The Arthritis of Systemic Lupus Erythematosus

Systemic lupus erythematosus (SLE) is a relatively uncommon ‘autoimmune’ disease. A wide variety of systemic changes can occur which is why SLE is often referred to as a protean disease. Children, adolescents, as well as adults can be affected.

For children 10 years and older, SLE has a higher incidence in females as a result of potential interactive effects of female sex hormones that can contribute to the pathogenesis of SLE. However, males can also become affected by SLE and race is a also a significant risk factor. According to Dr. David Pisetsky (Duke University School of Medicine, Durham, N.C.), peak incidence occurs between the ages of 15 and 40 years (during childbearing years) with a female to male ratio of about 5:1. Epidemiological studies showed the incidence of SLE in the 10-20 age group to vary as a function of gender and race, i.e., 0.004% for white females, 0.031% for Oriental females, 0.02% for blacks and 0.013% for hispanics. SLE shows strong familial patterns with a significant increase in frequency among first-degree relatives of SLE patients.

SLE as an ‘autoimmune’ disease is characterized by the production of autoantibodies to cell nuclear constituents which produce a variety of clinical manifestations which may include fevers, prolonged or chronic fatigue, skin rashes, and kidney involvement. While constitutional symptoms such as general malaise rank among the highest in the constellation of SLE symptoms both at the time of onset as well as anytime during the disease process, arthralgias (achy joints) and arthritis are among the 2 most common features of the SLE process. In one report from Dr. Thomas Lehman (The Hospital for Special Surgery, New York City), active effusions of the knee joint were reported to be commonly affected in active disease. In children, however, a positive test for ‘anti-nuclear antibodies’ and arthritis of the small joints may also present in Lyme disease and juvenile rheumatoid arthritis. In several compilations of data, arthritis is listed as a common symptom of SLE. According to Drs. Dafna Gladman and Murray Urowitz (Toronto, Canada) the frequency of arthritis is 63% during the course of active disease; other reports indicate arthritis as a symptom of SLE is 90% of patients. In general, arthritis is the second most frequent manifestation of SLE lagging behind only constitutional symptoms.

The arthritis of SLE “waxes and wanes” along with other manifestations of the disease. Pain, swelling and tenderness may occur insidiously, last only a few days, subside, only to return at a later time. The joints most frequently involved include, finger, wrist, elbow, knee and ankle. Several joints may be involved simultaneously. Interestingly, back pain and neck pain do not often occur as it has been shown that the spine is not frequently involved in SLE.

While pain and stiffness are common ailments of the arthritis of SLE, this occurs most frequently in the morning upon wakening; improvement usually occurs as the day wears on. Fatigue, a common constitutional symptom of SLE usually results in a return of the pain and stiffness later in the day. Joint pain frequently occurs on both sides of the body.

Joint remodeling, cartilage erosions and sclerosis of bone, common to other arthritic conditions such as osteoarthritis and rheumatoid arthritis do not occur in SLE. The reason for this is at present unclear, but may be related to the differences in the amount and types of soluble mediators of inflammation (i.e., cytokines and prostaglandins) which result in cartilage and bone destruction in osteoarthritis and rheumatoid arthritis. Evidence for the lack of joint changes can be seen by X-ray even in the swollen and painful joint of SLE patients. Synovial fluid analysis may be a useful surrogate measure to classify the inflammatory process in patients where arthritis is the sole symptom of SLE. To confirm the diagnosis of SLE in these cases, the peripheral blood must be obtained and assays for anti-nuclear antibodies and rheumatoid factor antibodies performed.

Treatment of the arthritis of SLE continues to include non-steroidal anti-inflammatory drugs (NSAIDs) and/or corticosteroids. In this sense, the anti-inflammatory properties of NSAIDs are employed to regulate the migration of cells into the joint whose soluble products contribute to the perpetuation of the pain and swelling and reduction in joint motion. The new class of COX-2 inhibitors as well as other remittive agents commonly employed in arthritis therapy may be particularly efficacious in the treatment of the arthritis of SLE. In a summary of potential therapies for the arthritis of SLE published under the auspices of the Lupus Foundation of America authored by Dr. Mary Betty Stevens (The Johns Hopkins University School of Medicine, Baltimore, MD), immunosuppresive and cytotoxic prescription drugs were rarely recommended for the treatment of the arthritis of SLE.

In keeping with the general thinking in the treatment of arthritis, it is highly recommended that after the pain and swelling are treated medically and the tenderness subsides, that a common-sense approach to exercise and fitness be established to bolster cartilage and joint health. The exercise program should focus on maintaining good muscle tone in and around the large joints such as the knee. Exercises designed to maintain the function of small joints, while more problematic, also exist. These exercise programs should be initiated and maintained as long as the patient is able to participate with appropriate consultation of the patient’s physician.

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