What can you say about systemic lupus erythematosus?

Nursing, Aug 2004 by McClintock, Rebecca

Prepare to answer your patient's questions about this mysterious disease.

If a patient with systemic lupus erythematosus (SLE) asks you about her disease, you have a lot of ground to cover. A chronic, inflammatory autoimmune disease with no known cause or cure, SLE can cause a wide range of signs and symptoms that vary in severity and complicate diagnosis. In this article, I'll spell out how to educate your patient about this complex disorder.

Immune system attack

Like other autoimmune diseases, SLE occurs when the immune system loses the ability to distinguish "self" from "nonself" and produces antibodies against body tissues to cause inflammation. Rather than targeting a specific tissue, however, SLE affects tissues throughout the body. Some patients have mild symptoms and don't require treatment; others may have significant damage to vital organs, including the kidneys, heart, and brain. The disease course commonly alternates between periods of illness (flares) and wellness (remission).

Women develop SLE at a rate nine times greater than men, commonly during the childbearing years. Women in black, Hispanic, Asian, and American Indian ethnic groups are more likely to have it than white women.

The cause of SLE is unknown, but hormones, chemicals, heredity, and environmental factors, including infection, stress, sunlight, and use of some antibiotics have been implicated. Some medications used to treat chronic illness, such as thyroid disease, heart disease, and hypertension, can trigger a lupus-like syndrome, but it typically resolves when the drug is withdrawn.

The signs and symptoms of SLE include joint pain, hair loss, severe fatigue, a facial "butterfly" rash, sun sensitivity, enlarged lymph nodes, and fever. Other relatively common problems include Raynaud's phenomenon (cold or stress causing the fingers and toes to blanch, redden, or turn blue), chest pain, and dry eyes and mouth.

Because SLE can affect multiple systems and diagnostic tests aren't definitive, diagnosis can be difficult. The patients clinical signs are significant. Certain blood tests are relatively specific, but the results aren't positive in all patients with SLE. Other tests suggest but don't confirm the diagnosis. To clarify diagnosis, the American College of Rheumatology in 1982 established diagnostic criteria that incorporate all these factors. (See Four Criteria Add Up to SLE.)

Diagnostic tests commonly done to support the SLE diagnosis include the following:

* anti-DNA, anti-Sm, anti-RNP, anti-Ro, and anti-La antibodies, which are highly suggestive of SLE but can occur in people without the disease

* complete blood cell count, to check for anemia and infection

* urinalysis, to assess for kidney involvement

* erythrocyte sedimentation rate, to detect inflammation

* antinuclear antibody (ANA) titer, to screen for antibodies that react with cell nuclei. Healthy people and some people with other disorders have a positive ANA titer, so the test isn't specific for SLE.

* levels of complement (typically C3 and C4), which helps the body combat infection and inflammation and tends to be low in people with SLE

* blood chemistries, such as blood urea nitrogen and creatinine, to detect renal involvement.

Treating the problem

The primary therapy goals for a patient with SLE include preventing and treating flares and minimizing organ damage and complications. (See Monitoring for Complications.) If your patient has just gotten a diagnosis of SLE, teach her that the signs and symptoms can vary considerably and that her therapy will depend on their severity. Acknowledge her physical pain: Inflammation in the joints can be very painful, and swollen glands can be uncomfortable. Encourage her to rest frequently. Teach her the purpose of her medications, how to take them, and potential adverse reactions. Stress the importance of taking them as prescribed for best results. Her regimen is likely to include drugs from the following categories.

Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and naproxen are used to combat inflammation, fever, and pain. Your patient shouldn't take them if she's pregnant or breast-feeding or has a peptic ulcer, bleeding disorder, renal or cardiac dysfunction, or salicylate allergy. If she can safely take NSAIDs and her health care practitioner recommends them, teach her to take them with food or milk to reduce the risk of gastrointestinal irritation.

Corticosteroids such as prednisone reduce inflammation but are contraindicated in anyone with a history of diabetes, glaucoma, ulcers, liver or kidney disease, heart failure, sensitivity to steroids, or infection. Tell your patient to take the medication with food or milk. Warn her not to stop taking it abruptly and to follow her health care practitioner's instructions to taper off the doses before ending therapy.

Antimalarial agents, such as hydroxychloroquine, may be used to manage joint pain, fever, rashes, ulcers, and fatigue, but they may take several months to reach a therapeutic blood level. Anyone with hypersensitivity to 4-aminoquinolone derivatives or who experiences retinal or visual field changes shouldn't take an antimalarial. Some patients with a history of allergy to the drugs, liver disease, psoriasis, or alcoholism, and those who are pregnant or breast-feeding, may take them under close supervision. Your patient will need careful eye examinations yearly while taking hydroxychloroquine because it can trigger serious vision problems.