Systemic lupus erythematosus (SLE) is an autoimmune disease that happens when your immune system mistakenly attacks different parts of your body, like your skin, joints, kidneys, heart, lungs, and brain. Although there’s no cure, many drugs can treat symptoms caused by inflammation in lupus and even prevent permanent damage. Some of the most important of these drugs are called immunosuppressants, which work by dialing down your overactive immune system. The exact drugs your doctor prescribes will depend on how serious your disease is and what your symptoms are.
The main immunosuppressant drugs used to treat lupus are:
Anifrolumab (Saphnelo)
Anifrolumab was approved in 2021 to treat moderate to severe lupus in adults. Research has shown that it can improve arthritis and skin rashes. But it hasn’t been evaluated for lupus nephritis or lupus that affects the central nervous system. Anifrolumab holds down a type of immune-system compound called type 1 interferons. Most adults with lupus have elevated levels of type 1 interferons.
How it’s taken
Anifrolumab is given as a 30-minute infusion once every 4 weeks in a medical facility.
Side effects
- Upper respiratory tract infections
- Herpes
- Cough
- Bronchitis
- Back pain
- Headache
- Nausea and vomiting
Potential drug interactions
According to the FDA, potential drug interactions haven't been formally studied.
Warnings
Like other immunosuppressives, anifrolumab can increase the risk of infections. Talk to your doctor before getting a live vaccine and if you are pregnant, want to become pregnant, or are breastfeeding. Anifrolumab may increase the risk of cancer.
Azathioprine (Imuran, Azasan)
Azathioprine reduces joint symptoms and damage and helps people who have lupus that affects their livers and kidneys. It works by stopping the spread of white blood cells.
How it’s taken
Azathioprine is taken as a pill once a day. Some relief may be seen in 6-8 weeks. The full effect often takes 12 weeks to kick in.
Side effects
- Abdominal pain
- Nausea and vomiting
- Loss of appetite
- Increased risk of infections
Potential drug interactions
- Allopurinol (Aloprim, Zyloprim) for gout
- Warfarin (Coumadin), a blood thinner
- Certain blood pressure medications including the ACE inhibitors Accupril and Vasotec
Warnings
Long-term use of azathioprine can increase the risk of cancer. Talk to your doctor before getting any vaccines or if you are pregnant, may become pregnant, or are breastfeeding.
Belimumab (Benlysta)
Belimumab was approved to treat lupus in adults in 2011. It was approved to treat children with lupus in 2019 and to treat lupus nephritis in 2020. Rather than taking wide aim at the immune system, the drug blocks a specific protein that produces antibodies which, in lupus, can mistakenly attack the joints, skin, and other organs. It is FDA-approved for use in combination with standard therapy for the treatment of lupus nephritis in adults.
How it's taken
You can give yourself injections of belimumab once a week, or a medical professional can give you an infusion in a clinic. Infusions, which take about an hour, are given every 2 weeks for the first 4 weeks and then once every 4 weeks. It can take 12 weeks or longer to take full effect.
Side effects
- Nausea and diarrhea
- Fever
- Muscle aches
- Respiratory and urinary tract infections
- Depression
Warnings
Researchers haven’t determined whether belimumab is safe for pregnant or breastfeeding women. You should talk to a doctor before taking any live vaccines. Belimumab may increase the risk of some cancers as well as PML.
Corticosteroids
Steroids are a time-tested anti-inflammatory drug used to treat numerous health conditions, including lupus. Steroid injections are sometimes given before rituximab infusions to prevent the flu-like symptoms that can happen with the treatment. For lupus itself, steroids (primarily prednisone) can benefit patients whose kidneys, heart, lungs, or central nervous system have been affected. It works by reducing inflammation.
How they’re taken
Prednisone and other steroids such as hydrocortisone and dexamethasone (Decadron) are usually given in tablets up to four times a day. They can also be given as an injection. Cream and gel formulations can help skin symptoms such as rashes.
Side effects
The side effects of steroids worsen with higher doses and longer treatment times, which is why doctors try to keep doses as low as possible for as little time as possible. They include:
- Acne
- Muscle weakness
- Weight gain and redistribution of fat
- Facial hair growth
- Irritability and mood swings
- Insomnia
- Increased risk of infection
- Worsening diabetes, glaucoma, high blood pressure
- Higher cholesterol and triglyceride levels
- Osteoporosis
- Cataracts
- Glaucoma
Potential drug interactions
Prednisone may increase the risk of stomach ulcers if you take it with NSAIDs.
Warnings
Although prednisone seems to be safe while breastfeeding, it has been linked with birth defects when taken during pregnancy. Some vaccines may not be suitable while taking steroids.
Cyclosporine (Neoral, Sandimmune, Gengraf)
Cyclosporine is also known as a disease-modifying antirheumatic drug (DMARD). It relieves pain, swelling, and stiffness in your joints and may also ward off long-term damage. It can help treat lupus nephritis (lupus-related inflammation in your kidneys) in people who haven’t responded to other drugs. Cyclosporine blocks the function of immune cells known as T cells.
How it’s taken
Cyclosporine is taken orally twice a day. Some symptoms may go away in the first week. But the full effect takes about 3 months.
Side effects
- High blood pressure
- Gout
- Headaches
- Stomach pain
- Nausea and vomiting
- Swelling of hands and feet
- Tremors
- Hair growth
- Numbness or tingling in hands and feet
- Swelling of the gums
Potential drug interactions
- Certain heart and blood pressure medications including some diuretics
- Lovastatin (Altoprev, Mevacor) and simvastatin (Flolipid, Zocor) to lower cholesterol
- Erythromycin and other antibiotics and antifungals
- Certain antiseizure medications
- Certain antidepression medications
Warnings
Don’t take cyclosporine if you’re pregnant, trying to get pregnant, or are breastfeeding. The drug can increase the risk of infection as well as the risk of skin and other cancers.
Hydroxychloroquine (Plaquenil)
Hydroxychloroquine was developed to treat malaria, but it and other malaria drugs can also be effective against lupus. It reduces pain and inflammation and cuts down on lupus flares and skin symptoms.
How it's taken
Hydroxychloroquine comes in pills and liquids. It can take up to 3 months to get results.
Side effects
Antimalarials usually don't produce many side effects. The ones that do happen can include stomach pain, nausea, or diarrhea. These usually don’t last very long.
Potential drug interactions
Hydroxychloroquine does not interact with many medications. But it’s still important to tell your doctor about all medications (prescription and over-the-counter) as well as any supplements and herbal formulas you are taking.
Warnings
Hydroxychloroquine seems to be safe during pregnancy and breastfeeding, but talk to your doctor about all safety issues.
Leflunomide (Arava)
Leflunomide is both a DMARD and an immunosuppressant. Geared toward symptoms of and long-term damage from arthritis, it is often prescribed for people who haven’t had a great response to methotrexate. It can also be used in addition to methotrexate. It reduces inflammation by interfering with the ability of immune cells to reproduce. Doctors have found it to be effective against lupus, even though it's not specifically approved for it.
How it’s taken
Leflunomide is a tablet taken once a day. You may start on a higher “loading” dose (to get it in the system sooner) before continuing on a lower maintenance dose. It can take up to 3 months to see its full effects.
Side effects
The most common side effect is diarrhea, affecting about 1 in 5 patients, though this typically improves over time. Other side effects can include:
- Nausea
- Stomach pain
- Indigestion
- Rash
- Hair loss
- Increased risk of infections
Potential drug interactions
Some medications may interfere with how well leflunomide works, such as:
- Cholestyramine (Questran) to lower cholesterol
- Tolbutamide for diabetes
- Rifampin (Rifadin, Rimactane), an antibiotic
Warnings
Talk to your doctor if you are pregnant, planning to become pregnant, or are breastfeeding. You should also tell your doctor before getting any vaccinations or having surgery.
Methotrexate (Rheumatrex, Trexall)
Originally developed to treat cancer, methotrexate is now a standard immunosuppressive treatment for lupus. The drug reduces joint pain and swelling by blocking folic acid production. This prevents the growth of certain immune system cells. Methotrexate is also a DMARD. Although the Food and Drug Administration (FDA) has not approved it for lupus, it has been approved for rheumatoid arthritis and other autoimmune conditions.
How it’s taken
Methotrexate is taken as a pill or an injection once a week. Arthritis symptoms should start to ease after 3-6 weeks, though the full effect may not kick in for 12 weeks.
Side effects
Side effects are usually minor and go away with time. They can include:
- Nausea
- Mouth sores
- Vomiting
- Abnormal liver tests
- Coughing or shortness of breath
- Hair loss
- Sun sensitivity
Potential drug interactions
- Trimethoprim (Bactrim), an antibiotic
- NSAIDs (nonsteroidal anti-inflammatory drugs) such as ibuprofen and celecoxib (Celebrex). Certain NSAIDs are also sometimes combined with methotrexate to treat lupus.
Warnings
Methotrexate may be risky if you’re pregnant, plan to become pregnant, or are breastfeeding. Your doctor will help guide you on whether it’s a good idea to take it. It also can put you at higher risk for infections.
Mycophenolate Mofetil (CellCept)
This treats symptoms of lupus-related kidney disease, like blood in your urine. The drug goes after a certain protein involved in immune system functioning.
How it’s taken
Mycophenolate mofetil is taken twice a day by mouth as a capsule, tablet, or liquid.
Side effects
- Stomach pain
- Nausea, vomiting, and diarrhea
- Headache
- Dizziness
- Difficulty sleeping
- Tremors
- Increased risk of infection
- Anemia
The chance of side effects is higher in people 65 and older.
Potential drug interactions
Certain drugs may interfere with how well your body absorbs mycophenolate mofetil, including:
- Antacids such as Maalox, Mylanta, or Rolaids
- Oral contraceptives
- Trimethoprim (Bactrim), an antibiotic
- Acyclovir (Sitavig, Zovirax), an antiviral
- Cholestyramine (Questran) to lower cholesterol
- Aspirin
- Phenytoin (Dilantin, Phenytek), an antiseizure medication
Warnings
Talk to your doctor if you are pregnant, plan to become pregnant, or are breastfeeding. Mycophenolate mofetil may increase the risk of certain cancers including lymphoma and skin cancer. Also check with your doctor before getting any vaccinations. Mycophenolate mofetil is associated with a rare but fatal neurological condition called progressive multifocal leukoencephalopathy (PML).
Rituximab (Riabni, Rituxan, Ruxience, Truxima)
Rituximab is another cornerstone of lupus treatment even though it is not approved for this condition. The drug calms down the overactive immune system by attaching to certain proteins on the surface of immune system cells, causing them to die.
How it’s taken
Rituximab is taken as an IV infusion, which can last several hours.
Side effects
- Diarrhea
- Back or joint pain
- Cough
- Decreased blood pressure
- Anxiety
- Increased risk of infections
Potential drug interactions
Tell your doctor if you are taking any other medications, including supplements and herbal and over-the-counter products.
Warnings
This drug could be risky if you are pregnant or trying to become pregnant, although it is considered safe for breastfeeding. Rare instances of PML have been reported.
Voclosporin (Lupkynis)
The FDA approved voclosporin in January 2021 to treat lupus nephritis. The drug attaches to a protein (calcineurin) that would normally activate T cells. This stops the immune system from attacking the kidneys.
How it’s taken
Adults take a voclosporin pill twice a day.
Side effects
- High blood pressure
- Diarrhea
- Headache
- Anemia
- Cough
- Greater risk of infections including urinary tract infections
- Abdominal pain
- Heartburn
- Fatigue
- Lack of appetite
Potential drug interactions
- Antifungals such as itraconazole and ketoconazole
- Clarithromycin, an antibiotic