DESTIN, FLA. – Patients with lupus are at increased risk for a number of long-term health issues that should be considered during the course of their care, according to Dr. Susan Manzi.
Bone disease, cardiovascular disease, cancer, and infection are particular areas of concern, Dr. Manzi said at the Congress of Clinical Rheumatology.
• Bone health. Women with systemic lupus erythematosus are known to be at increased risk for fractures. A 1999 retrospective cohort study, for example, showed that the observed number of nontraumatic fractures in more than 700 women with SLE was about fivefold greater than in the general population (Arthritis Rheum. 1999;42:882-90).
Dr. Susan Manzi
The standardized morbidity ratios ranged from 2.4 to 12.1 for various age groups, with the greatest risks in those aged 18-24 years (12.1), 45-64 years (7.6), and 70 years and older (4.9).
"We know that we cause a lot of the bone loss; we know that the bone loss may be part of the underlying disease. The fact is it’s there. We need to monitor for it and treat it," Dr. Manzi said. She noted that American College of Rheumatology guidelines are available to help in reducing fracture risk in patients with connective tissue diseases, such as lupus (Arthritis Care Res. 2010;62:1515-26).
• Cardiovascular health. Similarly, myocardial infarctions per 1,000 person-years are significantly greater among those with SLE than in the general population, according to the 1997 Framingham Offspring Study.
In that study, Dr. Manzi and her colleagues found that the incidence of MI was higher in SLE patients in every age category. The risk was 50-fold greater in those with SLE who were aged 35-44 years, compared with the overall study population (Am. J. Epidemiol. 1997;145:408-15).
Of note, in 2011 the American Heart Association officially recognized women with lupus and rheumatoid arthritis as at-risk groups for cardiovascular disease, and developed treatment and management recommendations for these groups, said Dr. Manzi, director of the Lupus Center of Excellence at the University of Pittsburgh. The AHA noted that SLE and RA may be unrecognized risk factors and that women with these conditions, even without clinically relevant cardiovascular disease, should be considered at risk and should be screened accordingly. The AHA recommendations "actually suggested that any woman who comes in with a cardiovascular event, particularly if it’s unexplained and they are young, should be screened for lupus and rheumatoid arthritis," she said.
• Cancer. In a 2005 study of more than 13,000 women from 30 centers, patients with lupus had a 20% increased risk for cancer, compared with the general population. A recent update similarly showed a 15%-20% increased risk (J. Autoimmun. 2013;42:130-5).
The greatest risk was for hematologic cancers, such as lymphomas and leukemia. Lung cancer and thyroid cancer were also increased in the lupus patients. A trend toward an increased risk of cervical and vulvar cancers was also noted, which could be associated with human papillomavirus infection. "This means we should be doing more paps and pelvics," she said.
Interestingly, women with SLE appear to have a reduced risk of breast, ovarian, and endometrial cancers, possibly as a result of avoidance of hormone replacement therapy, she said (Arthritis Rheum. 2005;52:1481-90).
• Infection. Patients with lupus are known to have an increased risk for infection, and it is important to exercise caution when using live attenuated vaccines. These include the herpes zoster vaccine; bacillus Calmette-Guérin tuberculosis vaccine; oral typhoid vaccine; measles, mumps, and rubella vaccine; varicella vaccine; oral polio vaccine; intranasal influenza vaccine; yellow fever vaccine; and endemic typhus vaccine, Dr. Manzi said.
These vaccines are not recommended for SLE patients being treated with immunosuppressive or biologic medications or with low immunoglobulins or hypocomplementemia.
Dr. Manzi has served as a consultant and/or advisory board member for Bristol-Myers Squibb, Exagen Diagnostics, Genentech, and other companies.