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

2. Autoimmune diseases overlapping with lupus
Raynaud’s phenomenon
Fibromyalgia

3. Autoimmune diseases overlapping with lupus
Raynaud’s phenomenon
Fibromyalgia

4. 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 Onset <5 years extraordinarily rare

5. SLE
APS
Hypothyroidism
Rhupus
ITP
Sjögren’s

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

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

8. 20% of ITP patients develop lupus
SLE
APS
Hypothyroidism
Rhupus
ITP
Sjögren’s
Low platelet count
20% of ITP patients develop lupus

9. 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

10. SLE
APS
Hypothyroidism
Rhupus
ITP
Sjogren’s

11. 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).

12. 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

13. 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. 

14. 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.

15. Autoimmune diseases overlapping with lupus
Raynaud’s phenomenon
Fibromyalgia

16. 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.

17. 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.

18. 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.

19. 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.

20. 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.

21. 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.

22. 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.

23. Autoimmune diseases overlapping with lupus
Raynaud’s phenomenon
Fibromyalgia

24. 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.

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

26. 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.

27. Fibromyalgia
Widespread pain
Sleep disturbance
Fatigue

28. 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)

29. 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.

30. 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

31. Autoimmune diseases overlapping with lupus
Raynaud’s phenomenon
Fibromyalgia

32. Questions?