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Lupus

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Lupus

Systemic lupus erythematosus (SLE) is a chronic inflammatory, rheumatic, autoimmune disease. Many body systems are possibly affected, including the joints, kidneys, mucous membranes, and blood vessel walls. The majority of people, about 90%, who have SLE are young women in their late teens to early 30s. SLE is characterized by acute exacerbations and remissions.

Discoid lupus of the skin is limited to involvement of the skin. Raised round bumps and scaling occur, sometimes with scarring and hair loss. In 10% of people with discoid lupus, other symptoms (generally mild) involving the joints, kidneys, and brain may occur.

Causes of lupus
Occasionally the use of certain medications, such as hydralazine and procainamide, which are used to treat heart conditions, may cause lupus. Other drugs that may cause lupus are isoniazids and some antiepileptic drugs. This drug-induced lupus generally disappears once the drug is discontinued. It is hypothesized that exposure to ultraviolet rays, genetic defect, or hormonal imbalance also may lead to lupus development. Between 80% and 90% of all people diagnosed with lupus today will live a normal life span.

Diagnosis
A great number and variety of antibodies appear in lupus. These antibodies determine which symptoms appear, but the number of antibodies does not correlate with the severity of symptoms. The body produces autoantibodies, specifically against DNA, secondary to hyperactivity of beta cells. These autoantibodies then combine with antigens to form immune complexes, and the buildup of these immune complexes within connective tissue initiates the inflammatory response. The chronic inflammation destroys connective tissue.

Doctors usually first test for serum antinuclear antibody (ANA). However, a positive test result does not necessarily mean that the person has lupus. The next test given is for antibodies to double-stranded DNA. A positive on this test almost definitely means that a person has lupus. However, not all people who have lupus have these antibodies.

Other medical tests used to predict the activity and course of the disease are:

  • Serum complement levels—decrease is likely
  • Complete blood count (CBC)—positive for anemia, leukocytopenia, and/or thrombocytopenia
  • Urinalysis—positive for proteinuria and/or hematuria
  • Blood urea nitrogen and creatinine—elevated
  • Erythrocyte sedimentation rate (ESR)—elevated
  • Antibodies to phospholipids—positive (identifies people at risk for thrombosis)

Symptoms
Presenting symptoms include fever, malaise, fatigue, weakness, and weight loss. The first-presenting symptoms may include migraine-type headaches, epilepsy, or severe mental disorders. Some women will only feel ill during the second half of their menstrual cycle, with improvement once menstruation begins. Flare-ups decrease once a woman reaches menopause. Joint symptoms occur in 90% of patients and may exist for years before other symptoms appear. Marked joint deformity, known as Jaccoud’s arthropathy, rarely occurs; the joints usually are not damaged.

The following symptoms may appear, depending on which organ systems are involved:

  • Musculoskeletal:
    • Polyarthralgia
    • Symmetrical arthritis
  • Integumentary:
    • Alopecia
    • Butterfly rash
    • Sclerosis of skin on fingers
    • Discoid lesions
    • Malar butterfly erythema
    • Petechiae
    • Photosensitivity
  • Cardiac:
    • Pericarditis
    • Coronary artery vasculitis, leading to angina or fibrosing myocarditis and heart failure
  • Lungs:
    • Pleural effusions
    • Pleuritis
  • Kidney:
    • Glomerulonephritis
    • Renal failure
  • Central nervous system/neuropsychiatric:
    • Seizures
    • Psychosis
    • Cerebral vascular accident
    • Senile dementias
    • Headaches
    • Stroke
    • Epilepsy
    • Personality changes
  • Hematological:
    • Anemia
    • Leukopenia
    • Thrombocytopenia
  • Other:
    • Infections
    • Ulceration of the mucous membranes
    • Lymph node enlargement
    • Splenomegaly
    • Blockage of arteries in the brain or lung because of thrombosis or embolism
    • Retinitis, leading to blindness

Treatment
Prognosis improves with early diagnosis and treatment. Infections from leukemia and renal failure are major causes of mortality. Nonsteroidal anti-inflammatory drugs (NSAIDs) are used for treatment of joint pain, antimalarials are used for treatment of joint pain and skin disorders, corticosteroids are used during acute exacerbation or at low-maintenance doses during remissions, and immunosuppressive drugs are used only during acute life-threatening exacerbations. The combination of a corticosteroid and immunosuppressive medication usually is reserved for severe kidney disease, severe nervous system disease, or vasculitis.

Side effects of corticosteroids include cushingoid effects, hypertension, and weight gain. Blindness can occur with antimalarials, and frequent eye exams are recommended. Therapeutic exercise and heat application may help with joint pain from lupus.

Important facts
People with lupus should:

  • Use a high-SPF (sun protection factor) sunscreen, wear sun hats, and use a beach umbrella to protect themselves from the sun
  • Avoid the use of birth control pills, sulfonamides, and penicillin
  • Receive instruction and understand about the importance of washing hands, food sanitation, etc
  • Get and follow oral care instructions
  • Know that 50% of women with lupus have completely normal pregnancies, 25% deliver normal babies prematurely, and the remaining 25% have pregnancies that end in either miscarriage or a fetal death

Nutrition
Note: Little conclusive research exists on the link between diet and lupus symptoms, and many of the following tips are based on preliminary research.

What to avoid: An article in the October 2000 issue of the Journal of Renal Nutrition states that alfalfa seeds may worsen lupus symptoms, because they contain L-canavanine, an immune system-stimulating compound. Echinacea, mushrooms, cured meats, hot dogs, beans, and soy products also are hypothesized to worsen symptoms.

Fats: People with lupus should limit saturated fat and omega-6 polyunsaturated fatty acids. Rich sources of omega-6 fatty acids include safflower oil, sunflower oil, poppy seed oil, and corn oil.

Vitamin E, vitamin A, and selenium: Vitamin E, vitamin A, and selenium have anti-inflammatory properties and may benefit people with lupus.

Vitamin C: People with lupus should frequently choose foods that are high in vitamin C. Oranges, other citrus fruits, tomatoes, broccoli, strawberries, cantaloupe, cabbage, and green peppers are a few choices.

Vitamin B6: As part of a balanced diet, include foods that are rich in vitamin B6. Sources include whole-grain cereals and breads, fish, poultry, meat, bananas, nuts, avocados, green beans, potatoes, and green-leafy vegetables.

Iron: Iron is especially important for people with lupus. Cream of wheat, beans, blackstrap molasses, prunes, apricots, green peas, and enriched breads and cereals are vegetarian sources of iron. Other sources of iron include meat, poultry, eggs, and liver.

Fish oils: Fish oils, rich in omega-3 fatty acids, may benefit people with lupus. You can take these in a supplement form or by consuming fatty fish, such as herring, tuna, salmon, mackerel, or whitefish, several times each week.

Bromelain: Bromelain, an enzymatic complex found in pineapple, eventually may become a recommended anti-inflammatory agent for people with lupus.

Calcium and vitamin D: Calcium and vitamin D supplements are recommended for anyone using steroids, which can cause osteoporosis.

A heart-healthy diet: Following a heart-healthy diet is strongly recommended, because people with lupus face an elevated risk of developing early and aggressive heart disease.

DHEA supplements: Some evidence suggests that dehydroepiandrosterone (DHEA) supplements of 200 milligrams/day may improve symptoms in women with mild to moderate lupus. The hormone DHEA is not yet proven safe or effective for people with lupus. Studies are ongoing.

Primrose oil: Taking primrose oil may help people with autoimmune diseases, including lupus.

Fever: Patients with fever, common during a lupus flare, should make sure they get plenty of protein and calories.

Irritable bowel syndrome: Irritable bowel syndrome (IBS) is common in people with lupus. Stress, inadequate fluids, and poor eating habits can exacerbate these symptoms.

References and recommended readings

Hogan MA, Hill K. Pathophysiology: Reviews and Rationales. Upper Saddle River, NJ: Pearson Education; 2004:186-188.

Lupus Canada. Nutrition, diet and lupus. Available at: http://www.lupuscanada.org/pdfs/factsheets/Nutrition-Online.pdf. Accessed January 5, 2010.

Lupus Foundation of America, Inc. Living with lupus. Available at: http://www.lupus.org/webmodules/webarticlesnet/templates/new_aboutfaq.aspx?articleid=381&zoneid=19. Accessed January 5, 2010.

Noble L. Lupus and diet. Available at: http://www.lupusuk.org.uk/latest-news/from-the-national-magazine/53-lupus-a-diet/. Accessed January 5, 2010.

Schumacher HR. Autoimmune disorders of connective tissue. In: Beers MH, ed. Merck Manual of Medical Information. 2nd ed. Whitehouse Station, NJ: Merck Research Laboratories; 2003:378-380.

The Lupus Site. Diet and lupus. Available at: http://www.uklupus.co.uk/diet.html. Accessed January 5, 2010.

WebMD. Diet linked to lupus symptoms. Available at: http://www.webmd.com/diet/features/diet-linked-to-lupus-symptoms. Accessed January 5, 2010.

 

Review Date 2/10
G-1256

 

 

G_1256_Lupus_Professional_Refresher.doc

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