Diagnosis and Treatment of Aches and Pain in SLE

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Diagnosis and Treatment of Aches and Pain in SLE

• H. Michael Belmont, M.D.
• Director Lupus Clinic
• Bellevue Hospital
• Chief Medical Officer
• Hospital for Joint Diseases
• Associate Professor of Medicine
• New York University School of Medicine

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Differential Diagnosis of Aches and Pain in SLE

• Arthralgia
• Myalgia
• Arthritis - Non-erosive Jaccouds
• Arthritis - Erosive Rhupus
• Myositis
• Osteonecrosis or Avascular Necrosis of Bone (hip,
  knee, shoulder, ankle)
• Fibromyalgia
• Osteoporosis with fracture (vertebral, hip,
  shoulder, wrist)
• Non-SLE (tendonitis, bursitis, gout,
  osteoarthritis)

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Arthralgia and Myalgia

• 90 of patients with SLE will experience episodes
  of joint aches and muscle pains
• Arthralgia joint pain and possible tenderness
  without other signs of inflammation (redness,
  swelling, and warmth)
• Myalgia muscle soreness and ache without
  weakness or elevation of muscle enzymes
• Fever (viral, bacterial or atypical infection)
• Mild SLE flare
• Antipyretic Aspirin, Acetaminophen, OTC NSAID
  such as ibuprofen, naproxyn and ketoprofen
• Treat underlying cause (antibiotic,
  hydroxychloroquine/plaquenil, SLE disease
  modifying medication)
• Rarely steroids and then not in excess of 10
  milligrams a day

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ARTHRITIS

• Jaccouds Deforming
• X-rays No erosions
• Hydroxychloroquine (Plaquenil)
• NSAIDs and Cox-2
• Methotrexate
• Azathioprine (Imuran)
• Leflunomide (Arava)

• Rhupus Deforming
• X-rays Erosions
• Hydroxychloroquine
• NSAIDs and Cox-2
• Methotrexate
• Azathioprine
• Leflunomide

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MYOSITIS

• Muscle inflammation with proximal muscle weakness
• Elevated muscle enzymes (CPK, aldolase, LDH,
  SGOT, SGPT)
• Abnormal EMG and muscle biopsy
• Steroids
• Azathioprine
• Methotrexate
• Leflunomide
• Mycophenolate mofetil
• IVGG intravenous gammaglobulin

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OSTEONECROSIS or AVASCULAR NECROSIS of BONE

• Condition affecting 5-40 of SLE patients
  associated with prolonged (more than 2 weeks)
  high dose (greater than 30 milligrams a day)
  prednisone treatment
• AVN most commonly hip, knee, shoulder and ankle
• Often bilateral (both sides) in lupus
• Loss of circulation to bone leads to bone injury,
  death of bone with subsequent painful collapse
  and arthritis
• Treatment pain relievers, rest, very early
  sometimes surgical decompression or late total
  joint replacement surgery
• Prevention Always use steroid (prednisone) at
  lowest effective dose for shortest interval to
  treat flare of lupus and consider use of STATIN
  drugs (such as lipitor) to prevent expansion of
  fat cells within bone that contribute to this
  problem

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FIBROMYALGIA

• Chronic widespread non-joint focused pain
  associated with fatigue and tender points
• Primary
• Secondary to SLE and other autoimmune and
  non-autoimmune chronic disorders
• No deformities, No erosions, No muscle
  deterioration
• Exercise, Exercise, Exercise (increase natural
  pain relieving endorphins)
• Pain relievers (Acetaminophen, OTC NSAIDs,
  prescription NSAIDs and Cox-2, tramodol,
  cyclobenzaprine-Flexeril)
• TCA TriCylic Antidepressants
• SSRI Selective Serotonin Reuptake Inhibitors
• Cognitive therapy