How to treat refractory arthritis in lupus?

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.