Drug-induced lupus

Drug-induced lupus (DIL) is an acquired autoimmune condition in which exposure to certain medications leads to lupus-like manifestations. Since the first reports of a lupus-like rash with sulfadiazine exposure in the 1940s, more than 100 drugs have been implicated, including: (1)

• hydralazine
• procainamide
• phenytoin
• isoniazid
• oral contraceptives
• penicillamine

Among the best-established agents are procainamide and hydralazine, both of which carry the highest documented risks of inducing DIL. Historical estimates suggest that up to 20% of patients on long-term procainamide and 5% to 10% of those on hydralazine may develop lupus-like symptoms. (2)

Patients with DIL typically present with arthralgia, myalgia, fever, and serositis, whereas severe organ involvement is less common than in idiopathic systemic lupus erythematosus (SLE). Symptoms usually resolve with withdrawal of the offending agent, although corticosteroids or antimalarials may be required in persistent cases. (1)

More recent pharmacovigilance studies confirm that biologic therapies, particularly tumour necrosis factor-α inhibitors, account for a large proportion of reported cases. (3)

In addition, immune checkpoint inhibitors have been associated with both cutaneous and systemic manifestations. (4)

DIL is estimated to account for up to 10% of new lupus cases annually (5) with affected patients having a median age of 49 years, a female-to-male ratio of approximately 4:1, and a median latency of roughly 6 months from drug initiation to symptom onset. (6)

DIL generally carries an excellent prognosis with most patients experiencing improvement within weeks of discontinuing the offending drug.

Reference

1. He Y, Sawalha AH. Drug-induced lupus erythematosus: an update on drugs and mechanisms. Curr Opin Rheumatol. 2018 Sep;30(5):490-497.
2. Jerome R, Randhawa JS, Badran S, Li S, Mohammadi N. Drug-Induced Systemic Lupus Erythematosus: A Rare Presentation of Hydralazine-Induced Lupus. Cureus. 2024 Oct;16(10):e72069.
3. He M, Yang J, Yan S, Shu Q, Liu PC. Conducting a real-world study of Tumor Necrosis factor-alpha inhibitors-induced Systemic Lupus Erythematosus based on the FAERS database. Sci Rep. 2025 Feb 26;15(1):6838.
4. Vitzthum von Eckstaedt H, Singh A, Reid P, Trotter K. Immune Checkpoint Inhibitors and Lupus Erythematosus. Pharmaceuticals (Basel). 2024 Feb 15;17(2)
5. Kirakossian D, Ghosh P. Drug-Induced Lupus, a One-time Hit or a Harbinger of Future Autoimmunity: A Case Report. Perm J. 2020;24
6. Arnaud L et al. Drug-induced systemic lupus: revisiting the ever-changing spectrum of the disease using the WHO pharmacovigilance database. Ann Rheum Dis. 2019 Apr;78(4):504-508