Lupus and overlapping medical conditions Dr Natasha Jordan Addenbrooke’s Hospital

Autoimmune diseases overlapping with lupus Raynaud’s phenomenon Fibromyalgia

Autoimmune diseases overlapping with lupus Raynaud’s phenomenon Fibromyalgia

Research has shown that patients with autoimmune diseases such as rheumatoid arthritis, multiple sclerosis, Sjögren’s syndrome, and SLE have an increased risk of developing another autoimmune disease, but why this happens is still not fully understood. 25% of patients with an autoimmune disease develop a second disorder. Juvenile onset more likely to have fhx than adult onset, 17% have first degree, 30% have first or second degree 33% of parents & 39% of sisters have positive ANA King et al Arthritis Rheum 1977 Onset <5 years extraordinarily rare

SLE APS Hypothyroidism Rhupus ITP Sjögren’s

Underactive thyroid gland >20% of lupus patients SLE APS Hypothyroidism Rhupus ITP Sjögren’s Underactive thyroid gland >20% of lupus patients

Lupus & rheumatoid antibodies SLE APS Hypothyroidism Rhupus ITP Sjögren’s 5% of lupus patient Lupus & rheumatoid antibodies Erosions on x-ray

20% of ITP patients develop lupus SLE APS Hypothyroidism Rhupus ITP Sjögren’s Low platelet count 20% of ITP patients develop lupus

Sicca symptoms are common in lupus Lupus/Sjögren’s overlap SLE APS Hypothyroidism Rhupus ITP Sjögren’s Sicca symptoms are common in lupus Secondary Sjögren’s Lupus/Sjögren’s overlap

SLE APS Hypothyroidism Rhupus ITP Sjogren’s

Antiphospholipid syndrome (APS) Also known as ‘sticky blood syndrome’ or Hughes syndrome, can cause blood clotting in your arteries or veins. APS is a major cause of recurrent miscarriage. APS affects all age groups but is most common between the ages of 20 and 50. APS was first diagnosed in people who had lupus but it was later discovered that APS can occur on its own (primary APS).

How is APS diagnosed? APS can only be diagnosed if: you have a positive blood test and you've suffered either thrombosis or recurrent miscarriages. What tests are there? There are three main blood tests used to diagnose APS: • anti-cardiolipin antibodies • lupus anticoagulant • anti-beta-2-glycoprotein-1 antibodies

Antiphospholipid antibodies (aPL) The tests are usually repeated after 12 weeks as levels of aPL vary and can sometimes go up when you have an infection. If you only have one positive test and it quickly becomes negative again then you probably don’t have APS. Higher levels of antibodies suggest you may be at greater risk of blood clots and other symptoms. Being positive in more than one of the three tests also suggests a higher risk. 

I repeatedly test positive for aPL I repeatedly test positive for aPL. Does this mean I'll definitely get APS? No, it doesn't mean that you’ll definitely develop APS. Many people who have lupus are tested for these antibodies and about 20–30% will be positive for aPL. People who carry the antibodies but who’ve never had either clots or miscarriages aren't said to have APS but to be aPL-positive.

Autoimmune diseases overlapping with lupus Raynaud’s phenomenon Fibromyalgia

What is Raynaud’s? Raynaud’s phenomenon can cause discomfort as the blood supply to your fingers or toes reduces if you’re cold or feeling stressed. May not experience all three stages. Colour changes are often accompanied by pain or a tingling feeling. For example, your hands may simply go blue then red. www.arthritisresearchuk.org

What is Raynaud’s? Raynaud’s phenomenon can occur: on its own (primary) with another condition such as scleroderma or, less commonly, lupus (secondary) Most people with primary Raynaud's won't go on to develop any further problems.

Raynaud’s attacks often only last a few minutes. Moving into a warmer environment often stops the attack. Attacks can be a nuisance and can cause you a lot of discomfort. Secondary Raynaud’s phenomenon especially in scleroderma can be more severe and may cause: open sores (digital ulcers) on the fingers loss of circulation and tissue at the fingertips.

Conservative Management of Raynaud’s Keeping warm Wearing warm gloves when outdoors in cold weather and warm your hands before you put the gloves on. Electrically heated gloves/portable hand warmers may be helpful. Try to keep your whole body warm. Make sure you wear warm socks and a hat. Layers of clothing work better at trapping the heat than thicker clothes. Looking after your hands Dry hands and water can lead to the development of cracks or fissures on your hands. Short-acting water-based cream, such as E45 or aqueous cream, or an oil-based cream that is thicker and longer lasting, such as emulsifying ointment. www.arthritisresearchuk.org

Conservative Management of Raynaud’s Stop smoking Keep an attack diary There may be a pattern to your Raynaud’s attacks, and that will help you in reducing the risk of an attack. Exercise Regular exercise will improve your circulation and, if you’re outside on a cold day, keeping active will improve the blood flow to your hands and feet and help you to stay warm. www.arthritisresearchuk.org

Medical Management of Raynaud’s There are a number of different drugs that are prescribed for Raynaud’s phenomenon. Most of these work by making your blood vessels wider (vasodilation). Side-effects such as flushing of the face, headaches or dizziness. Drugs used to treat high blood pressure, such as losartan and ACE inhibitors, can also help. Fluoxetine (which is sometimes prescribed for depression) is another drug that can help improve circulation.

Medical Management of Raynaud’s Phosphodiesterase inhibitors such as sildenafil (trade name Viagra).  In severe cases – almost always in cases of secondary Raynaud’s – some treatments may be given as an intravenous drip, most commonly used is iloprost.

Autoimmune diseases overlapping with lupus Raynaud’s phenomenon Fibromyalgia

Muscle & joint pain in lupus Is one of the most common symptoms of lupus and most people will experience such problems during there disease course. Very common in the general population. Not all joint and muscle problems experienced by people with lupus are directly related to their lupus.

Arthralgia & arthritis related to lupus Lupus myositis Osteoarthritis Fibromyalgia Osteoporosis Carpal tunnel syndrome

Fibromyalgia Fibromyalgia can occur in people with and without lupus. Widespread pain in the muscles, tendons and ligaments. 1 person in every 25 may be affected. More common in women than men. Is not inflammatory or degenerative. Will not cause permanent damage to muscles, bones or joints.

Fibromyalgia Widespread pain Sleep disturbance Fatigue

Other features of fibromyalgia Tingling, numbness in hands and feet Headaches Poor memory/concentration ‘fibrofog’ An urgent need to urinate especially at night Irritable or uncomfortable bowels (diarrhoea or constipation and abdominal pain)

Treatment of fibromyalgia Patient education Aerobic exercise Graded exercise program/hydrotherapy (physiotherapy) Pacing & strategizing (occupational therapy) Pain Clinic assessment there’s no convincing evidence that they’re effective in most people with fibromyalgia, especially as many different areas of your body can be affected at the same time.

Treatment of fibromyalgia Low-dose amitriptyline Can reduce muscle pain and improve sleep pattern Pregabalin and gabapentin 6 weeks before expected response Antidepressants such as fluoxetine, paroxetine, duloxetine Can help with pain, sleep disturbance and low mood

Autoimmune diseases overlapping with lupus Raynaud’s phenomenon Fibromyalgia

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