Are there any psychiatric drugs that can cause drug-induced lupus?

Psychiatric Drugs That Can Cause Drug-Induced Lupus

Several psychiatric medications can cause drug-induced lupus, with chlorpromazine being the most well-documented among them. 1, 2

Psychiatric Medications Associated with Drug-Induced Lupus

• Chlorpromazine (a phenothiazine antipsychotic) is clearly documented in FDA labeling to potentially cause "a systemic lupus erythematosus-like syndrome" 1
• Clozapine (an atypical antipsychotic) has been reported to cause drug-induced lupus that resolved upon discontinuation and recurred with rechallenge 3
• Other phenothiazines may carry similar risks as chlorpromazine 2
• Carbamazepine and lithium carbonate have been identified as potentially lupus-inducing drugs 4

Clinical Presentation and Diagnosis

• Drug-induced lupus typically presents with:
  • Arthralgia and myalgia 2
  • Pleurisy 2
  • Rashes and fever 2
  • Positive antinuclear antibodies in serum 2
• Unlike idiopathic lupus, drug-induced lupus rarely causes serious manifestations such as:
  • Nephritis 2
  • Cerebral involvement 2
• Diagnosis requires:
  • Temporal relationship between drug initiation and symptom onset
  • Exclusion of other causes
  • Resolution of symptoms after drug discontinuation 2
  • In some cases, symptom recurrence with drug rechallenge (as seen with clozapine) 3

Management of Drug-Induced Lupus

• Discontinuation of the offending drug is the primary treatment 2
• Symptoms typically resolve within a few weeks after stopping the medication 2
• For neuropsychiatric manifestations of lupus:
  • Immunosuppressive therapy may be beneficial for inflammatory manifestations 5
  • Glucocorticoids combined with immunosuppressive agents (cyclophosphamide, followed by azathioprine maintenance) can be effective 5
  • In refractory cases, rituximab has shown significant improvement of psychiatric manifestations 5

Safer Alternatives for Patients with Lupus Requiring Psychiatric Treatment

• For patients with existing lupus requiring psychiatric medication:
  • Avoid known lupus-inducing drugs like chlorpromazine, carbamazepine, and lithium 4
  • Consider newer atypical antipsychotics with fewer reported associations to lupus
  • Aripiprazole has been used successfully in adolescents with lupus-associated psychosis 6
  • SSRIs like paroxetine have been used as adjunctive therapy for neuropsychiatric lupus 7
  • In patients with Sjögren's syndrome (which can co-occur with lupus), avoid drugs with anticholinergic effects like phenothiazines and tricyclic antidepressants 4

Important Considerations

• Psychiatric symptoms in patients with lupus may be due to:
  • Direct disease activity on the central nervous system 4
  • Side effects of medications used to treat lupus (e.g., corticosteroids) 4
  • Psychological reaction to chronic illness 4
• When psychiatric symptoms develop in patients taking potentially lupus-inducing psychiatric medications, consider drug-induced lupus in the differential diagnosis 2
• Early recognition is crucial as symptoms typically resolve with drug discontinuation 2

When prescribing psychiatric medications, especially antipsychotics like chlorpromazine, clinicians should maintain vigilance for symptoms suggestive of drug-induced lupus and promptly discontinue the medication if such symptoms develop.