Joint and muscle pain is one of the most common
symptoms of lupus and most people will
experience some such problems during their
illness. This fact sheet will 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 (do
not exceed the maximum safe dose – see packet
for details) or others as prescribed by your GP, are
all that are needed to control the joint pain. If this
is not enough then the addition of an antiinflammatory
drug prescribed by your GP can
improve the pain and swelling. If there are just one
or two troublesome joints an injection of steroids
into the particular joints may be recommended;
this is often an effective way of 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 be 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
medications to be recommended are
antimalarials, usually hydroxychloroquine. They
are effective in reducing joint pain and
inflammation over a long period of time, but can
take up to 3 months to become effective.
Steroids by mouth are also effective in controlling
joint pain and are commonly used. Sometimes
joint pain and inflammation can be particularly
troublesome and stronger drugs such as
azathioprine, methotrexate and cyclosporin may
be prescribed 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 if 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 centred 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 prescribed and used together with
steroids to improve or maintain the condition
including azathioprine and cyclosporin. In life
threatening cases cyclophosphamide and gammaglobulin
(an intravenous treatment consisting of
human antibodies) may be prescribed.
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 person 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 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 steroids. Taking steroids
over a long period of time can cause thinning of the
bones, osteoporosis, and increase the risk of
fractures. Steroids can also affect 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 the past and try to keep
the dose of steroids low enough to keep the lupus
under control and reduce the occurrence of side
effects. Some of the other drugs prescribed in lupus
can affect joints and muscles, these include
methotrexate and cyclosporin but these effects tend
to be rare.