Immunosuppressants

Lupus is a complex autoimmune disease, so its treatment can vary widely. Doctors may prescribe different medicines for lupus. What your doctor prescribes will depend on your symptoms, how severe your lupus is, and your response to previous treatment. One treatment option for moderate to severe lupus is immunosuppressant drugs. These drugs can help slow the body’s overactive immune response.^1,2

How do immunosuppressants work?

In people with lupus, the immune system mistakenly attacks healthy tissue. The result can be wide-ranging symptoms such as fatigue, skin rash, and joint pain. In more severe cases, lupus can damage 1 or more organs. This damage can lead to serious complications like kidney failure.^2,3

Immunosuppressants, in general, suppress the immune system to prevent it from attacking healthy cells. Different drugs do this in different ways. For example, some immunosuppressant drugs prevent immune cells from dividing. When these cells cannot divide, they cannot attack healthy tissue.²

By blocking certain immune processes, immunosuppressants can slow down the organ damage caused by lupus.²

Examples

There are many immunosuppressants that help control the symptoms and progression of lupus. But the US Food and Drug Administration (FDA) has not approved some of these drugs to treat lupus specifically. So, they are prescribed “off-label,” meaning for a different condition than they are approved for.⁴

Different immunosuppressants may be appropriate for different symptoms or symptom severity. Some may be used in combination with each other or other drugs to treat lupus. Examples of immunosuppressants commonly used to treat lupus include:^2,4-7

• Azathioprine (Imuran®, Azasan®) – This drug helps reduce inflammation. It can be especially helpful for joint, liver, and kidney symptoms caused by lupus.
• Methotrexate (Rasuvo®) or Leflunomide (Arava®) – These disease-modifying antirheumatic drugs (sometimes called DMARDS) also reduce inflammation in the body. They can help manage autoimmune conditions that involve joint pain, such as rheumatoid arthritis and lupus.
• Mycophenolate mofetil (Cellcept®) or mycophenolic acid (Myfortic®) – Doctors often prescribe these drugs to stop the immune system from attacking the kidneys.
• Cyclosporine (Neoral®, Sandimmune®, Gengraf®) – Cyclosporine can help control organ inflammation and damage, especially in the kidneys. But because of its side effects, doctors typically prescribe it only when other treatments have not worked.
• Cyclophosphamide – This drug is approved to treat certain cancers. Doctors may prescribe it for lupus when there is severe organ damage or during a life-threatening flare.
• Voclosporin (Lupkynis®) – Voclosporin is approved by the FDA to treat lupus nephritis in adults. Nephritis is inflammation in the kidneys, which can lead to a number of serious health problems.
• Tacrolimus (Prograf®) – Doctors may also prescribe this drug to treat lupus nephritis.

Certain immunosuppressants are considered “steroid-sparing.” This means that taking them reduces the need to take steroids for lupus symptom control. Examples of these drugs:¹

• Azathioprine
• Methotrexate
• Mycophenolate mofetil

What are the possible side effects?

Side effects can vary depending on the specific drug you are taking. Common side effects of immunosuppressants for lupus include:^2,7-13

• Stomach pain or discomfort, nausea, vomiting, or diarrhea
• Infections
• High blood pressure
• Headache
• Hair loss
• Fever
• Sleepiness or dizziness

These are not all the possible side effects of immunosuppressant drugs. Talk to your doctor about what to expect when taking immunosuppressants. You also should call your doctor if you have any changes that concern you when taking an immunosuppressant.

Other things to know

Before prescribing an immunosuppressant, your doctor will weigh its benefits against its risks. For example, because they suppress your immune system, these drugs make it harder for your body to fight off infections. You will need to avoid people who are sick and other sources of germs. Your doctor will monitor you closely for signs of infection.²

Many immunosuppressant drugs are not safe for pregnant people to take. These drugs can cause harm to the fetus. If you are pregnant or planning to become pregnant, tell your doctor. Also tell them if you plan to breastfeed (or chestfeed) the baby.^2,3

Several immunosuppressant drugs prescribed for lupus can damage your liver or lower certain blood counts. Your doctor will monitor you for signs of liver damage as well as low red, white, or platelet blood cell counts.³

Taking immunosuppressant drugs over a long period may increase your risk for certain cancers. Lupus itself also increases your risk for developing cancer. Your doctor can help you understand these risks and whether a drug may be worth taking.^2,7

Immunosuppressants should not be taken with certain other drugs. Before beginning treatment for lupus, tell your doctor about all your health conditions and any other drugs, vitamins, or supplements you take. This includes over-the-counter drugs.²

Additional therapy

Experts recommend that all people who have lupus take hydroxychloroquine (Plaquenil®). This is an antimalarial drug. Your doctor will likely prescribe this drug first, possibly along with fast-acting steroid drugs. Steroids help to control symptoms while the hydroxychloroquine takes effect.¹

However, steroids can cause serious side effects over time. So, your doctor may prescribe an immunosuppressant to control symptoms or to slow organ damage in the longer term. If your lupus is mild and has not caused organ damage, you may not need to take an immunosuppressant drug.¹