Although lupus manifests in different ways in different people, the information that is provided can help with diet and lifestyle considerations common to most lupus patients. Light exercise is the most important part of condition your body to last a long time without having a flare.
Things to Avoid If you have lupus or a condition that predisposes you to lupus, such as undifferentiated connective tissue disease (UCTD), there are certain foods and medications that you should avoid.
People with lupus should avoid the sun, since sunlight can cause rashes and flares. Some people are more sensitive to sunlight than others, but all people with lupus are advised to be cautious when they are outside. Of course, it would be impractical to completely avoid going outdoors, but try to be prepared. Carry a sunscreen with an SPF of at least 70 and be sure that your sunscreen contains Helioplex, an ingredient that blocks UV-A and UV-B rays, both of which are harmful to people with lupus. Apply sunscreen to all areas of the body, even those covered by your clothes, since most normal clothing items only protect your skin to the level of SPF 5. In addition, carry a hat with you when you know you will be outside. Certain sportswear manufacturers now make hats with SPF built into the material, which may be helpful for people with greater photosensitivity.
Bactrim and Septra (sulfamethoxazole and trimethoprim)
Bactrim and Septra are antibiotics that contain sulfamethoxazole and trimethoprim. They are grouped as “sulfa” antibiotics because they contain a substance called sulfonamide. Bactrim and Septra are often prescribed for bacterial infections, especially urinary tract infections. They are also sometimes given prophylactically (i.e., to prevent infection), especially in people taking immunosuppressive medications. However, it is very important that you avoid Bactrim and Septra, because these antibiotics are known to cause an increase in sun sensitivity and lower blood counts in people with lupus, resulting in lupus flares. Several medications can be used instead of Bactrim or Septra for the prevention and treatment of infection; perhaps the most frequently used substitute is Dapsone (diaminodiphenyl sulfone) to prevent Pneumocystis pneumonia.
Scientists believe that three substance in garlic: llicin, ajoene, and thiosulfates, rev-up your immune system by enhancing the activity of white blood cells, particularly macrophages and lymphocytes. Scientists also believe that the sulfur components of garlic help to prevent and suppress cancer in the body. For this reason, garlic is often used as a supplement to combat colds and infections. Unfortunately, the enhancement of immune response is counterproductive in people with autoimmune disease such as lupus, because their immune system is already overactive. As a result, people with lupus and lupus-like signs should avoid cooking with garlic and adding it to food. Of course, a tiny amount of the herb will not harm you but try to consciously avoid purchasing and preparing foods with garlic.
Alfalfa sprouts contain an amino acid called L-canavanine that can increase inflammation in people with lupus by stimulating the immune system. As a result, people with lupus and similar autoimmune conditions should avoid alfalfa sprouts completely.
Melatonin and Rozerem (ramelteon)
Melatonin is a hormone secreted by the pineal gland in your brain that regulates other hormones in the body that control how your body reacts to daily patterns of light and dark. Melatonin release is suppressed during the light hours of the day and stimulated by dark, helping you stick to patterns of nighttime sleep and daytime wakefulness. As a result, melatonin is often used as a sleep aid over other medications. Melatonin and melatonin-containing supplements should be avoided in people with lupus and other autoimmune disorders because they may stimulate the immune system. In addition, people with these conditions should also avoid the prescription sleep aid Rozerem (ramelteon), because it mimics melatonin in the body. It is important that you understand the necessity of avoiding both melatonin and Rozerem, since sleep aids are often used to help people with fibromyalgia and other conditions to attain normal sleep patterns. In general, be sure that you speak with a Naturopathy or a physician before taking any new medications or supplements.
Echinacea is often used as a dietary supplement to boost the immune system against colds and other illnesses. However, because Echinacea boosts your immune system, it may cause flares in people with autoimmune diseases such as lupus. In fact, Echinacea supplements sold in Europe bear warning labels that advise against use by people with autoimmune diseases. As a result, people with lupus and other autoimmune diseases should avoid these supplements. In general, it is important that you speak with your physician before taking any new medications or supplements.
Systemic lupus erythematosus (“lupus” or “SLE”) and other autoimmune diseases are linked to an increased risk of certain types of cancer. Specifically, lupus patients may experience an elevated risk of lymphoma and other cancers, such as cancer of the cervix. Lupus and lymphoma.
Studies show an increased risk of both Hodgkin’s and non-Hodgkin lymphoma in lupus patients. It is believed that the elevated risk of lymphoma results from the disease process of lupus—specifically the overstimulation of B-cells coupled with defects in the immune system’s surveillance system and not just from medications or other associated risk factors. Some suggest that immunosuppressive medications also increase the risk of lymphoma and other blood cancers, especially five or more years after taking the drug. In addition, people with Sjogren’s syndrome, which is relatively common in lupus, experience an even greater elevation of lymphoma risk, suggesting that lymphoma in lupus patients may also be linked to this condition.
Lupus and breast cancer
Some data indicate that women with lupus experience an increased risk of breast cancer. Increased estrogen levels might contribute to a higher risk of breast cancer in women with lupus.
Lupus and lung cancer
Lung cancer is about 1.4 times more common in people with lupus than in the general population. Interestingly, people with lupus and lung cancer are more likely to experience rare types of lung cancer. However, like the general population, many of the people with lupus who develop lung cancer are smokers. In fact, 85% of lung cancer is caused by tobacco. It is very important that people with lupus do not smoke. Smoking not only increases the chance of developing lung cancer, it also ups the risk for cardiovascular disease (which is also markedly increased in people with lupus) and prevents lupus drugs like Plaquenil from working properly. If you need help quitting, talk to a Naturopathy or your doctor. They can help you find the most effective strategy to curb your smoking habit.
Lupus and cervical cancer
Certain studies have shown an elevated risk of cervical cancer and abnormal PAP tests in women with lupus. One study linked the increased incidence of abnormal PAP tests with histories of sexually transmitted disease, contraceptive use, and immunosuppressive medications. Some physicians suggest that either the use of immunosuppressive or flawed inherent immunity lead to a decrease in the ability of lupus patients to fight off human papilloma virus (HPV), a virus associated with cervical cancer. Gardasil (the HPV vaccine) is recommended for young women with lupus to reduce the risk of later cervical cancer.] However, like much of our knowledge of cancer in lupus, these connections are not fully known or understood.
Lupus and endometrial cancer
New evidence suggests that lupus patients also experience an elevated incidence of endometrial cancer, although the cause for this risk is unknown.
NSAIDs and cancer
It has been found that people with Rheumatoid Arthritis, another autoimmune disease, experience a lower incidence of colorectal cancer than the general population. Although the precise cause of this phenomenon is unknown, it has been attributed to the long-term (10 years or more) use of non-steroidal anti-inflammatory drugs (NSAIDS) and aspirin. Evidence has also been found that long-term aspirin and NSAID use may also reduce the risk of colorectal, breast, and prostate cancer in the general population. It is likely that this benefit also holds for people with lupus, but that does not mean that one should begin taking aspirin and NSAIDs for this reason. In fact, long term NSAID use can increase cardiovascular disease. Therefore, you should only take medications as directed by a Naturopathy or your physician.
The importance of regular cancer screenings
Despite the increased risk of cancer in people with lupus, studies show that lupus patients are actually equally or even less likely than the general population to undergo cancer screenings. Thus, it is very important that you speak with a Naturopathy or a doctor about lupus and cancer to ensure that you see the appropriate physicians for cancer screenings as often as recommended.
Certain risk factors, such as smoking, obesity, hormone replacement therapy, and exposure to immunosuppressive medications, increase the chance that an individual will develop cancer. Therefore, it is also important that you practice healthy lifestyle habits. Obesity also increases the risk of certain cancers, so try to eat foods that help you maintain a healthy weight.
Sunlight causes lupus flares and also increases the risk of skin cancer. People with lupus should avoid the sun whenever possible.
No overarching diet exists for people with lupus. An overall healthy dietary choices and foods that may be helpful and harmful to people with certain conditions that commonly occur with lupus would be helpful. No overarching diet exists for people with lupus. However, lupus is a systemic disease, so maintaining good nutritional habits will help your body remain as healthy as possible. Generally, Naturopathy and or doctors recommend a diet composed of about 50% carbohydrates, 15% protein, and 30% fat. However, since people with lupus often experience symptoms like weight loss or gain, inflammation, osteoporosis, kidney disease, high blood pressure, and atherosclerosis, certain specific nutritional concerns may also need to be taken into consideration. If you need help managing your weight or making healthy food choices, please speak with a Naturopathy or a doctor.
Foods to avoid
Certain foods, including garlic and alfalfa sprouts, should be avoided by people with lupus. Recently controversy has also arisen over whether aspartame induces lupus. However, scientists have concluded that there is no evidence to suggest that aspartame causes lupus.
Weight changes, high blood pressure, and kidney disease
Often, people with lupus experience weight loss or gain due to loss of appetite, unhealthy dietary habits, or decreased energy and mobility. If you experience weight loss or loss of appetite, talk to a Naturopathy or a doctor. Weight gain can be caused by many factors, including reduced activity levels and overeating due to steroid use or increased stress. However, remember that women with lupus between the ages of 35 and 44 experience a risk of heart attack that is 50x that of the normal population. Therefore, it is very important that you try to stick to a diet that is low in cholesterol and saturated fats. A low-sodium diet is also essential for people suffering from high blood pressure (above 120/80 mmHg for people with lupus) and kidney disease.
Steroid medications such as prednisone can also cause significant weight gain and redistribution of fat stores in the body. While taking steroids, your cholesterol, triglyceride, and blood sugar (glucose) levels may increase. For these reasons, it is absolutely essential that you follow a low-fat, low-cholesterol diet. You do not need to cut out all of the foods you love but concentrate on eating whole grain breads and cereals and lean sources of protein such as chicken and fish. When you need a snack, look to raw vegetables they are low in sugar and calories and provide the perfect food for “grazing.” Try to eat them without Ranch dressing or vegetable dip, because these items carry lots of fat and calories. If you need something to accompany your vegetables, try lighter dips like hummus. It is also important that you minimize alcohol intake because combining alcohol with corticosteroids, Tylenol, warfarin, and other lupus medications could be very harmful to your liver and stomach. For those taking methotrexate, alcohol is never allowed.
A diet high in omega-3 fatty acids may help to mitigate inflammation. Although omega-3s have not been adequately studied in lupus, studies of the general population suggest that these essential fatty acids may also boost mood and improve cardiovascular health. Fish, nuts, and flax are excellent sources of omega-3s and can be easily incorporated into everyday meals. Try to avoid saturated fats, such as those in beef and fried snack foods, since these fats are known to increase the risk of cardiovascular disease and may actually stimulate the immune system.
An article written by Dr. Petri on lupus and pregnancy, including the risks of miscarriage and preterm birth, maternal risks, management, and monitoring. Because lupus is a disease that strikes predominantly young women in the reproductive years, pregnancy is both a practical and a research issue. For most women with lupus, a successful pregnancy is possible. This is an immense change from the 1970’s, when most women with lupus were counseled not to become pregnant. Studies of the immune system in pregnancy are of interest for what they have taught us about the effect of hormones on lupus flares.
Risk of Miscarriage
First, the risks of pregnancy in lupus patients are real and involve both the mother and the fetus. About ten percent of pregnancies currently end in miscarriage. The first trimester losses appear either to have no known cause or to associate with signs of active lupus. Later losses occur primarily due to the antiphospholipid antibody syndrome in spite of treatment with heparin and aspirin. All women with lupus, even if they do not have a previous history of miscarriage, should be screened for antiphospholipid antibodies, both the lupus anticoagulant (the RVVT and sensitive PTT are the best screening battery) and anticardiolipin antibody.
The classification criteria for the antiphospholipid antibody syndrome were revised last year. There are now two major criteria–vascular thrombosis and pregnancy morbidity. A woman who has had a past venous or arterial thrombosis should be therapeutically anticoagulated during the next pregnancy. A woman who has pregnancy morbidity one or more late losses, three or more first trimester losses, or severe pre-eclampsia or placental insufficiency should be treated with prophylactic doses of heparin and a baby aspirin during the next pregnancy. Several clinical trials have indicated that the combination of heparin and aspirin is likely preferable to aspirin alone, although some women do have successful pregnancies on aspirin alone. These pregnancies should be considered high risk, with appropriate fetal monitoring, including ultrasounds to monitor growth and placental development, and biophysical profiles, usually from the 26th week onwards. Many of these babies can be rescued by early C-section when there are signs of severe placental insufficiency. There is no consensus on whether treatment is indicated for the woman with lupus who has antiphospholipid antibodies in her first pregnancy. Many authorities in the field would use a baby aspirin in this situation.
Risk of Preterm Birth and Intrauterine Growth Retardation
An equal, if not more important risk is the risk of preterm birth. Preterm birth in lupus is usually not due to antiphospholipid antibodies, but due to pre-eclampsia and premature rupture of membranes. Risk factors for preterm birth in general include active lupus, high dose prednisone, and renal disease. Maternal hypertension in the second trimester is a good predictor. Overzealous treatment of maternal blood pressure could reduce placental blood flow and is not recommended. We have not found any risk factors that predict premature rupture of membranes. In addition to being preterm, the baby is also at risk for intrauterine growth retardation (IUGR). We have not found a clinical variable that is predictive of IUGR. In fact, lupus activity, prednisone, and antiphospholipid antibodies are not predictive of IUGR. The best predictor using ultrasound monitoring is an abdominal circumference below the 10th percentile and an estimated fetal weight below the 50th percentile.
The most important maternal risk, that of a lupus flare, is actually the most controversial. In prospective studies at both Hopkins and in London, the risk of flare is greater in a pregnant than a non-pregnant woman. However, other centers have not confirmed this. There may be differences in patient selection that account for the different findings. We have found that the hormone prolactin, which rises during pregnancy, is associated with lupus activity during pregnancy. Likely other hormonal influences, especially estrogen, changes in cytokines are involved as well, although these have not been studied. We have found that the type of organ system involvement is different in pregnant vs. non-pregnant patients. In pregnancy we have found an excess of renal and hematologic flares and fewer arthritis flares.
Some of the risk to the mother is not directly due to lupus. In a case-control study we found that women with lupus were more likely to have multiple complications of pregnancy, including diabetes, urinary tract infections, and pre-eclampsia. For this reason, referral to a high-risk obstetrician is always appropriate. Women on prednisone were more likely to have hypertension and diabetes, as would be expected. The physician caring for a woman with lupus who wishes to become pregnant must review her medications. Prednisone is largely metabolized by the placenta and is unlikely to cause any fetal malformations but will increase the risk of diabetes and hypertension in the mother. Some immunosuppressive, such as Imuran (azathioprine) have been continued during lupus pregnancy when necessary to control maternal lupus. Cyclophosphamide should never be used during pregnancy because of the high risk of important birth defects. Because of potential teratogenicity, Coumadin should be switched to heparin as soon as the woman knows she is pregnant.
ACE-inhibitors, because of effects on fetal kidney development, should be stopped as soon as the woman knows she is pregnant. NSAIDs are usually allowed during the first trimester only, because of potential adverse effects on the fetal ductus arteriosus. Plaquenil (hydroxychloroquine) has a good safety record in lupus pregnancy and is usually continued if needed to control maternal lupus.
Management and Monitoring
Lupus pregnancy should be timed to coincide with a period of good disease control if at all possible. It does not make sense to taper medication simply because a woman desires pregnancy, because of the likelihood of inducing a flare if medications are reduced too low. General screening tests should include the antiphospholipid antibodies, and also anti-Ro and anti-La. A woman who is positive for these antibodies is at increased risk of congenital heart block in the baby, and monitoring of the fetal cardiac conduction system by four-chamber fetal cardiac echo should be instituted. We generally monitor the mother monthly during pregnancy and obviously more often if disease activity warrants it. Laboratory monitoring done monthly includes the complete blood count, creatinine, liver function tests, urinalysis and a 24-hour urine for creatinine clearance and total protein. It is controversial whether serologic tests are helpful during pregnancy. In normal pregnancy the C3 and C4 should rise.
Petri M. Systemic lupus erythematosus and pregnancy. Rheum Dis Clin North America20:87117, 1994.