosteroid side effects

With long-term use, corticosteroids can result in any of the following side effects. However, taking care of yourself as discussed below may reduce the risks.

Increased doses needed for physical stress

Steroid use for over two weeks can decrease the ability of your body to respond to physical stress. A higher dose of steroid may be needed at times of major stress, such as surgery or very extensive dental work or serious infection. This could be needed for as long as a year after you have stopped steroids.

Self-care tips:

• Discuss this possibility with the surgeon or dentist, etc. who is taking care of you at the time. Your physician or surgeon may not feel you need to take the extra steroid at the time of surgery, but if they know you have been on corticosteroids they can watch you more carefully after surgery.

Steroid withdrawal syndrome

Rapid withdrawal of steroids may cause a syndrome that could include fatigue, joint pain, muscle stiffness, muscle tenderness, or fever. These symptoms could be hard to separate from those of your underlying disease.

Self-care tips:

• If you get symptoms like these when you taper your steroids, discuss them with the doctor. Your physician will work with you to continually try to taper your steroid dose, at a safe rate of decrease, depending on how you are doing. On each visit, discuss with the physician whether it is possible to decrease your steroid dose.

• Note that even if you are having a steroid side effect, however, steroids still must be tapered slowly.

• When used for less than two weeks, more rapid tapering of steroids is generally possible.

Infection

Long-term steroids can suppress the protective role of your immune system and increase your risk of infection.

Self-care-tips:

• Since steroids can decrease your immunity to infection, you should have a yearly flu shot as long as you are on steroids. If you are on steroids for a prolonged period of time, you should also discuss with your doctor the possibility of getting “Pneumovax,” a vaccination against a certain type of pneumonia as well as “Prevnar 13,” another pneumonia vaccine. Shingles vaccination (Shingrix®) may also be considered. Your physician will take your age and risk factors into account when deciding which vaccinations you need.
• Signs of possible infection, such as high fever, productive cough, pain while passing urine, or large “boils” on the skin should have prompt medical attention. If you have a history of tuberculosis, exposure to tuberculosis, or a positive skin test for tuberculosis, report this to your doctor.

Gastrointestinal symptoms

Steroids may increase your risk of developing ulcers or gastrointestinal bleeding, especially if you take these medications along with non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or aspirin. If at all possible, don’t combine steroids with NSAIDs. If you are on low-dose aspirin for heart protection, your physician may want you to continue this when you take the prednisone, but might consdier adding a medication for stomach protection during the course of steroids.

Self-care tips:

• Report to your physician any severe, persisting abdominal pain or black, tarry stools.
• Take the steroid mediation after a full meal or with antacids, as this may help reduce irritation of the stomach. Steroids can increase your appetite.

Osteoporosis

Steroid therapy can cause thinning of the bones (osteopenia and osteoporosis), and increase the risk of bone fractures. At the beginning or before your steroid therapy, many patients will be asked to have a bone density test, especially if the steroid dose is high. If density is low, the bone density study It will be repeated in the future to assess the effectiveness of measures you will be using to prevent bone loss. Preventative strategies are important: a person can lose 10% to 20% bone mass within the first six months of corticosteroid therapy.

Self-care tips: 

• Most people taking corticosteroids will need to take a calcium supplement unless they can get enough calcium from their diet (if you can get it from your diet, that’s the best option). See this reference from the National Institutes of Health about how much calcium you need for your sex and age, and how to get as much as possible from diet.
• The minimal daily requirement of vitamin D is 800 international units (UI) daily, and most people on corticosteroids should take this amount. Your physician may check your vitamin D level and see if you actually need a higher dose.
• Smoking and alcohol increase the risk of osteoporosis, so limiting these is helpful.
• Weight-bearing exercise (walking, running, dancing, etc) is helpful in stabilizing bone mass.
• People on corticosteroids who have low bone density may be put on medications such as alendronate (Fosamax®) or Prolia®, and there are a number of others.
• Assess risk of falls. Make a thorough examination of your home and correct situations that might result in a fall, such as eliminating scatter rugs and any obstacles between bedroom and bathroom, and installing night lights.

Weight gain

Steroids affect your metabolism and how your body deposits fat. This can increase your appetite, leading to weight gain, and in particular lead to extra deposits of fat in your abdomen.

Self-care tips:

• Watch your calories and exercise regularly to try to prevent excessive weight gain. But don't let weight gain damage your self-esteem. Know that the weight will be easier to take off in the six months to a year after you discontinue steroids.

Insomnia

Steroids may impair your ability to fall asleep, especially when they are taken in the evening.

Self-care tips:

• If possible, the physician will try to have you take your entire daily dose in the morning. This may help you sleep better at night (evening doses sometimes make it difficult to fall asleep).

Mood changes

Steroids, especially in doses over 30 milligrams per day, can affect your mood. Some people can feel depressed, some extremely “up” without any apparent reason. Just being aware that steroids can do this sometimes makes it less of a problem. Sometimes, this side effect requires that the steroid dosage be decreased. When the steroids are absolutely necessary, sometimes another medication can be added to help with the mood problem. Make sure your family knows about this possible side effect.

Self-care tips:

• Simply being aware that steroids can have an effect on your mood can sometimes make it less of a problem. But, at times, this side will require that the steroid dosage be decreased. If maintaining the same steroid dosage is absolutely necessary, sometimes another medication can be added to help with the mood problem.
• Make sure your family and friends know about this possible side effect so they will know what's going on if you respond to them in unexpected ways. Ideally, tell your family and friends about this possible side effect as you start the medication, so that they can help you detect any changes in your behavior.

Fluid retention and elevated blood pressure

Because cortisone is involved in regulating the body's balance of water, sodium, and other electrolytes, using these drugs can promote fluid retention and sometimes cause or worsen high blood pressure.

Self-care tips:

• Watch for swelling of your ankles, and report this to your doctor. Occasional patients benefit from diuretics (water pills). Low sodium diet helps reduce fluid accumulation and may help control blood pressure.
• Have your blood pressure monitored regularly while you are on steroids, especially if you have a history of high blood pressure. Steroids can raise blood pressure in some patients.

Elevated blood sugar

Since cortisone is involved in maintaining normal levels of glucose (sugar) in the blood, long-term use may lead to elevated blood sugar or even diabetes.

Self-care tips:

• Your blood sugar should be followed while you are on steroids, especially if you are a diabetic, since corticosteroids can raise blood sugar.

Eye problems

Steroids can sometimes cause cataracts or glaucoma (increased pressure in the eye).

Self-care tips:

• If you have a history of glaucoma or cataract follow up closely with the ophthalmologist while on steroids. If you develop any visual problems while on steroids, you will need to see the ophthalmologist. Temporarily blurred vision when you start corticosteroids is often not a serious problem, but ophthalmology evaluation should always be arranged if you experience other, new visual symptoms while taking steroids.

Atherosclerosis (hardening of the arteries)

It is possible that steroids may increase the rate of "hardening of the arteries," which could increase the risk of heart disease. This risk is probably much more significant if steroids are taken for more than a year, and if taken in high dose.

Self-care tips:

• Low cholesterol diet may help. If you develop signs suggesting heart problem, such as chest pain, get medical attention quickly. Work with your physician to address any heart risks that can be modified, such as exercise, weight and cholesterol level.

Aseptic necrosis

• Steroids, particularly at higher doses for long periods of time, can sometimes lead to damage to bones, called aseptic necrosis (also known as osteonecrosis or avascular necrosis). This can happen in a number of joints, but the hip is the most common.

Self-care tips:

• Hip pain, especially if you have no known hip arthritis, could be an early sign of this damage. Report this to your doctor.

From: HSS.edu 

The 5 Types Of Lupus Fatigue

Fatigue is the most common and disabling symptom experienced by those with autoimmune disorders. According to the Lupus Foundation, approximately 80% of those with lupus experience fatigue. I disagree, lol! I have never heard of someone with lupus that didnt experience fatigue! I have read several prominent rheumatologists say that they feel fatigue is about 100% in lupus.

Exhaustion, for us affected by Lupus is a permanent part of life. It is just as much a part of me as the fact that I have 2 feet. It will not go away..no matter how much I beg, plead, or wish it to. I have had SLE and other AI disorders for 23 years, and I do not remember what it is like to live life without my constant passenger of fatigue. Over the years it has worsened and evolved into a more severe exhaustion. But I have also gotten much better at dealing with it and accomodating my life around it without beating myslf up so much. I grieve for my inability to be spontaneous, to go about life without carefully planning each day. And I do so long to quell my fatigue with refreshing sleep. But, there is no sense wringing my hands, as it will not change a thing to just feel sorry for myself--and it actually will make me even more tired! It is very important for us to have understanding about what our daily struggles are about. Please share this with your family and friends. It is my hope that this will help you to minimize your sources of fatigue that are controllable, and learn to recognize the cues your body is telling you to address your level of fatigue. This will serve to give us all some empowerment.

1. Daily exhaustion 

This is the inherent fatigue that I attribute to the inflammatory, autoimmune nature of Lupus and the other autoimmune disorders I have such as Rheumatoid Arthritis, Sjogren's, and Polymyositis, to nme a few. It never goes away, and can vary from day to day but is always there. Pain levels definitely increase this, as can the weather (too hot, too cold, or major weather changes that I can "feel" in my bones) Think what it feels like to function without having any sleep for 2 days. That is the blanket of exhaustion that is the basis for daily living with autoimmune illness. All of the following are added to this basic fatigue. 

2. Overdoing fatigue

 If I push myself too far and ignore the cues my body is sending me to stop and rest, my body will fight back. When I do more than I should, the result is an immobilizing fatigue. It comes on after the fact, i.e., do too much one day and feel it the next. If I push myself today, I very likely will have to cancel everything tomorrow and most likely a few days after that. An extended period of doing more than I should will almost certainly cause a flare. 

3. Crumple and collapse fatigue 

This complete exhaustion comes on suddenly, and I have to stop whatever I'm doing and sit (or lay down) as soon as possible. It can happen anywhere, at any time. This fatigue feels like I have just run 26 miles and worked out using weights strenuously..my muscles will literally shake from any effort. My brain loses its ability to compute anything—even simple tasks are impossible to figure out. I am unable to match socks, or even to care for my basic needs..as my body and brain are on total disconnect. I cannot complete a thought, and lists do not help..as I will most likely either not remember to look at them, or I will not be able to understand what is on them. Others can notice this fatigue, even though I may try to hide it with incredible effort. If I do not heed the warnings from this fatigue, I will end up in a major flare. And many times I will anyways. 

4. Peanut butter fatigue  

This fatigue is present when I open my eyes in the morning and know that it is going to be a particularly bad day. This tends to happen more in the cold weather, and seems to coincide with Raynaud’s symptoms. It feels like every effort I make to move is as if the air is made of thick peanut butter. My muscles and joints hurt, and doing anything is like walking with heavy weights. That super sore and heavy feeling you get from working out too strenuously..multiplied x 10! This fatigue prevents me from exercising on days when it is present, as even a little walking will make it much worse, and actually will increase my level of exhaustion. The best thing for me to do with peanut butter fatigue is heat, rest, and gentle stretches. 

5. Flare exhaustion 

Flare-related fatigue is the mother of all exhaustion..an unpredictable state of increased fatigue that can last for days or weeks. It can actually be all of the above types combined. There is no way to put off, or not heed this fatigue..or I will literally collapse. (Has happened) This is like someone who has had no sleep for about 3-4 days, then ran a marathon, lifted weights strenuously, and took sleeping meds..but didn't sleep! In addition, a flare brings multiple other symptoms that add to the exhaustion..pain, GI problems, like nausea, vomiting, diarrhea, abdominal pain, headache, etc. I have no choice but to rest..I will literally sleep 12-20 hours in a day during flares. Rest is vital, as is communication with my physician, as undetected infections can also disguise themselves with a flare and this fatigue. Once a flare starts, it is impossible to tell how long it will last, or how severe, and which bodily systems will be affected.   

The following issues will add to the above fatigue, so be sure that you are in touch with your physician regarding them, to minimize the effect on your level of exhaustion.

*Stress (well doh)

*Depression and Anxiety

*Thyroid problems...make sure your dr has checked these at least once a year. 3-4 times a year if you are on thyroid medications.

*Anemia (This is common with Lupus)

*Sleep Apnea

*Pulmonary fibrosis

*Low vitamin d levels

*COPD

*Congestive heart failure 

*Chronic pain

*Other concurrent conditions (Diabetes, Rheumatoid Arthritis, MS, etc.)

The following medications can cause or contribute to fatigue:

*Cold and allergy meds (allegra, benadryl, dextromethorphan)

*Muscle relaxants (flexeril, zanaflex, soma, robaxin, etc)

*Narcotic pain medications (percocet, vicodin, tramadol, morphine, dilaudid, eyc.)

*Other pain medications (lyrica, neurontin)

*Blood pressure medications (lopressor, labetalol, zestril, norvasc, procardia, lasix, bumex, atenolol, etc)

*Prednisone (acts as a stimulant, preventing sleep.Talk with your Dr about dosing earlier in the day)

*Antidepressnts (paxil, zoloft, prozac, celexa, lexapro, trazodone, elevil, remeron, seroquel, abilify, effexor, cymbalta, etc)

*Anxiety Medications (valium, ativan, xanax, klonopin, buspar, vistaril, etc.)

*Migraine prevention medications (elavil, topamax, depakote, inderal, etc.)

~Jenn Schoch <3 Facebook.com/Lupusandme

Lupus Symptoms & Complications

Lupus Symptoms

SLE symptoms may develop slowly over months or years, or they may appear suddenly. Symptoms tend to be worse during winter months, perhaps because prolonged exposure to sunlight in the summer causes a gradual build-up of factors that trigger symptoms months later.

ARTHRITIC PAIN

The most common symptom is joint pain, which occurs in about 90% of patients with SLE. Characteristics of this symptom vary widely:

It is often accompanied by swelling and redness.

It can last from hours to months.

It may be mild or severe.

It can occur in one joint, move from one to another, or flare erratically.

Pain often occurs in the morning and improves during the day, only to return later when the patient tires.

The joints most affected are fingers, wrists, elbows, knees, and ankles. (Joints in the spine and neck are not affected.)

Children may experience these symptoms as growing pains, and, in all patients, they may be the only symptoms for many years.

FEVER

Fever occurs in 90% of patients with SLE and is usually caused by the inflammatory process of the disease, not by infection. It is low-grade except during an acute lupus crisis.

SKIN RASHES

Three-quarters of patients with SLE have skin inflammation and skin lesions (ulcers, rashes, or other injured areas). About half of these lesions are photosensitive; that is, they are aggravated by ultraviolet (UV) radiation from sunlight, even from light coming through a window. (UV radiation may even trigger systemic flares in patients with SLE.)

A number of different skin conditions have been described in patients with SLE.

Discoid Lupus Erythematosus. About 20% of patients have discoid lesions. In such cases, the condition is often known as discoid lupus erythematosus (DLE). Patients with this condition may have the following skin abnormalities:

Discoid means coin-shaped, so these lesions are round and raised. They are also scaly. Untreated, the margins gradually extend outward as the center dries out and shrivels, causing severe scarring. If discoid lesions appear on the scalp, they can plug hair follicles and cause irreversible hair loss. Discoid lesions can also appear on the upper body.

Lupus, discoid -- view of lesions on the chest: This close-up picture of the neck clearly shows the typical rounded appearance of discoid lupus. The whitish appearance is caused by scaling. The two dark spots are biopsy sites and are not part of the disease.

A butterfly-shaped rash across the face may accompany this condition. This rash causes little scarring, although spidery, branching lines of swollen capillaries (the tiniest blood vessels) may appear.

Most patients with this condition have only a limited skin disorder. In only about 10% of cases does discoid lupus develop into full-blown SLE.

Subacute Cutaneous Lupus Erythematosus. Subacute cutaneous lupus erythematosus (SCLE) can cause skin lesions on parts of the body that are exposed to sunlight. These lesions do not cause scarring.

Vasculitis. Patients with SLE sometimes develop inflammation in the blood vessels (vasculitis) that may have the following effects on the skin:

Red welts may form across large areas of the body.

Sometimes deep red bumps may appear, particularly on the leg, where they may ulcerate.

In some people, reddish-purple lesions appear on the pads of fingers and toes or near the nails of fingers and toes.

Lesions caused by vasculitis may ulcerate or blister if they erupt on mucous membranes in the mouth, nose, or vagina and can be painful if they occur on the throat.

Vasulitis can attack blood vessels in almost any other organ, including the brain, the heart, and the gastrointestinal tract.

OTHER SLE SYMPTOMS

Other symptoms include:

Fatigue

Loss of appetite, nausea, and weight loss

Chest pain

Bruising

Menstrual irregularities

Thought and concentration disturbances

Personality changes

Sleep disorders, such as restless legs syndrome and sleep apnea

Dryness of the eyes and mouth

Brittle hair or hair loss

Hair loss or breakage may also occur in about half of patients with SLE during severe flares or after pregnancy or severe illness. In such cases, hair grows back.

RAYNAUD'S PHENOMENON

Raynaud's phenomenon is a condition in which cold or stress can cause spasms in impaired blood vessels, resulting in pain in fingers and toes. It occurs as part of the inflammatory response in blood vessels, which can narrow them and reduce circulation. In extreme cases, gangrene can result.

CONDITIONS WITH SIMILAR SYMPTOMS

A number of conditions overlap with SLE:

Scleroderma: Hardening of the skin caused by overproduction of collagen

Rheumatoid arthritis: Inflammation of the lining of the joints

Sjogren syndrome: Characterized by dry eyes and dry mouth

Mixed connective tissue disorder: Similar to SLE, but milder

Myositis: Inflammation and degeneration of muscle tissues

Rosacea: Flushed face with pus-filled blisters

Seborrheic dermatitis: Sores on lips and nose

Lichen planus: Swollen rash that itches, typically on scalp, arms, legs, or in the mouth

Dermatomyositis: Bluish-red skin eruptions on face and upper body

Lyme disease: Bulls-eye rash, joint inflammation, and flu-like symptoms

Lupus Overview

Complications

Systemic lupus erythematosus (SLE) can cause systemic complications throughout the body.

COMPLICATIONS OF THE BLOOD

Almost 85% of patients with SLE experience problems associated with abnormalities in the blood.

Anemia. About half of patients with SLE are anemic. Causes include:

Iron deficiencies resulting from excessive menstruation

Iron deficiencies from gastro-intestinal bleeding caused by some of the treatments

A specific anemia called hemolytic anemia, which destroys red blood cells

Anemia of chronic disease

Hemolytic anemia can occur with very high levels of the anticardiolipin antibody. It can be chronic or develop suddenly and be severely (acute).

Antiphospholipid Syndrome. Between 34 - 42% of patients with SLE have antiphospholipid syndrome (APS). This is a specific set of conditions related to the presence of autoantibodies called lupus anticoagulant and anticardiolipin. These autoantibodies react against fatty molecules called phospholipids, and so are called antiphospholipids. Their actions have complex effects that include causing narrowing and abnormalities of blood vessels.

Patients who have APS have a very incidence of blood clots, which most often occur in the deep veins in the legs. Blood clotting, in turn, puts patients at higher risk for stroke and pulmonary embolism (clots in the lungs).

This picture shows a red and swollen thigh and leg caused by a blood clot (thrombus) in

the deep veins in the groin (iliofemoral veins). Such a clot prevents normal return of blood from the leg to the heart.

The effects on blood vessels have also been associated with confusion, headaches, and seizures. Leg ulcers can also develop.

Patients with APS who become pregnant have a high incidence of pregnancy loss, especially in the late term.

Not all patients with APS carry both of the autoantibodies, and they can also wax and wane and so have varying effects. APS also occurs without lupus in about half of patients with the syndrome.

Thrombocytopenia. In thrombocytopenia, antibodies attack and destroy blood platelets. In such cases, blood clotting is impaired, which causes bruising and bleeding from the skin, nose, gums, or intestines. (This condition can also occur in APS, but it is not considered to be one of the standard features of the syndrome.)

Neutropenia. Neutropenia is a drop in the number of white blood cells. Patients with SLE often neutropenia, but the condition is usually harmless unless the reductions are so severe that they leave the patient vulnerable to infections.

Acute Lupus Hemophagocyte Syndrome. A rare blood complication of SLE that occurs primarily in Asians is called acute lupus hemophagocytic syndrome. It is generally of short duration and characterized by fever and a sudden drop in blood cells and platelets.

Lymphomas. Patients with SLE and other autoimmune disorders have a greater risk for developing lymph system cancers such as Hodgkin’s disease and non-Hodgkin’s lymphoma (NHL).

HEART AND CIRCULATION COMPLICATIONS

Heart disease is a primary cause of death in lupus patients. The immune response in SLE can cause chronic inflammation and other damaging effects that can cause significant injury to the arteries and tissues associated with the circulation and the heart. In addition, SLE treatments (particularly corticosteroids) affect cholesterol, weight, and other factors that can also affect the heart.

Patients with SLE, have a higher risk for developing the following conditions, which put them at risk for heart attack or stroke:

Atherosclerosis, or plaque buildup in the arteries

Increased stiffness in the arteries

Unhealthy cholesterol and lipid (fatty molecules) levels

High blood pressure, most likely because of kidney injury and corticosteroid treatments

Heart failure

Pericarditis, an inflammation of the tissue surrounding the heart

Myocarditis, an inflammation of the heart muscle itself (rare)

Abnormalities in the valves of the heart (rare)

Blood clots

The risk for cardiovascular disease, heart attack, and stroke is much higher than average in younger women with SLE. The risks decline as such women age.

LUNG COMPLICATIONS

SLE affects the lungs in about 60% of patients:

Inflammation of the membrane lining the lung (pleurisy) is the most common problem, which can cause shortness of breath and coughing.

In some cases, fluid accumulates, a condition called pleural effusion.

Inflammation of the lung tissue itself is called lupus pneumonitis. It can be caused by infections or by the SLE inflammatory process. Symptoms are the same in both cases: fever, chest pain, labored breathing, and coughing. Rarely, lupus pneumonitis becomes chronic and causes scarring in the lungs, which reduces their ability to deliver oxygen to the blood.

A very serious and rare condition called pulmonary hypertension occurs when high pressure develops as a result of damage to the blood vessels of the lungs.

KIDNEY COMPLICATIONS (LUPUS NEPHRITIS)

The kidneys are a crucial battleground in SLE because it is here that the debris left over from the immune attacks is most likely to be deposited. Also, the immune response can also attack different parts of the kidney causing damage. About 50% of patients with SLE exhibit inflammation of the kidneys (called lupus nephritis).This condition occurs in different forms and can vary from mild to severe. Poor kidney function and kidney failure may result from this damage.

Serious complications occur eventually in about 30% of patients. If kidney injury develops, it almost always occurs within 10 years of the onset of SLE, rarely after that.

CENTRAL NERVOUS SYSTEM COMPLICATIONS

Nearly all patients with SLE report some symptoms relating to problems that occur in the central nervous system (CNS), which includes the spinal cord and the brain. CNS involvement is more likely to occur in the first year, usually during flare-ups in other organs.

Symptoms vary widely and overlap with psychiatric or neurologic disorders. They may also be caused by of some medications used for SLE. Central nervous system symptoms are usually mild, but there is little effective treatment available for them. CNS symptoms get worse as the disease progresses.

The most serious CNS disorder is inflammation of the blood vessels in the brain (vasculitis), which occurs in 10% of patients with SLE. Fever, seizures, psychosis, and even coma can occur. Other CNS side effects include:

Irritability

Emotional disorders (anxiety, depression)

Mild impairment of concentration and memory

Migraine and tension headaches

Problems with the reflex systems, sensation, vision, hearing, and motor control

INFECTIONS

Infections are a common complication and a major cause of death in all stages of SLE. The immune system is indeed overactive in SLE, but it is also abnormal and reduces the ability to fight infections. Patients are not only prone to the ordinary streptococcal and staphylococcal infections, but they are also susceptible to fungal and parasitic infections (called opportunistic infections), which are common in people with weakened immune systems. They also face an increased risk for urinary tract, herpes, salmonella, and yeast infections. Corticosteroid and immunosuppressants, treatments used for SLE, also increase the risk for infections, thereby compounding the problem.

GASTROINTESTINAL COMPLICATIONS

About 45% of patients with SLE suffer gastrointestinal problems, including nausea, weight loss, mild abdominal pain, and diarrhea. Severe inflammation of the intestinal tract occurs in less than 5% of patients and causes acute cramping, vomiting, diarrhea, and, rarely, intestinal perforation, which can be life-threatening. Fluid retention and swelling can cause intestinal obstruction, which is much less serious but causes the same type of severe pain. Inflammation of the pancreas can be caused by the disease and by corticosteroid therapy.

JOINT, MUSCLE, AND BONE COMPLICATIONS

Arthritis caused by SLE almost never leads to destruction or deformity of joints. The inflammatory process can, however, damage muscles and cause weakness. Patients with SLE also commonly experience reductions in bone mass density (osteoporosis) and have a higher risk for fractures, whether or not they are taking corticosteroids (which can increase the risk for osteoporosis). Women who have SLE should have regular bone mineral density scans to monitor bone health.

EYE COMPLICATIONS

Inflamed blood vessels in the eye can reduce blood supply to the retina, resulting in degeneration of nerve cells and a risk of hemorrhage in the retina. The most common symptoms are cotton-wool-like spots on the retina. In about 5% of patients sudden temporary blindness may occur.

SOCIOECONOMIC CONSEQUENCES

In one study, 40% of patients with SLE quit work within 4 years of diagnosis, and many had to modify their work conditions. Significant factors that predicted job loss included high physical demands from the work itself, a more severe condition at the time of diagnosis, and lower educational levels. People with lower income jobs were at particular risk for leaving them.

PREGNANCY AND SYSTEMIC LUPUS ERYTHEMATOSUS

Women with lupus who conceive face high-risk pregnancies that increase the risks for themselves and their babies. It is important for women to understand the potential complications and plan accordingly. The most important advice is to avoid becoming pregnant when lupus is active.

Research suggests that the following factors predict a successful pregnancy:

Disease state at time of conception. Doctors strongly recommend that women wait to conceive until their disease state has been inactive for at least 6 months.

Kidney (renal) function. Women should make sure that their kidney function is evaluated prior to conception. Poor kidney function can worsen high blood pressure and cause excess protein in the urine. These complications increase the risk for preeclampsia and miscarriage.

Lupus-related antibodies. Antiphospholipid and anticardiolipin antibodies can increase the risks for preeclampsia, miscarriage, and stillbirths. Anti-SSA and anti-SSB antibodies can increase the risk for neonatal lupus erythematosus, a condition that can cause skin rash and liver and heart damage to the newborn baby. Levels of these antibodies should be tested at the start of pregnancy. Certain medications (aspirin, heparin) and tests (fetal heart monitoring) may be needed to ensure a safe pregnancy.

Medication use during pregnancy. Women with active disease may need to take low-dose corticosteroids, but women with inactive disease should avoid these drugs. Steroids appear to pose a low risk for birth defects, but can increase a pregnant woman’s risks for gestational diabetes, high blood pressure, infection, and osteoporosis. For patients who need immunosuppressive therapy, azathioprine (Imuran) is an option. Methotrexate (Rheumatrex) and cyclophosphamide (Cytoxan) should not be taken during pregnancy.

Pregnancy Risks

Women with lupus are 20 times more likely to die during pregnancy than women without the disease. The risk for maternal death is due to the following serious conditions that can develop during pregnancy:

Miscarriages. About 25% of lupus pregnancies result in miscarriage. The risk is highest for patients with antiphospholipid antibodies, active kidney disease, or high blood pressure.

Blood clots. Women with lupus have a 6 times greater risk for developing deep vein thrombosis (blood clots) than women without the disease.

Clotting complications. Low blood platelet count and anemia are also risks. Women with lupus are 3 times more likely to need a transfusion during pregnancy than women without lupus.

Infections. Blood infections (sepsis), pneumonia, and urinary tract infections are more common in pregnant women with lupus.

Preeclampsia. Women with lupus are three times more likely than healthy women to develop preeclampsia (pregnancy-related high blood pressure), which can be potentially life threatening.

Birth Complications. Women with SLE have an increased risk of having a pre-term birth, stillbirth, or Caesarean section.

Despite these obstacles, many women with lupus have healthy pregnancies and deliver healthy babies. To increase the odds of a successful pregnancy, it is important for women to plan carefully before becoming pregnant. Be sure to find knowledgeable doctors with whom you can communicate and trust. Pregnant women with lupus should try to assemble an interdisciplinary health care team that includes a rheumatologist, high-risk obstetrician, and (for patients with kidney disease) a nephrologist.

Source: lupus.org, rheumatology.org, upodate.com

Causes/Risk Factors for Lupus

.                                

Systemic lupus erythematosus (SLE) is a chronic, often life-long, autoimmune disease. It can be mild to severe, and affects mostly women. SLE may affect various parts of the body, but it most often manifests in the skin, joints, blood, and kidneys. SLE was first described in 1828. Its very name helps define the disease:

Systemic is used because the disease can affect organs and tissue throughout the body.

Lupus is Latin for wolf. It refers to the rash that extends across the bridge of the nose and upper cheekbones and was thought to resemble a wolf bite.

Erythematosus is from the Greek word for red and refers to the color of the rash..   

Lupus has many different symptomsn ones include:

Fatigue

Joint pain or swelling

Skin rashes

CAUSES/RISK FACTORS FOR LUPUS

Systemic lupus erythematosus is a complex disorder that most likely results from a combination of processes and factors.

Environmental factors, such as viruses, exposure to chemicals, or sunlight, trigger inflammatory or immune activity. This immune activation may begin as an appropriate response to an unwanted "invader." But, because of a combination of genetic factors, an individual with lupus develops an ongoing immune response that does not shut itself off appropriately. This leads to waxing and waning flares of inflammation that can involve various organs of the body, depending on specific features of this self-perpetuating immune response in individual patients.

The exact combination of genes that predispose individuals to SLE may differ somewhat from patient to patient, but probably share certain common features which tend to impair the ability of the body to get rid of immune-triggering particles and which tend to prolong or increase the degree of immune responsiveness to these triggers.

A major characteristic of lupus is that it is an autoimmune response in which immune factors, called autoantibodies, attack the person's own cells. Some autoantibodies are normal in a well-balanced immune system, and serve various roles to help the body dispose of wastes, protect from infectious invaders, and to keep blood vessels clear. In healthy people, autoantibodies tend to be well-regulated and well "masked," or covered up, until needed. Therefore, it is probably the high activity and high detestability of autoantibodies that makes lupus unique, not the fact that they exist.

THE INFLAMMATORY PROCESS AND AUTOIMMUNITY

The Normal Immune System Response. The inflammatory process is a byproduct of the activity of the body's immune system, which fights infection and heals wounds and injuries:

When an injury or an infection occurs, white blood cells are mobilized to rid the body of any foreign proteins, such as a virus.

The masses of blood cells that gather at the injured or infected site produce factors to fight any infections.

In the process, the surrounding area becomes inflamed and some healthy tissue is injured. The immune system is then called upon to repair wounds by clotting any bleeding blood vessels and initiating fiber-like patches to the tissue.

Under normal conditions, the immune system has special factors that control and limit this inflammatory process.

The Infection Fighters. B cells and T cells are two important components of the immune system that play a role in the inflammation associated with lupus. Both B cells and T cells belong to a family of immune cells called lymphocytes. Lymphocytes help fight infection.

B cells and T cells are involved in the immune system's response to infection. Antigens are foreign bodies (such as bacteria and viruses) that stimulate the immune system to produce autoantibodies. When a T cell recognizes an antigen it will produce chemicals (cytokines) that cause B cells to multiply and release many immune proteins (antibodies). These antibodies circulate widely in the bloodstream, recognizing the foreign particles and triggering inflammation in order to rid the body of the invasion.

An antigen is a substance that can provoke an immune response. Typically antigens are substances not usually found in the body.

For reasons that are still not completely understood, both the T cells and B cells become overactive in lupus patients. In lupus, a complex interaction between activated immune cells and an impaired antigen-elimination process leads to a greater than normal range of what the antibodies recognize. Eventually, antibodies are made that recognize more of the body's own tissues in a stronger or more persistent manner than is healthy, and inflammatory responses are mounted in these tissues.

Autoantibodies. In the majority of patients with SLE, antinuclear antibodies (ANA) are detectable. Such autoantibodies may be present in individuals up to 7 years prior to their developing symptoms of lupus. Some subtypes of ANA are found in lupus patients and only rarely in people without lupus. These include:

Anti-ds DNA. An autoantibody called anti-double stranded DNA (anti-ds DNA) may play an important role in some lupus patients.

Anti-Sm antibodies. This antibody is found most often in lupus patients of African descent and is almost never detected in people without lupus.

Anti-Ro (SSA) and Anti-La (SSB)

Antiphospholipid antibodies

Cytokines. Most immune cells secrete or stimulate the production of powerful immune factors called cytokines. In small amounts, cytokines are indispensable for maintaining the balance of the body during immune responses, including:

Infections

Injuries

Tissue repair

Blood clotting

Clearing of debris from inflamed blood vessels

Other aspects of healing.

If overproduced, however, they can cause serious damage, including dangerous levels of inflammation and cellular injury. Specific cytokines called interferons and interleukins play a critical role in SLE by regulating the secretion of autoantibodies by B cells.

Complement. Another immune factor of high interest in SLE is the complement system. This is comprised of more than 30 proteins and is important for defending and regulating the immune response. Inherited deficiencies in certain complement components (C1q, C1r, C1s, C4, and C2) have long been associated with SLE.

GENETIC FACTORS

SLE is a complex disorder and researchers are still in the early stages of unraveling how genetic factors may alter and affect the immune system. Researchers estimate that 20 - 100 different genetic factors may make a person susceptible to SLE.

RISK FACTORS
 The number of people diagnosed with lupus has more than tripled over the past four decades. This may simply indicate a greater degree of doctor training in recognizing the syndrome. GENDER About 90% of lupus patients are women, most diagnosed when they are in their childbearing ages. Hormones may be an explanation. After menopause, women are only 2.5 times as likely as men to contract SLE. Flares also become somewhat less common after menopause in women who have chronic SLE.

ETHNICITY
African-Americans are three to four times more likely to develop the disease than Caucasians and to have severe complications. Hispanics and Asians are also more susceptible to the disease.

FAMILY HISTORY
A family history plays a strong role in SLE. A brother or sister of a patient with the disorder has 20 times the risk as someone without an immediate family member with SLE.
RISK FACTORS IN CHILDREN
The disease is rare in childhood. When it does occur, it is often associated with thrombotic thrombocytopenia purpura, a condition resulting from abnormally low levels of blood platelets. SLE in children may also be caused by certain medications, including minocycline and zafirlukast.

PRESENCE OF OTHER AUTOIMMUNE DISORDERS
Rheumatoid Arthritis. Studies have investigated the relationship among hormones, SLE, and rheumatoid arthritis, another autoimmune disease. Higher levels of estrogen are associated with SLE, while lower levels are associated with rheumatoid arthritis. Some research suggests that some patients, in fact, progress from one disease to the other, and that such transitions occur during major hormonal shifts, such as the onset of menopause or pregnancy. Rheumatoid arthritis is a systemic autoimmune disease that initially attacks the lining, or synovium, of the joints.

DRUG-INDUCED LUPUS
Many prescription drugs can cause lupus-like skin symptoms. These include high blood pressure (hypertension) medications, including hydrochlorothiazide, angiotensin-converting-enzyme inhibitors, and calcium-channel blockers. About 40 different drugs have been linked to lupus onset. Anyone diagnosed with cutaneous lupus erythematosus should be sure to tell their doctors all the medications (including herbs and supplements) that they are taking.

LIFESTYLE FACTORS
Smoking. Smoking may be a risk factor for triggering SLE and can increase the risk for skin and kidney problems in women who have the disease.

POSSIBLE SLE TRIGGERS
In genetically susceptible people, there are various external factors that can provoke an immune response. Possible SLE triggers include colds, fatigue, stress, chemicals, sunlight, and certain drugs.

Viruses. Patients with SLE may be more likely to have been exposed to certain viruses than the general population. These viruses include the Epstein-Barr virus (the cause of mononucleosis), cytomegalovirus, and parvovirus-B1. In particular, some research suggests a strong association between Epstein-Barr virus (EBV) and increased risk of lupus, particularly for African-Americans.

Sunlight. Ultraviolet (UV) rays found in sunlight are important SLE triggers. When they bombard the skin, they can alter the structure of DNA in cells below the surface. The immune system may perceive these altered skin cells as foreign and trigger an autoimmune response against them. UV light is categorized as UVB or UVA depending on the length of the wave. Shorter UVB wavelengths cause the most harm.

Chemicals. Clusters of SLE cases have occurred in populations with high exposure to certain chemicals. Chlorinated pesticides and crystalline silica are two suspects. A number of other chemicals are under investigation. However, it is very difficult to determine a causal role for any specific chemicals. (Silicone breast implants have been under intense scrutiny as a possible trigger of autoimmune diseases, including SLE. The weight of evidence to date, however, finds no support for this concern.) Some drugs have been associated with a temporary lupus syndrome (drug-induced lupus), which resolves when these drugs are stopped.

Hormones. Cytokines, major immune factors that are active in SLE, are directly affected by sex hormones. In general, estrogen enhances antibody production, and testosterone reduces antibody production, although their exact role in SLE may be more complicated than that since there are various ways in which each hormone might influence various immune cells. Women with SLE may have lower levels of several active male hormones (androgens), and some men who are affected by SLE may also have abnormal androgen levels. Premature menopause, and its accompanying symptoms (such as hot flashes), is common in women with SLE. Hormone replacement therapy (HRT), which is used to relieve these symptoms, increases the risk for blood clots and heart problems. It is not clear whether HRT triggers SLE flares. Women should discuss with their doctors whether HRT is an appropriate and safe choice. Guidelines recommend that women who take HRT use the lowest possible dose for the shortest possible time. Women with SLE who have active disease, antiphospholipid antibodies, or a history of blood clots or heart disease should not use HRT.

Oral Contraceptives. Female patients with lupus used to be cautioned against taking oral contraceptives (OCs) due to the possibility that estrogen could trigger lupus flare-ups. However, recent evidence indicates that OCs are safe, at least for women with inactive or stable lupus. Women who have been newly diagnosed with lupus should avoid OCs. Lupus can cause complications in its early stages. For this reason, women should wait until the disease reaches a stable state before taking OCs. In addition, women who have a history of, or who are at high risk for, blood clots (particularly women with antiphospholipid syndrome) should not use OCs. The estrogen in OCs increases the risk for blood clots.

Sources: lupus.org, rheumatology.org, hopkinslupus, hss.edu

Living In The Now

Living in the Now

 Benefits of Living in The Moment:
 ✓ You become more connected with your  thoughts and feelings
 ✓ Are more connected to others
 ✓ Feel more gratitude and enjoyment of life
 ✓ If you live in the moment, it won't pass you  by
 ✓ Feel more focused, peaceful and alive
 ✓ Feel less anxious and fearful

 Like all skills, training yourself to enjoy and live in the moment takes time and practice. Begin now and see life from a fresh, new perspective. Carpe diem!

 Yes, for this moment IS your life! Living in the moment, or the now, is a conscious act that requires participation, not just observation. Every moment of your Life is a journey, rather than a destination...each step of which is a continuing discovery of yourself.....as yourself.

 Seizing each moment in life allows us to prolong its value and make it more meaningful. Rather than seeking quantity of time, when we live in the moment we enjoy and savor every minute.No other moment in time actually exists, so unless we live in the moment of now, we are not really living at all. We are just projecting either backwards or forwards.

 The reason our mind becomes still when we live in the moment of now is because there are no preconceptions brought forward from the past. Each moment is seen anew. So there is no guilt, no fear, no baggage filling our mind. Our mind is empty. To live in the moment, or now, means being conscious, aware and in the present with all of your senses. It means not dwelling on the past, nor being anxious or worrying about the future.

 When we concentrate our attention on the present we focus on the task at hand. We give our full attention to what we are doing and we let go of outcomes. When we train ourselves to live in each moment, we immerse ourselves in it and begin to discover its beauty and wonder. We learn focus and how to manage our energy. Professional athletes understand and employ this kind of focus very well. They know that accomplishment and success are a result of the skillful management and balancing of energy.

When we train ourselves to live in each moment, we immerse ourselves in it and begin to discover its beauty and wonder.  To make every moment count we must embrace it. Everything we do and every person we come in contact with deserves our full attention. Even when resting we should savor the moment. It gives us the opportunity to recharge, renew and gain clarity.

 Quite often we put huge expectations on ourselves and our lives. We rush to do this, hurry up with that, without actually enjoying the process. What's the rush? Where do we think we're going? If we don't stop and think about where we're at, we're probably missing the point.

Instead, when we appreciate each moment and garner the lessons from it, we live consciously, purposefully and responsibly. Likewise, when we live in the past and don't let go of painful experiences, perceived wrongs, or difficult times, we condemn ourselves to a present and future of the same. We cannot change the past. We can, however, come to terms with it, know that it's over, and move on. Living in the moment means letting go of the past and trusting in the future. When we are positive and optimistic in the present, we open the possibility of a positive and promising future. We owe it to ourselves to make every moment count - now!

Tips for Living in The Moment
Train your mind to focus on the current activity.
Engage in, and feel what you are doing.
Enjoy the process.
Learn relaxation techniques in order to be present in each moment.
Take notice of your surroundings - sights, sounds, smells, ambiance.
Listen attentively to the conversation of others, music, even silence.
Savor your food and drink.
Taste each morsel.

Enjoy the journey <3 Namaste
Jenn Schoch, MSN, FNP-BC