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Diagnosis 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.

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Diagnosis and Treatment of Aches and Pain in SLE

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  1. 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

  2. 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)

  3. 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

  4. 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 ARTHRITIS

  5. 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

  6. 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

  7. 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

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