Transcript Diagnoses and Treatment of Aches and Pain in SLE

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
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)
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
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
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
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
FIBROMYALGIA
Chronic widespread non-joint focused pain
associated with fatigue and tender points
Primary
Secondary to SLE and other autoimmune and nonautoimmune 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