Trends in the Outpatient Medication Management of Lupus Erythematosus in the United States

May 2014 | Volume 13 | Issue 5 | Original Article | 545 | Copyright © 2014

Daniel Y. Sugai MD,a Cheryl J. Gustafson MD,a Jacqueline F. De Luca MD,a Scott A. Davis MA,aJoseph L. Jorizzo MD,a Kenneth S. O'Rourke MD,b and Steven R. Feldman MD PhDa,c,d

aCenter for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, NC bCenter for Dermatology Research, Department of Internal Medicine (section on Rheumatology and Immunology), Wake Forest School of Medicine, Winston-Salem, NC cDepartment of Pathology Wake Forest School of Medicine, Winston-Salem, NC dPublic Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC

Abstract

BACKGROUND: Systemic lupus erythematosus (SLE) and chronic cutaneous lupus (CCLE) therapy has changed little over the past 50 years. In March 2011, the US Food and Drug Administration (FDA) approved belimumab, complementing the three preexisting approved therapies: low dose aspirin, prednisone, and hydroxychloroquine.
OBJECTIVE: The objectives for this study were to evaluate trends in the medications prescribed for the management of lupus erythematosus (LE) and to assess how treatment varies among different specialists.
METHODS: Outpatient visits for treatment of lupus and its comorbidities were identified in the National Ambulatory Medical Care Survey (NAMCS), a representative survey of visits to physician offices in the United States. Data was evaluated to determine patient demographics, treatments prescribed by each specialty, and comorbidities encountered during the study period of 1993-2010.
RESULTS: From 1993-2004, prednisone was the most frequently prescribed medication; however, prednisone became the second most frequently prescribed medication in 2005-2010, as hydroxychloroquine became the leading medication prescribed for LE. In primary care physicians and other non-dermatology specialists, the most frequently prescribed medications for lupus were prednisone and hydroxychloroquine; whereas, hydroxychloroquine and triamcinolone were the top two medications preferred by dermatologists.
LIMITATIONS: The NAMCS collects cross-sectional data, such that individual patients cannot be followed over time. Hence, it does not provide data regarding the incidence of disease, patient age at the time of diagnosis, change in individual patient’s medication regimens over time, or prognosis related to patient demographics. In addition, it is possible that the physician did not always record nonprescription medication use, such as NSAIDS, since these are typically used first line.
CONCLUSION: First-line treatment of LE changed minimally from 1993 to 2010, with prednisone and hydroxychloroquine serving as the primary medications utilized by most physicians for the management of LE.

J Drugs Dermatol. 2014;13(5):545-552.

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INTRODUCTION

Systemic lupus erythematosus (SLE) is the second most common autoimmune disorder amongst women of childbearing age after thyroid disease. SLE is challenging to manage as it affects the body systemically, including cardiovascular, pulmonary, renal, cutaneous, musculoskeletal and neuropsychiatric systems. SLE was initially regarded as an inevitably fatal disease before advancements in the treatment options for SLE, such as high dose corticosteroids. Improvements in diagnostic tests also contributed to the significant decrease in SLE mortality rates, for more sensitive and specific laboratory tests enabled the disease to be detected at an earlier, milder stage, thereby allowing treatment to be initiated sooner. In the beginning of the 20th century, characteristic cutaneous findings were the sole diagnostic signs for LE. Thus, many of the initial case series regarding SLE were written by dermatologists.1 During the early 1900s, multiple treatment options, such as gold compounds and irradiation, were used to manage SLE.1,2

Since the emergence of high dose corticosteroids in the 1950s, SLE mortality rates have improved immensely. Although 5-year survival rates increased from less than 50% in the 1950s to more than 95% in present day, the mortality rate is estimated to be three- to four-fold higher compared to the general population.1,3 During the past five decades, researchers have sought to develop new medications for the treatment of SLE with the hope of further reducing mortality and morbidity rates.3,4 Prior to 2011, the US Food and Drug Administration (FDA) had only approved three medications for the treatment of SLE: 1) prednisone, 2) hydroxychloroquine, and 3) low-dose aspirin, the most recent of which was approved in 1955.5 An improved understanding of the pathogenesis of SLE has permitted more specific treatment to be developed, and in March 2011, the FDA approved belimumab.6

The primary focus of this study was to investigate medication treatment trends for SLE, prior to the advent of belimumab. In

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