The sex or gender of most lupus patients is female. The reasons for this gender skew are not known. There are many attractive theories as to why the above is true but none seem to be satisfactory or fully explain the differences between the disease in men and women. We will attempt to look at all aspects of gender predisposition in the talk on hormones. This will begin with a brief look at prolactin, a protein from the brain that influences immunity to estrogens and androgens the usual sex steroids that have substantial effects on a variety of organs, not just the immune system. The curious aspect of this part of lupus is that new aspects of the disease can be uncovered by studying the sex steroids. Some of these will be discussed. Moreover, the current therapies like dehydroepiandrosterone (DHEA) are based on this research.

Dr Robert Labita - USA

ORAL CONTRACEPTIVES AND HORMONAL REPLACEMENT THERAPY FOR LUPUS PATIENTS

Hormones such as estrogen and prolactin may be involved in the pathogenesis of lupus. However, women with lupus may benefit from taking oral contraceptives or hormone replacement therapy. We will review the safety information during the talk.

In the old days, lupus was routinely treated with steroids - usually in big doses. Perhaps the major advance in the treatment of lupus has been the more conservative approach practised during the past three decades.

One of the main stimuli to the more discriminating use of steroids came from the description, in 1983, of the antiphospholipid syndrome (APS) (Hughes' syndrome). This syndrome, associated with a thrombotic tendency in veins, arteries, requires bloodthinning treatment such as aspirin and warfarin, rather than steroids and immunosuppressives. It is a pivotal factor in the assessment of lupus patients, as well as of patients "outside" the lupus definition.

The features include headaches, migraine, memory loss, recurrent miscarriages, DVT and other vein clotting problems, but more critically, arterial thrombosis, including strokes.

The syndrome is now recognised as an important medical condition, affecting many thousands of people with and without lupus. To give some examples, 1 in 5 of all strokes in the under 40's are due to the syndrome. One in 5 cases of recurrent pregnancy loss are due to Hughes' syndrome. One in 5 cases of DVT (including probably some cases occurring on long-haul flights) are diagnosable (and preventable). More speculatively, the differential diagnosis includes multiple sclerosis, Alzheimer's and migraine.

The most important feature of the syndrome is that it can be detected (by a simple blood test) and potentially prevented.

For more information: http://www.hughes-syndrome.org

NON-PHARMACOLOGICAL MEASURES FOR LUPUS

A variety of approaches used in the management of lupus do not require medication. These include sun avoidance, pacing to manage fatigue, exercise, applying heat to painful joints, biofeedback to treat Raynaud's, and counselling. Additionally, dietary considerations include avoiding alfalfa sprouts and perhaps eating more fish. These approaches will be discussed along with life style changes, physical therapy for "lupus fog". Sleep hygiene and recognizing fibromyalgia are also important in the optimal management of lupus.

Daniel J Wallace MD - USA

There are nearly 100 medical disorders involving autoimmunity, a phenomenon in which the body's immune system attacks its own tissues. Although we now have a great deal of information on how these diseases affect the body, their causes are mostly still unknown. The possibility of environmental factors such as infections or certain substances playing a role is quite possible and there has been considerable investigation to the present time. The association with lupus syndromes and medications has been known since 1945 and there are now over 70 drugs which have been reported to cause lupus syndromes in some patients. They can occur in men and women, young and old. Some of the major drugs include chlorpromazine, hydralazine, isoniazid, methyldopa, procainamide, quinidine and minocycline.

Interest is growing in the potential for environmental substances as possible causes of these lupus syndromes. Some of those so related include hydrazines, tatrazine, silica, heavy metals such as mercury, cadmium and gold, L-canavanine and L-tryptophan. There is much speculation but little data on triclorethylene, industrial emissions and hazardous wastes.

There are now in use guidelines for the identification and definition of environmentally-associated rheumatic disorders and these, with other interesting aspects of these disorders, will be reviewed.

RESEARCH AND FURTHER THERAPIES FOR LUPUS

The last fifteen years yielded a significant improvement in survival of SLE patients, 95% of whom survive 5 years. Yet there is a demand for more prolonged survival rates, less toxic therapies and even cures. The aim in the future will be to define subjects at risk (genes, NMC, lgA def C1q def., etc) and advice to avoid some environmental insults or even vaccinations (i.e. EBV?). Better therapy discussed will entail peptide therapy, anti-eytokines agents (i.e. anti-IL-10, anti-IL-6), chemical (i.e. ASID1), gene therapies (ie. from B.M. transplantation to anti-cytokines), the role of IVIG and duper IVIG.

Neutrolization of activating molecular in the immune system (i.e. anti-CTLA-4, anti-CD-40). Last but not least, restoration of tolerance (i.e. oral tolerance) will be discussed.

The aim of future therapy should be simple, cost-effective, low side effects and high affectivity. The idea of combining 2-3 different methods will be analyzed.

Dr Yehuda Shoenfeld - Israel