The Lupus Book: A Guide for Patients and Their Families, Third Edition by Daniel J. Wallace

patients, which may lead to severe flareups.
    Hormones
    Birth control pills in young women and estrogen replacement therapies after
    menopause as well as other hormonal preparations are frequently prescribed to
    lupus patients. Their use has been controversial, and this complex topic is covered in Chapter 17.
    Drugs That May Cause Lupus or Produce Flareups
    [51]
    DRUG-INDUCED LUPUS ERYTHEMATOSUS (DILE)
    Approximately 15,000 to 20,000 new cases of prescription drug-induced lupus
    are reported annually in the United States. First identified shortly after the introduction of hydralazine (Apresoline) for hypertension in 1951, DILE is usually a benign, self-limited process. Although more than seventy agents have been
    implicated as inciters of drug-induced autoimmunity, most cases are associated
    with three products whose use has been decreasing: hydralazine, procainamide
    (Pronestyl), and methyldopa (Aldomet). If isoniazid (INH), chlorpromazine
    (thorazine), TNF blockers, and D-penicillamine are added to the list, 99 percent of all clinically relevant cases can be accounted for. A more complete list of
    these drugs is given in Table 9.1.
    Epidemiology of Drug-Induced Lupus
    Three principal features distinguish DILE from SLE. First, unlike SLE, DILE
    affects the same number of men as it does women. Second, DILE is very rare
    among African Americans in the United States. Also, the average age of onset
    for DILE is 60, as opposed to the 20-to-40 age group typical for SLE.
    Table 9.1. Drugs Implicated in Provoking Lupus Erythematosus
    1. Drugs proven to induce clinical lupus in at least 1 out of 1000 users
    Hydralazine (Apresoline)
    Methyldopa (Aldomet)
    Procainamide (Pronestyl)
    D-penicillamine
    TNF Blockers (Remicade, Humira,
    Enbrel)
    2. Drugs proven to induce clinical lupus in at least 1 out of 10,000 users
    Isoniazid (INH)
    Phenothiazines (including Thorazine)
    Sulfasalazine (Azulfidine)
    Quinidine
    Carbamazepine (Tegretol)
    Griseofulvin (Fulvicin)
    3. Drugs rarely associated with positive ANAs and very rare clinical lupus
    Anticonvulsants (phenytoin, trimethadione, primidone, ethosuximide)
    Lithium carbonate
    Captopril (Capoten)
    Antithyroid preparation (propylthiouracil, methimazole)
    Beta-blockers (practolol, acebutolol, atenolol, labetalol, pindolol, timolol eyedrops) Lipid-lowering medicines (Mevacor, Pravachol, Lopid)
    Prazosin (Minipress)
    4. Drugs that can exacerbate lupus or increase the risk of allergic reactions but do not cause lupus Antibiotics (sulfa, tetracycline—rarely, penicillins or ciprofloxacins)
    Nonsteroidal anti-inflammatory agents (e.g., ibuprofen)
    Oral contraceptives and other hormones
    Sulfa diuretics and diabetic drugs (Dyazide, Aldactone)
    Cimetidine (Tagamet), alpha-interferon, and gold salts
    5. Case reports have appeared implicating nearly fifty other drugs
    [52]
    What Causes Lupus?
    A Note of Caution
    If you are a lupus patient, how do you know if you have DILE? If you are
    prescribed a medication by your doctor, and after several weeks to months, start noticing a rash, fevers, pain on taking a deep breath, or swollen joints, consult your doctor immediately. Most DILE patients do not fulfill the criteria for systemic lupus. All seventy or so drugs implicated in DILE induce the formation
    of antinuclear antibody to varying degrees, but the process is self-limited. In other words, once the drug is stopped, the formation of antinuclear antibody
    stops as well.
    Only a small percentage of these ANA-positive individuals ever develop clin-
    ical lupus. A positive ANA does not constitute grounds to discontinue treatment with a useful drug . Since DILE is completely reversible, the risks of not taking lifesaving heart or seizure medications, for example, are much more ominous.
    Moreover, there is no evidence that a lupus-causing drug administered to a
    patient who already has the disease will make the condition worse.
    How Do Drugs Cause Lupus?
    An exciting research challenge is presented by DILE, since