The annual American College of Rheumatology conference was held last week in San Francisco. I had the chance to interview Dr. Daniel Wallace, a world expert in lupus (systemic lupus erythematosis) management, to tell me about the latest advances in the treatment of this disease.
Dr. Wallace is currently a Clinical Professor of Medicine at the David Geffen School of Medicine at UCLA. His clinical practice is based at Cedars-Sinai, where he is involved in the care of 2,000 lupus patients, the largest practice of its kind in the United States. The Wallace Rheumatic Disease Research Center currently runs over 30 clinical trials for patients with lupus and other rheumatic diseases. Dr. Wallace is the author of 6 medical textbooks, 15 book chapters, and over 200 medical publications.
Dr. Val: What is Lupus?
Dr. Wallace: Lupus is what happens when the body becomes allergic to itself. It’s the opposite of cancer and AIDS. There are probably about 1 million people living with lupus in the United States. Ninety percent of them are women, and 90% develop lupus during their reproductive years.
Dr. Val: Historically speaking, what has treatment been like for patients with lupus, and how has that changed over the years?
Dr. Wallace: Lupus is divided into two types: organ threatening and non-organ threatening disease. In non-organ threatening lupus, the heart, lung, kidney, and liver are not affected. Patients may be tired and achy and have swollen joints and rashes, but their organs are spared. These patients are managed with sun-avoidance, relaxation techniques, cortisone creams for their rashes, and ibuprofen or other non-steroidal anti-inflammatory agents for pain.
For people with more active disease, we use a group of drugs called “anti-malarials” which have anti-inflammatory properties. Sometimes corticosteroids are required to manage the inflammation as well. A small percentage of patients with organ-sparing lupus also need immune suppressive agents.
Organ-threatening lupus is very serious. They are always treated with moderate to high doses of corticosteroids and immune suppressants.
There is a new class of agents to treat lupus – called biologics – and they specifically target the immune cells that are attacking the body. Some of them are antibodies, some are fusion proteins, and others are “tolerogens” (which are designed to make the body more tolerant to itself).
Dr. Val: How does a patient with lupus get access to these biologic therapies?
Dr. Wallace: There are two kinds of targeted therapies – 1) those that are already on the market but have not been approved by the FDA for the treatment of lupus (for example the anti-tumor necrosis factor drugs that have only been approved for Rheumatoid Arthritis), and 2) drugs that are being studied in clinical trials but are not yet on the market. Keep in mind that there hasn’t been a new drug approved for lupus treatment in over 50 years.
Dr. Val: Wow, so what advances have there been in lupus management over the last half century?
Dr. Wallace: The advances we’ve seen have been in managing the comorbidities (symptoms and side effects) of lupus, not the disease itself. For example, chronic steroid use can cause weakness of the bones – and we can treat this osteoporosis with bisphosphonates and calcium. Lupus patients also commonly suffer from high blood pressure and atherosclerosis, both of which we can treat with medications, healthy diet, and regular exercise. It’s not uncommon for lupus patients to contract rare infections and fungal diseases due to being immunocompromised. Thankfully we have good antibiotics, imaging studies, and surveillance systems to help to combat these infections early on.
Dr. Val: What are the most exciting research projects in progress now?
Dr. Wallace: There are a whole host of biologic agents that are being studied in lupus that will have a major impact in our ability to treat the underlying cause of the disease in the future. Half of lupus patients with organ-threatening disease currently die by the time they’ve had the disease for 20 years. That’s simply not acceptable.
The current research projects can be organized into 4 categories: 1) agents that block T-cells such as abatacept, though they’ve had disappointing results 2) agents that block B-cells, such as rituximab and epratuzumab (epratuzumab seems really promising) 3) agents that block cytokines like interleukins, or are antibodies to interferons, 4) or agents that promote immune tolerance.
The data presented this week showed that epratuzumab improves quality of life, decreases the need for steroids, and decreases the number of significant disease flares. However, at this point epratuzumab is only available to patients through a clinical trial. Patients can find a trial through the clinicaltrials.gov website, or they can contact the manufacturer directly at the UCB website.
Dr. Val: How can patients with lupus find out about all their treatment options?
Dr. Wallace: There are many support organizations in the United States. The SLE Foundation, the Arthritis Foundation, the Lupus Foundation of America, the National Institutes of Health, the Alliance For Lupus Research all have websites and publish helpful literature that can be downloaded from their websites.
Dr. Val: What advice do you have for patients living with lupus now?
Dr. Wallace: Don’t give up. There are a lot of new and exciting treatments being studied. Beyond the new medications, we also have improved imaging techniques that dramatically improve our ability to diagnose and treat the disease.
Dr. Val: What’s the most important thing for Americans in general to know about lupus?
Dr. Wallace: Lupus is the linchpin or ultimate paradigm of autoimmune disease. If we can determine the cause of lupus, and define a cure for it, the discovery will impact how we understand other autoimmune and infectious disease, allergies, and cancer. All of these disorders involve manipulating the immune system. If we can find a cure for lupus, we could also find a cure for cancer. Lupus research is extremely important.