ABSTRACT: About half of patients with systemic lupus erythematosus experience musculoskeletal involvement: arthritis, arthralgia, myalgias, myositis, tenosynovitis, fibromyalgia, or osteonecrosis. Patients with arthritis often have symmetrical large- and small-joint polyarthritis unassociated with radiographic evidence of erosive or deforming disease. Treatment generally focuses on anti-inflammatory agents, such as NSAIDs and corticosteroids. Antimalarials are commonly used. When NSAIDs prove ineffective, limited use of corticosteroids may help, but patients need to be informed of the adverse effects. Antimalarial agents usually are recommended for all persons with lupus arthritis. Shared decision making can allay concerns about drug toxicity and adverse effects and encourage compliance with treatment. (J Musculoskel Med. 2008;25:458-463)
Systemic lupus erythematosus (SLE) is widely regarded among rheumatologists as the prototypical autoimmune disorder. An estimated 250,000 persons in the United States—mostly women of childbearing age—are affected with lupus.1 Treatment is directed at mitigating damage with immunosuppressive agents, which dampen the formation of autoantibodies and immune complexes, and controlling symptoms related to the immune-mediated effects of the disease on specific organs.
Shared decision making, which refers to the collaborative effort between the patient and physician, helps determine a course of management when no best treatment option is available. This process may be especially challenging in the setting of a disease like lupus, because there are few "hard" data from the published literature to guide physicians as they formulate the patient's treatment plan. In shared decision making, the principal dynamic shifts from a physician-focused approach to diagnosis and treatment to a patient- and physician-focused approach. Presenting the patient with choices may give him or her a greater sense of control when confronting a somewhat uncommon chronic illness that has no known identifiable cause and no well-documented, widely prescribed course of treatment.
In this article, I review treatments often used to manage problems of the musculoskeletal system, which affect between 50% and 90% of patients with SLE.2 Although arthritis, arthralgia, myalgias, myositis, tenosynovitis, osteonecrosis, fibromyalgia syndrome (FMS), and osteoporosis all are musculoskeletal problems affecting patients with lupus, only arthritis—defined as non-erosive tenderness, swelling, or effusion in 2 or more peripheral joints—is included in the classification criteria for lupus (Table 1).3 At various points throughout the text, I offer insights into how you might incorporate shared decision making into the overall management protocol.
ARTHRITIS AND ARTHRALGIA
Identifying the specific cause of musculoskeletal pain in a patient with known or suspected SLE can be challenging. A leading question to answer, because it affects the approach to treatment, is whether the cause of pain is noninflammatory or inflammatory (Table 2). Findings associated with ongoing disease and inflammation include such objective signs as synovitis, joint swelling, and muscle inflammation with possible weakness, as well as certain laboratory abnormalities, chiefly, elevated values for erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) level, and double-stranded DNA (dsDNA) level.
Patients with lupus often may have symmetrical large- and small-joint polyarthritis. Although they typically present with joint pain, they may have little demonstrable synovitis and do not have radiographic evidence of erosive or deforming disease.4 Jaccoud arthropathy, which is a deforming arthropathy associated with reducible deformities, can also be seen. Complaints of pain and the presence of synovitis signify ongoing disease activity. This sometimes is associated with serological markers of disease activity: worsening leukopenia, normochromic anemia, hypocomplementemia, and an increasing level of anti-dsDNA antibodies. The patient also may have extra articular manifestations of lupus—rash, myalgia, oral ulcers, and clinically significant renal disease.
Additional causes of arthritis to consider in the differential diagnosis include other rheumatologic diseases that affect large and small joints, such as rheumatoid arthritis (RA) and Sjögren's syndrome, and bacterial/viral arthritides, including infectious mononucleosis, parvovirus B-19, acute hepatitis B infection, and rheumatic fever. Hepatitis C is also associated with arthralgias.