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. 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

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