ABSTRACT: Increased disease recognition and therapeutic advances have led to improved survival in patients with systemic lupus erythematosus (SLE) over the past several decades. As a result, management of the long-term comorbidities and complications of SLE has taken on greater importance. Maintaining a high index of suspicion for cardiovascular disease in SLE and screening for traditional risk factors is prudent. Minimizing the use of immunosuppressive agents remains the main strategy for decreasing infections, but providing routine vaccinations also can decrease the burden of infections. Despite the high prevalence of osteoporosis, screening and treatment remain suboptimal in patients with SLE and deserve increased attention. Patients with SLE are at increased risk for malignancy and physicians should remain vigilant for cancer in these patients. (J Musculoskel Med. 2008;25:316-320)
Systemic lupus erythematosus (SLE) is a complex autoimmune disease characterized by frequent disease exacerbations and an unpredictable clinical course. Over the past several decades, increased recognition and awareness of SLE and therapeutic advances—resulting in earlier diagnosis and more aggressive treatment—have dramatically improved survival. Now that many patients with SLE are living longer, however, management of long-term comorbidities and complications has taken on greater importance.
Four areas of SLE comorbidity have gained increased attention: cardiovascular disease (CVD), infection, bone loss, and malignancy (Table). Each complication is increased in SLE and may cause significant morbidity or mortality.
Improving outcomes in these areas will require a stronger emphasis on coordinated interdisciplinary care in SLE. Both the SLE specialist, often a rheumatologist or nephrologist, and the generalist physician need to remain attentive to long-term complications and formalize efforts to coordinate care. Such care coordination probably will require innovations that vary with the practice setting. Electronic medical records, patient reminders, and direct communication via telephone, e-mail, or correspondence among providers provide ways to ensure that the care will occur in a timely fashion.
In this article, I describe the comorbidities and complications of SLE. I also discuss ways to ensure that these conditions are managed in a timely fashion.
COMORBIDITIES AND COMPLICATIONS
Cardiovascular disease: Suspicion and screening
The association between CVD and SLE first became evident almost 4 decades ago, when researchers described a bimodal pattern of mortality in SLE: early mortality resulting from disease-related complications and late mortality resulting from CVD.1 Women with SLE aged 35 to 44 years were 50 times more likely to have a myocardial infarction (MI) than women of similar age in the Framingham Offspring Study,2 a longitudinal cohort study, and women aged 45 to 64 years were about 2 to 4 times more likely to have an MI.3 The risk of other CV events also appears to be elevated in SLE. One study found not only a 10-fold increase in the risk of nonfatal MI in SLE but also striking differences in the risk of death resulting from CVD (relative risk [RR], 17) and stroke (RR, 7.9).4
Several studies have cited an increased prevalence of traditional CV risk factors in SLE compared with controls. Of note, these risk factors do not fully explain the morbidity and mortality of atherosclerosis in this population.4 Research indicates that a number of novel risk factors also may contribute to CVD in SLE.5
The optimal strategy for decreasing CV risk in SLE is still unclear, and research in this area is ongoing. Until such information is available, maintaining a high index of suspicion for CVD and screening for and addressing traditional CV risk factors is prudent.