Systemic Lupus Erythematosus (SLE) and implications for your training

Background of lupus

Systemic lupus erythematosus (SLE), otherwise known as lupus, is a chronic autoimmune disease characterized by periods of relapse and remission.  The disease affects the body by producing antibodies that target one’s own joints, kidneys, white blood cells, platelets, mucus membranes, lungs, skin…..the list could go on.

Lupus tends to affect women ten times more than men, especially in the 20-40 age range.  Amongst women, it affects black women about 8 times more than white women.  There are some genetic implications behind SLE as incidence has been increased in twins and in families with a history of SLE.

As a result arthritis occurs in 90% of patients at some time during the illness, kidney problems affect around 50% of patients, along with facial “butterfly rashes,” oral ulcerations,  and cold intolerance of the hands/feet.  Regarding the cardiovascular system, SLE can decrease one’s lung function making them susceptible to lung illnesses and can increase one’s chances of coronary artery disease (CAD).  Combined, this can not only lead to the patient becoming fatigued much easier, but also reducing their quality of life.  Not to mention many patients have some form of mild anemia only making their fatigue levels worse.

Photo credit: www.Mollysfund.org
Photo credit: www.Mollysfund.org

Management of lupus

Since the disease is an autoimmune disease there is no cure however the goal of treatment is to improve quality of life, manage symptoms and prevent further damage to the patient.

Drug therapy.  For the purposes of staying within the scope of merely educating the reader I decided to focus on therapy for patients with mild lupus.  These patients will most likely be prescribed hydroxychloroquinolone, an antimalarial agent, an NSAID of some type, and prednisone.

Hydroxychloroquinolone is often given twice a day at 400mg with the length of prescription varying on the severity of the lupus relapse.  As a patient taking this drug you need to alert your health care provider if you notice any changes in your vision, hearing, or if you start to have muscle weakness.

Prednisone is a glucocorticoid that suppresses inflammation within the body.  Side effects are noticed more in patients who take glucocorticoids for prolonged periods, especially at higher doses.  The principle side effects of prednisone are weight gain, thinning of the skin, decreased calcium absorption, increased risk of developing a stomach ulcer, risk for infection and high blood sugar.

Prednisone’s mechanism of action clearly explains why these side effects can occur:  in the stomach, prednisone blocks a chemical responsible for synthesizing the mucus layer that protects the stomach from it’s own acids; combine it with NSAIDs, which do the same action and it puts the person at a higher risk of developing a stomach ulcer.  Systemically, prednisone blocks the actions of white blood cells and other chemicals which protect us for infection and inflammation.  By blocking one’s own defenses, it makes the patient more susceptible to infection.  By blocking the absorption of calcium in the stomach the person is more likely to have weaker bones.

Dietary implications.  Although there really isn’t a consensus on a lupus diet, per se, guidelines do exist to prevent relapses and help with managing symptoms and side effects of the medications.

Many of the dietary suggestions are derived from the understanding of the side effects of the medications.  Since we know that steroids can reduce calcium intake (thus increasing one’s risk of weakened bones) it would be advisable to increase one’s calcium intake.  When increasing calcium intake you must also consume vitamin D as well (they aid in the absorption of one another).  Let’s not forget that patients with lupus should avoid UV light and sunlight — therefore, they are most likely vitamin D deficient anyway.

Steroids also increase blood glucose, blood lipids (fats in the blood), cholesterol and water retention.  All of these combined can contribute to heart disease and diabetes.  It would be wise to reduce one’s intake of sugar, sodium, and saturated fats in an effort to offset these side effects of steroids.

Supplementation implications.  At this time the literature regarding supplementation is rather limited.  However, it has been noted that a patient with SLE should avoid alfalfa.  Alfalfa has been considered to be a cause of lupus flare ups.

Some literature suggests taking supplemental iron, folic acid and vitamin C to prevent anemia (and aid with fatigue levels).  Also, supplemental vitamin D and calcium could help with bone health.  Omega-3 fatty acids, vitamins C and E have demonstrated antioxidant/anti-inflammatory properties which may prevent relapses and help with symptom management.  Typically, a multivitamin will cover all of these bases in a single pill.

A study by Minami et al. (2011) found that patients who increased vitamin B6 and dietary fiber decreased their incidence of active disease.

Exercise implications.  START SLOW!!!   There’s no better advice that I can give.  Lupus comes and goes in flare ups however relapses can be triggered by illness and stress, thus the last thing you want to do is trigger a relapse whilst trying to get healthier.

As stated earlier the steroid medications have a tendency to retain water, increase blood sugar and increase appetite.  All of these combined can lead to major weight gain, therefore exercising is a critical piece of managing SLE.

When exercising it is advisable to take breaks during your sessions.  There’s nothing wrong with going for a few minutes followed by resting for a few minutes.  In fact, this will be a safer measure on your joints and will prevent you from fatiguing too quickly.  Ask yourself this, “am I making progress if I take two steps forward, then one step back?”  Yes, you are!  Any progress is good progress.

Performing resistance training is crucial to ensuring bone health.  In order to stimulate bone growth you must impose a resistance upon them.  But just like cardiovascular training, start with a lower resistance, preferably a weight that you can move 10-12ish times with good control.

If exercising outdoors it is best to do it either early in the morning or in the evening as to avoid excessive sunlight.  Sunlight (and UV lamps) can trigger a lupus bout.  If you do decide to exercise during the day, then it is recommended that you wear SPF 50 or stronger.  Also, make sure the sunscreen blocks UV-A and UV-B.

 Putting it all together

  • Focus on reducing sodium, sugar and saturated fats from your diet
  • Increase calcium and vitamin D to offset loses from steroids and lack of sunlight, respectively
  • Exercise in the morning or evening; wear sunscreen SPF 50 or higher if going outside
  • Take frequent rests during exercise — do a few minutes on, then a few minutes off
  • Make sure to perform resistance training 2-3X/week to offset bone losses from steroids
  • Although research is limited, increasing vitamins B6, B12, C, and D and increasing folate and fiber may prevent relapses

References

Schur, P. and Wallace, D. (2014).  Overview and the management of systemic lupus erythematosus in adults.  M. Ramirez. (Ed.), UpToDate.  Retrieved from www.UpToDate.com.

Should I be following a specific diet or nutrition plan for my lupus? (n.d.). Retrieved November 13, 2014, from http://www.lupus.org/answers/entry/lupus-diet-and-nutrition

Minami, Y. et al. (2011).  Intakes of vitamin B6 and dietary fiber and clinical course of systemic lupus erythematosus:  A prospective study of Japanese female patients.  Journal of Epidemiology.  21(4):  pp. 246-254.  Retrieved from PubMed on November 13, 2014.

Lehne, R. (2011). Pharmacology for nursing care (7th ed.). St. Louis, MO: Saunders Elsevier.

Goroll, A. and Mulley, A. (2009).  Primary care medicine:  Office evaluation and management of the adult patient (6th ed.). Philadelphia, PA:  Wolters Kluwer

McCance, K. and Huether, S. (2014).  Pathophysiology:  The biological basis for disease in adults and children (7th ed.). St. Louis, MO:  Saunders Elsevier.

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