Lupus Site - a guide for lupus patients and their families

Joint and muscle pain is one of the commonest symptoms experienced by people with lupus and most people will suffer from some such problems during their illness. This fact sheet wlll discuss some of the problems encountered and their treatment.

What happens to the joints in lupus?

In lupus the joints can become inflamed causing pain and swelling. The joints most frequently involved in this inflammation or arthritis are the hand joints, the wrists and the knees, although any joint can be involved. The arthritis frequently comes and goes and affects different joints at different times. The ligaments and tendons around the joints can also become inflamed and tender. If the inflammation is not brought under control with medication and continues for a long period of time, the tendons and ligaments can weaken. Once this happens the tendons and ligaments can no longer support the joint properly The affected joint becomes lax, or unstable, and can appear to be deformed. The hand joints are the most frequently affected by such deformities. The underlying bones themselves are not affected by the arthritis in lupus, and at least initially the deformities can be painlessly corrected by pushing the joint back into position.

What treatment is available for the joints in lupus?

Sometimes painkillers, such as paracetamol or coproxamol, are all that are needed to control the joint pain. If this is not enough then the addition of an anti-inflammatory such as ibuprofen or diclofenac can improve the pain and swelling. If there are just one or two troublesome joints an injection of steroid into the particular joints may be recommended; this is often an effective way getting the maximum benefit of the steroids without much risk of side effects. If there are more joints affected than could easily be injected then steroids may given into the muscle (intramuscular) or directly into the vein (intravenous). Intramuscular and intravenous steroids can result in a rapid and dramatic reduction in pain and inflammation of the joints. However the effect is often short lived and the treatment usually needs to be supplemented by some oral medication.

The commonest oral medication to be recommended are the antimalarials, hydroxychloroquine and chloroquine. Both of these are effective in reducing joint pain and inflammation over a long period of time, but they can take up to 3 months to become effective Steroids by mouth are also effective in controlling joint pain but because of their long-term side effects they are usually held in reserve. Sometimes joint pain and inflammation can be particularly troublesome and stronger drugs such as azathioprine, methotrexate and cyclosporin are needed to control the arthritis.

What about surgery?

Surgery can be helpful for some people. Hand surgeons can correct some of the hand deformities with operations on the tendons, ligaments and joints. Orthopaedic surgeons can replace some of the larger joints, for example knees and hips, if they are particularly badly damaged. Surgery is a big undertaking in people with lupus and the disease needs to be well controlled to make the procedure as safe as possible and to increase the likelihood of a good result from the operation.

How does lupus affect the muscles?

Lupus can affect the muscles in a number of ways. The commonest cause of muscle pain is related to arthritis in nearby joints and in this case treating the joints also helps the muscle pain. An infrequent but serious cause of muscle pain in lupus is direct inflammation of the muscles or myositis. Weakness is often more of a problem than pain in myositis, and this can be a serious problem when the muscles that control breathing and swallowing are affected. Myositis is diagnosed by a number of tests including blood tests, electrical testing of the muscles and a muscle biopsy where a small sample of muscle is taken usually from the thigh. A less serious but more common muscle problem is a condition called fibromyalgia. Fibromyalgia can occur in people both with and without lupus. It causes persistent pain in most muscles but tends to be centered around the shoulders and hips. It causes sleep disturbance and tender spots in the muscles can develop. The causes of fibromyalgia are unknown, but thankfully it does not go on to cause muscle or joint destruction although it can cause considerable discomfort.

How can myositis be treated?

Myositis although a serious problem usually responds well to treatment with steroids; depending on how ill the person is these may need to be given intravenously. Other drugs are frequently added to the steroids to improve or maintain the condition including azathioprine and cyclosporin. In life threatening cases cyclophosphamide and gamma-globulin (an intravenous treatment consisting of human antibodies) can be used.

How can fibromyalgia be treated?

Fibromyalgia, although not as serious as myositis, can be a difficult problem to treat. It is known that the less mobile a person becomes with fibromyalgia, then the more painful the joints become. Therefore the first line of attack is to get the people doing some exercise either on their own or under the supervision of a physiotherapist. Although this often causes more pain to start with if the person persists the pain diminishes and sleep improves. If these simple measures are not enough drug therapy can be helpful. The drugs most commonly used are the antidepressants. In low doses these drugs do not act as an anti-depressant but have beneficial effects on sleep patterns and can help reduce pain. The most frequently used drug is amitriptyline although there are many different ones available.

Are there any other joint or muscle problems in lupus?

Long-term treatment with drugs can cause problems to the joints and muscles. The most well known problems are with the steroids. Steroids over a long period of time can cause thinning of the bones, osteoporosis, and increase the risk of fractures. Steroids can also have effects on the muscles causing weakness and a similar condition to myositis. Steroids have also been linked to a condition called avascular necrosis of bone. In this condition the blood supply to certain areas of bone (usually the hips and shoulders), is reduced, causing the bone to die and the joint to crumble. The only treatment available for avascular necrosis is joint replacement. Doctors are more aware of the problems of steroids than in previous years and try to keep the dose of steroids low enough to keep the lupus under control but reduce the occurrence of side effects. Some of the other drugs used in lupus can have effects on the joints and muscles including methotrexate and cyclosporin but these effects tend to be rare.