Elsevier

Joint Bone Spine

Volume 79, Issue 4, July 2012, Pages 347-350
Joint Bone Spine

Review
How to treat refractory arthritis in lupus?

https://doi.org/10.1016/j.jbspin.2011.12.010Get rights and content

Abstract

Arthritis in systemic lupus erythematosus (SLE) is episodic and self-limited in most patients. However, in some cases, refractory joint problems occur and may be poorly controlled by NSAIDs and other treatments. Damage to joints and to other organs must be considered when making any decision to prescribe such other treatments. In the context of new and potent biodrugs, we have reviewed and analysed here all Medline published data on arthritis treatment in SLE, as well as the French recommendations (Protocol national de diagnostic et de soins [PNDS] and Club Rhumatismes et Inflammation [CRI]). In SLE patients with isolated, intermittent joint symptoms, short courses of NSAIDs should be used as the first-line treatment. If joint symptoms are more severe or recurrent, a combination of low-dose corticosteroids (≤ 10 mg/day) and antimalarial drugs is recommended. Corticosteroid infiltrations may be useful on occasions, in cases of persistent localised arthritis. If joint symptoms persist, treatment indications depend on the other organs affected. In joint forms that are refractory to treatment or corticodependent and requiring an unacceptable dose of prednisone in a patient with confirmed compliance with treatment, methotrexate should be proposed initially, in combination with antimalarial drugs. In cases of treatment failure or intolerance, mycophenolate mofetil or even azathioprine may be considered as an alternative treatment. As a last resort, after having weighed up the individual benefit-risk ratio, leflunomide, belimumab, rituximab or abatacept may be considered, on a case-by-case basis, and anti-TNF antibodies may be considered in exceptional cases.

Section snippets

Antimalarial drugs

Two synthetic antimalarial drugs have been authorised for use in the treatment of SLE: hydroxychloroquine and chloroquine. The most frequently used doses are 400 mg/day for hydroxychloroquine (≤ 6.5 mg/kg/day, to limit the risks of ocular toxicity) and 4 mg/kg/day for chloroquine. Recent data have implicated toll-like receptors in SLE and may represent further indirect evidence for a role of antimalarial drugs in the treatment of this auto-immune disease [6]. In a double-blind, prospective,

Corticosteroids

Low-dose corticosteroids are widely used in the treatment of SLE and its joint signs. The beneficial effects of such treatment were suggested, in particular, by a double-blind, prospective, randomised study comparing corticosteroids with placebo for the prevention of clinical relapses in 41 patients suffering from SLE with an isolated increase in markers of biological activity [10]. In the placebo group, there were six severe flare-ups, including three with joint symptoms, whereas no flare-ups

Methotrexate

Methotrexate is the molecule most studied for the treatment of joint symptoms associated with lupus. A double-blind, randomised study compared methotrexate (15–20 mg/week) with placebo over a period of 6 months, in 41 SLE patients; more than 80% of the patients presented arthralgia or arthritis, the frequencies of these conditions being similar in the two groups [11]. At the end of the study, 16 patients in the placebo group and one of the 18 patients in the group treated with methotrexate still

Other immunosuppressants

According to the PNDS guidelines published in 2009, the efficacy of other immunosuppressants (azathioprine, off-label mycophenolic acid, cyclophosphamide) against joint symptoms remains unproven [3].

Rituximab

Two large, double-blind, randomised studies have reported no significant benefits of rituximab in the treatment of extrarenal [22] or renal [23] signs of SLE. These results contrast with the results obtained in many open studies. However, neither of these two studies specifically reported findings for joint symptoms. The French AIR Registry has analysed the data of 136 patients with lupus who had been treated with rituximab [24]. Joint symptoms were present and evaluable in 50 of these patients

Disclosure of interest

The authors declare that they have no conflicts of interest concerning this article.

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