From the Guidelines
Drug-induced lupus (DIL) is best managed by discontinuing the offending medication, with hydralazine being a common culprit, particularly at higher doses, as noted in the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults 1. The most common drugs associated with DIL include:
- Hydralazine
- Procainamide
- Isoniazid
- Minocycline
- Tumor necrosis factor inhibitors Symptoms of DIL typically include:
- Joint pain
- Muscle pain
- Fatigue
- Fever
- Chest pain from pleurisy or pericarditis Unlike idiopathic lupus, DIL rarely affects the kidneys or central nervous system. Laboratory findings often show positive antinuclear antibodies (ANA) and anti-histone antibodies, which are particularly characteristic of DIL. During recovery, symptomatic treatment with:
- NSAIDs for joint pain
- Short courses of corticosteroids for more severe symptoms may be helpful It's essential to note that patients who develop DIL may not necessarily develop lupus from other medications, but they should avoid the specific drug that triggered their reaction. Healthcare providers should maintain a high index of suspicion for DIL when patients on these medications develop new autoimmune symptoms, as early recognition and drug discontinuation lead to better outcomes, as supported by the guideline 1.
From the FDA Drug Label
In a few patients hydrALAZINE may produce a clinical picture simulating systemic lupus erythematosus including glomerulonephritis. A lupus erythematosus-like syndrome of arthralgia, pleural or abdominal pain, and sometimes arthritis, pleural effusion, pericarditis, fever, chills, myalgia, and possibly related hematologic or skin lesions is fairly common after prolonged PA administration, Positive ANA titers have been reported in patients receiving propafenone They have been reversible upon cessation of treatment and may disappear even in the face of continued propafenone therapy.
Drug-induced lupus can occur with certain medications, including:
- Hydralazine (PO) 2
- Procainamide (PO) 3
- Propafenone (PO) 4 These medications may produce a clinical picture simulating systemic lupus erythematosus, including symptoms such as arthralgia, pleural or abdominal pain, and sometimes arthritis. If drug-induced lupus is suspected, the medication should be discontinued unless the benefit-to-risk determination requires continued therapy.
From the Research
Definition and Characteristics of Drug-Induced Lupus
- Drug-induced lupus is a syndrome resembling mild systemic lupus erythematosus that can complicate treatment with certain therapies 5.
- The syndrome is characterized by arthralgia, myalgia, pleurisy, rashes, and fever in association with antinuclear antibodies in the serum 5.
- More serious features of idiopathic lupus, such as nephritis and cerebral disease, are rare in drug-induced disease 5.
Associated Drugs
- The most common individual agents associated with drug-induced lupus are procainamide and hydralazine 5, 6, 7, 8, 9.
- Other drugs less frequently associated with the disease include chlorpromazine, isoniazid, methyldopa, penicillamine, quinidine, and sulfasalazine 5.
- Whole drug groups have also been implicated, such as anticonvulsants, beta-blockers, sulfonamides, and some of the newer 'biological' agents 5.
- Recently, cases of drug-induced lupus have been reported with anti-TNFalpha agents, which present with disparate clinical features including arthritis/arthralgia, skin rash, serositis, cytopenia, and variable laboratory abnormalities 6, 7.
Pathogenesis and Diagnosis
- The pathogenesis of drug-induced lupus is unknown, but in some cases, it is thought to be due to interactions between the drug and DNA or histones, rendering them immunogenic 5.
- For biological agents, including interferons and antibodies to tumour necrosis factor-alpha, it has been suggested that it is due to disruption of the cytokine network 5.
- Diagnosis of drug-induced lupus requires identification of a temporal relationship between drug administration and symptom development, and in traditional drug-induced lupus, there must be no pre-existing lupus 7, 8.
- Recognition of drug-induced lupus is important because it reverts within a few weeks of stopping the drug 5.