Disorders of Joints and Connective Tissue

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Disorders that affect joints and their compo-nents-muscles, bones, cartilage, and tendons- -are considered connective tissue diseases because these structures contain large amounts of connective tissue. However, many are also a type of autoimmune disease, involving immune reactions in which something triggers the immune system to react against the body's own tissues and to produce abnormal antibodies that attack these tissues (autoantibodies).

Immune reactions are characterized by inflam-mation, which is normally a repair process and subsides when the repair is completed. However, in autoimmune diseases, the inflammation may be chronic, resulting in damage to normal tissues. For example, in rheumatoid arthritis, chronic inflammation damages the joint's cartilage. In rheumatoid arthritis and many autoimmune diseases, the inflammation affects several joints, probably because it's caused by antibodies that circulate throughout the body in the bloodstream.

Connective tissue in and around joints and else-where in the body can become inflamed. Commonly, muscles also become inflamed. The sac that surrounds the heart (pericardium), the membrane that covers the lungs (pleura), and even the brain can be affected. The type and severity of symptoms depend on which organs are affected.

Diagnosis

Each autoimmune disease is diagnosed on the basis of its particular symptom pattern, the findings during a physical examination, and the results of laboratory tests. Sometimes the symptoms of one disease overlap with another so much that a distinction can't be made, so undifferentiated connective tissue disease or overlap dis-ease is diagnosed.

Anemia (an insufficient number of red blood cells) often accompanies connective tissue diseases. The erythrocyte sedimentation rate, which measures the rate at which red blood cells settle to the bottom of a test tube containing blood, is often above normal in these diseases. A rate that's above normal suggests that active inflammation is present, but this test alone can't identify the cause of the inflammation. Doctors may monitor the sedimentation rate when symptoms are mild to determine whether the disease is still active.

In some connective tissue diseases, unusual antibodies can be detected and measured in the blood. If the antibodies are virtually specific to a disease, their presence confirms the diagnosis. For example, antibodies to double-stranded DNA occur almost exclusively in systemic lupus erythematosus. However, in most diseases, antibod-ies are not specific to the disease. For example, 70 percent of the people with rheumatoid arthritis have antibodies called rheumatoirl factor, but the rest do not, and rheumatoid factor can occur in several other diseases. In such cases, laboratory test results can help a doctor make a diagnosis but they can't confirm it.

When a disease affects a specific tissue or organ, a doctor may perform a biopsy, in which a sample of that tissue is removed and examined under a microscope for changes. The results may be helpful in confirming a suspected diagnosis or in following the progression of a disease.

Treatment

Treatment varies according to the type of disease and its severity. Drug treatment is aimed at reducing inflammation. When the inflammation can cause severe symptoms or can even be fatal. aggressive treatment must be started immediately.

Drugs that reduce inflammation include non-steroidal anti-inflammatorydrugs (NSAIDs), such as aspirin and ibuprofen) which are used for mild inflammation and minor flare-ups. These drugs also control pain. Certain nonsteroidal anti-inflammatory drugs can be purchased without a prescription, but high doses, which are generally needed to treat autoimmune diseases, require a prescription. Side effects, most commonly stomach upset, are generally minor when the drugs are taken in modest doses for short periods of time. However, side effects can be numerous and severe, especially when the drugs are taken in high doses for a long time.

Corticosteroids that are synthetic forms of natural hormones are very potent anti-inflammatory drugs that can be given by injection or by mouth. Prednisone is the most widely used corticosteroid given by mouth. Low doses of a corticosteroid may have to be taken for months or years after the inflammation has been controlled with higher doses. Compared with nonsteroidal anti-inflammatory drugs, corticosteroids produce many more severe side effects, such as high blood sugar levels, an increased risk of infection, osteoporosis, water retention, and fragility of the skin. To avoid these side effects, a doctor prescribes the lowest effective dose, especially for long-term treatment.

Immunosuppressive drugs, such as methotrexate, azathioprine, and cyclophosphamide, are used to suppress the immune response, thereby reducing inflammation. These drugs, some of which are also used to treat cancer, have potentially dangerous side effects. Long-term use of azathioprine and cyclophosphamide may increase the risk of developing some forms of cancer. Some immunosuppressive drugs may contribute to reproductive system dysfunction. Because the immune system is suppressed, common infections can become life threatening. Con-sequently, the most potent immunosuppressive drugs are generally used only in severe cases.

Rheumatoid Arthritis

Rheumatoid arthritis is an autoimmune disease in which joints, usually including those of the hands and feet, are symmetrically inflamed, resulting in swelling, pain, and often the eventual destruction of the joint's interior.

Rheumatoid arthritis can also produce a variety of symptoms throughout the body. Its exact cause isn't known, but many different factors, including genetic predisposition, may influence the autoimmune reaction. This disease develops in about 1 percent of the population, affecting women two to three times more often than men. Usually, rheumatoid arthritis first appears between 25 and 50 years of age, but it may occur at any age. In some people, the disease resolves spontaneously, and treatment relieves symptoms in three out of four people; however, at least 1 out of 10 people eventually becomes disabled.

In this disease, the immune system attacks the tissue that lines and cushions joints. Eventually, the cartilage, bone, and ligaments of the joint erode, causing scars to form within the joint. The joints deteriorate at a highly variable rate.

Symptoms

Rheumatoid arthritis may start suddenly, with many joints becoming inflamed at the same time. More frequently, it starts subtly, gradually affecting different joints. Usually, the inflammation is symmetric: When a joint on one side of the body is affected, the corresponding joint on the other side is also affected. Typically, the small joints in the fingers, toes, hands, feet, wrists, elbows, and ankles become inflamed first. The inflamed joints are usually painful and often stiff, especially just after awakening or after prolonged inactivity. Some people feel tired and weak, especially in the early afternoon.

Affected joints enlarge and can quickly become deformed. Joints may freeze in one position (contractures) so that they can't extend or open fully. The fingers tend to bend toward the little finger on each hand, causing tendons in the fingers to slip out of place. Swollen wrists can result in carpal tunnel syndrome. Cysts, which may develop behind affected knees, can rupture, causing pain and swelling in the lower legs. About 30 to 40 percent of people with rheumatoid arthritis have hard bumps (nodules) just under the skin, usually near diseased areas.

Rheumatoid arthritis may produce a low-grade fever and occasionally an inflammation of blood vessels (vasculitis) that causes nerve damage or leg sores (ulcers). Inflammation of the membranes around the lungs (pleurisy) or the sac surrounding the heart (pericarditis) or inflammation and scarring of the lungs can lead to chest pain, difficulty in breathing, and abnormal heart function. Some people develop swollen lymph nodes, Sjogren's syndrome, or an eye inflammation.

Still's disease is a variation of rheumatoid arthritis in which high fever and other generalized symptoms develop first.

Diagnosis

Distinguishing rheumatoid arthritis from the many other conditions that can cause arthritis may be difficult. Conditions that resemble rheumatoid arthritis in some aspects include acute rheumatic fever, gonococcal arthritis, Lyme disease, Reiter's syndrome, psoriatic arthritis, ankylosing spondylitis, gout, pseudogout, and osteoarthritis.

Rheumatoid arthritis may produce a characteristic pattern of symptoms, but laboratory tests, an examination of a joint fluid sample obtained with a needle, and even a biopsy (removal of a tissue sample for examination under a microscope) of nodules may be needed to pin down the diagnosis. Characteristic changes in the joints may be seen on x-rays.

Some laboratory test results are typical of rheumatoid arthritis. For example, in 9 out of 10 people who have rheumatoid arthritis, the erythrocyte sedimentation rate is increased. Most people have mild anemia. Rarely, the white blood cell count becomes abnormally low. When a person has a low white blood cell count, an enlarged spleen, and rheumatoid arthritis, the condition is called Felty's syndrome.

Many people with rheumatoid arthritis have distinctive antibodies in their blood. Seven out of 10 people have an antibody called rheumatoid factor. (This factor also occurs in several other disorders, such as chronic liver disease and some infections; some people have this factor without any evidence of disease.) Usually, the higher the level of rheumatoid factor in the blood, the more severe the rheumatoid arthritis and the poorer the prognosis. The rheumatoid factor level may decrease when joints are less inflamed and increase when flare-ups occur.

Treatment

Treatments range from simple, conservative measures such as rest and adequate nutrition to drugs and surgery. Treatment starts with the least aggressive measures, moving to more aggressive ones if needed.

A basic principle of treatment is to rest the affected joints, because using them aggravates the inflammation. Regular rest periods often help relieve pain, and sometimes a short period of total bed rest helps relieve a severe flare-up in its most active, painful stage. Splints can be used to immobilize and rest one or several joints, but some systematic movement of the joints is needed to prevent stiffening.

A regular, healthy diet is generally appropriate. Some people have flare-ups after eating certain foods. A diet rich in fish and plant oils but low in red meat can have minor beneficial effects on the inflammation.

The main categories of drugs used to treat rheumatoid arthritis are nonsteroidal anti-inflammatory drugs (NSAIDs), slow-acting drugs, corticosteroids, and immunosuppressive drugs. Generally, the stronger the drug, the more severe its potential side effects, so that closer monitoring is needed.

Nonsteroidal Anti-inflammatory Drugs

The nonsteroidal anti-inflammatory drugs, which include aspirin and ibuprofen, are the most widely used drugs. They reduce the swelling in affected joints and alleviate the pain. Aspirin is the traditional cornerstone of treatment for rheumatoid arthritis; the newer nonsteroidal anti-inflammatory drugs may have fewer side effects and are usually simpler to take, but they are more expensive.

People usually begin aspirin treatment with 2 tablets (325 mg) four times a day but may have to increase the dose for sufficient relief. Ringing in the ears is a side effect that indicates the dose is too high. Upset stomach, a common side effect of high doses, and ulcers can often be prevented by eating food or taking antacids or other drugs at the same time. Misoprostol may help prevent erosion of the stomach's lining and the formation of stomach (gastric) ulcers in people at high risk of developing such conditions, but it also may cause diarrhea and doesn't prevent the nausea or abdominal pain that can result from taking aspirin or other nonsteroidal anti-inflammatory drugs.

If aspirin can't be tolerated, other nonsteroidal anti-inflammatory drugs are tried. However, all such drugs can upset the stomach and can't be taken by anyone who has active gastrointestinal tract (peptic) ulcers. Other, less common side effects include headaches, confusion, increased blood pressure, swelling (edema), and sometimes kidney disease.

Slow-acting Drugs

Slow-acting drugs sometimes alter the course of the disease, although improvement may take several months and side effects can be dangerous. Their use must be closely supervised and monitored by a doctor. These drugs are usually added if nonsteroidal anti-inflammatory drugs have proved ineffective after 2 or 3 months or sooner if the disease is progressing rapidly. The slow-acting drugs currently in use are gold com-pounds, penicillamine, hydroxychloroquine, and sulfasalazine.

Gold compounds, which can slow the formation of bone deformities, may cause a temporary remission of the disease. Usually, the gold com-pound is given as a weekly injection, although a preparation given by mouth is available. The weekly injections are continued until a total of I gram has been given or until side effects or significant improvement occurs. If the drug is effective, the frequency of the injections can be gradually decreased. Sometimes improvement is sustained for years on maintenance doses.

Gold compounds can adversely affect several organs, and people who have severe liver or kidney disease or certain blood disorders can't take these drugs. Consequently, blood and urine samples are tested before treatment begins and frequently-up to once a week-during treatment. Side effects of these drugs include potentially dangerous rashes, itchy skin, and decreased num-bers of blood cells. Less commonly, gold compounds can affect the liver, lungs, and nerves, and rarely, they cause diarrhea. Gold is usually discontinued if any of these severe side effects occurs.

Penicillamine has beneficial effects similar to those of gold and may be used when gold isn't effective or when it causes intolerable side effects. The dose is gradually increased until a person shows some improvement. Side effects include suppression of blood cell production in the' bone marrow, kidney problems, muscle disease, rash, and a bad taste in the mouth. If any of these side effects occur, the drug must be discontinued. Penicillamine can also cause disorders such as myasthenia gravis, Goodpasture's syndrome, and a lupus-like syndrome. Blood and urine samples are tested as frequently as every 2 to 4 weeks during treatment.

Hydroxychloroquine is used rather than gold compounds or penicillamine to treat less severe rheumatoid arthritis. Side effects, which are usually mild, include rashes, muscle aches, and eye problems. However, some eye problems can be permanent, so people taking hydroxychloroquine must have their eyes checked by an ophthalmologist before treatment begins and every 6 months during treatment. If the drug hasn't helped after 6 months, it's discontinued. Otherwise, it can be continued as long as necessary.

Sulfasalazine is increasingly prescribed for rheumatoid arthritis. The dose is increased gradually, and improvement usually occurs within 3 months. Like the other slow acting drugs, it can cause stomach upset, liver problems, blood cell disorders, and rashes.

Corticosteroids

Corticosteroids, such as prednisone, are the most dramatically effective drugs for reducing inflammation anywhere in the body. Although corticosteroids are effective for short-term use, they tend to become less effective over time, and rheumatoid arthritis is usually active for years. They generally don't slow the progression of the disease. Furthermore, the long-term use of corticosteroids invariably leads to many side effects, involving almost every organ in the body.

Common side effects are thinning of the skin, bruising, osteoporosis, high blood pressure, elevated blood sugar levels, and cataracts. Consequently, these drugs are usually reserved for the immediate treatment of flare-ups when several joints are affected or when all other drugs have been ineffective. They're also useful in treating inflammation outside of joints, for example, in the membrane covering the lungs (pleurisy) or the sac surrounding the heart (pericarditis). Because of the risk of side effects, the lowest effective dose is almost always used. Corticosteroids can be injected directly into the affected joints for fast, short-term relief but can actually contribute to long-term damage, especially when a person who receives frequent injections overuses the temporarily pain-free joint, hastening its destruction.

Immunosuppressive Drugs

Immunosuppressive drugs (methotrexate, azathioprine, and cyclophosphamide) are effective in treating severe rheumatoid arthritis. They suppress the inflammation so that corticosteroids can be avoided or lower doses of a corticosteroid can be given. But these drugs have potentially fatal side effects, including liver disease, lung inflammation, an increased susceptibility to infec-tion, the suppression of blood cell production in the bone marrow, and, with cyclophosphamide, bleeding from the bladder. In addition, azathioprine and cyclophosphamide may increase the risk of developing cancer.

Methotrexate, given by mouth once a week, is being used increasingly to treat rheumatoid arthritis in its early stages because this drug can take effect quickly-sometimes after several weeks; it may given before slow-acting drugs when the arthritis is severe. People tolerate this drug well but must be closely monitored. They must refrain from drinking alcohol to minimize the risk of liver damage. Cyclosporine, which suppresses lymphocytes (a type of white blood cell), may be used to treat severe arthritis when other drugs have been ineffective.

Other Therapies

Along with drugs to reduce joint inflammation, a treatment plan for rheumatoid arthritis can include exercise, physical therapy, the application of heat to inflamed joints, and sometimes surgery. Inflamed joints should be exercised gentlyso they don't freeze. As the inflammation subsides, regular, active exercises can help, although a person shouldn't exercise to the point of fatigue. For many people, exercise in water may be easier.

Treatment of frozen joints consists of intensive exercises and occasionally the use of splints to gradually extend the joint. If drugs haven't helped, surgery maybe needed. Surgically replacing knee or hip joints is the most effective way to restore mobility and function when the joint disease is advanced. Joints can also be removed or fused, especially in the foot, to make walking less painful. The thumb can be fused to enable a per-son to grasp, and unstable vertebrae at the top of the neck can be fused together to prevent them from compressing the spinal cord.

People who are disabled by rheumatoid arthritis can use several aids to accomplish daily tasks. For example, specially modified orthopedic or athletic shoes can make walking less painful, and devices such as grippers reduce the need to squeeze the hand forcefully.

Psoriatic Arthritis

Psoriatic arthritis is a form of arthritis that occurs in people who have psoriasis of the skin or nails. The disease resembles rheumatoid arthritis but doesn't produce the antibodies characteristic of rheumatoid arthritis.

Symptoms and Diagnosis

Psoriasis (a skin condition causing flare-ups of red, scaly rashes and thickened, pitted nails) may precede or follow the joint inflammation. The ar-thritis usually affects joints of the fingers and toes, although other joints, including the hips and spine, are often affected as well. The joints may become swollen and deformed when inflammation is chronic. The skin and joint symptoms may appear and disappear together.

The diagnosis is made by identifying the characteristic arthritis in a person who has psoriasis or a family history of psoriasis.

Prognosis and Treatment

The prognosis for psoriatic arthritis is usually better than that for rheumatoid arthritis because fewer joints are affected. Nonetheless, the joints can be severely damaged.

Treatment is aimed at controlling the skin rash and alleviating the joint inflammation. Several drugs that are effective in treating rheumatoid arthritis are also used to treat psoriatic arthritis. They include gold compounds, methotrexate, cyclosporine, and sulfasalazine. Another drug, etretinate, is usually effective in severe cases, but its side effects may be serious; because it can cause birth defects, it should not be taken by pregnant women. Etretinate remains in the body for a long time, so women should not become pregnant while taking the drug or for at least 1 year after discontinuing it. The combination of taking methoxsalen by mouth and undergoing ultraviolet light (PUVA) treatments alleviates the skin symptoms and most joint inflammation but not inflam-mation of the spine.

Discoid Lupus Erythematosus

Discoid lupus erythematosus is a chronic, recurring disordercharacteriaed by clearly defined round, red patches on the skin.

Its cause is unknown. The disorder is more common in females, most often women in their 30s. The age range is much wider than the usual range for systemic lupus erythematosus.

Symptoms

The characteristic rash may persist or may come and go for years. The appearance of the patches changes over time. At first, they're red and round, about the diameter of a pencil eraser. Usually, they develop on the cheeks, bridge of the nose, scalp, and ears, but they can also develop on the upper trunk, back of the arms, and shins. Mouth sores are very common. If the disorder isn't treated, each patch gradually spreads outward. The central area degenerates, leaving a scar. In particularly scaly areas, the plugged hair follicles dilate, leaving pits shaped like carpet tacks. Scarring can cause widespread hair loss. The rash may be accompanied by achy joints and a decreased number of white blood cells but is only infrequently accompanied by the more se-vere symptoms of systemic lupus erythematosus.

Diagnosis and Treatment

The diagnosis isn't easy to confirm because the rash in discoid lupus erythematosus may be identical to the one in systemic lupus erythematosus and similar to rashes caused by diseases such as rosacea, seborrheic dermatitis, lymphoma, and sarcoidosis. A doctor takes a thorough medical history and performs a complete examination to make sure that no other organs are affected. Blood tests to measure the number of red and white blood cells and evaluate kidney function can help the doctor eliminate other possible diagnoses. Another laboratory test can be performed to look for antibodies to double-stranded DNA, which are found in many people who have systemic lupus erythematosus but in almost none who have discoid lupus erythematosus.

Treatment, if begun early, can prevent or reduce the severity of permanent scarring. Sunlight and ultraviolet light, as used in tanning salons, can make the rash worse and should be avoided. Sunscreen can be used as a preventive measure. Small patches of rash can usually be treated successfully with a corticosteroid cream. Larger, more resistant rashes often require a few months of treatment with corticosteroids given by mouth or with immunosuppressive drugs such as those used to treat systemic lupus erythematosus.

Systemic Lupus Erythematosus

Systemic lupus erythematosus (lupus) is an auto-immune disease that results in episodes of inflam-mation in joints, tendons, and other connective tis-sues and organs.

Different tissues and organs become inflamed in different people, and the severity of the disease ranges from mild to debilitating, depending on the number and variety of antibodies that appear and the organs affected. About 90 percent of the people who have lupus are young women in their late teens to 30s, but children, mostly girls, and older men and women can also be affected.

Occasionally, certain heart drugs (hydralazine, procainamide, and beta-blockers) can cause a lupus-lilfe syndrome that disappears after the drug is discontinued.

Symptoms

The number and variety of antibodies that can appear in lupus are greater than those in any other disease, and they along with other unknown factors determine which symptoms de-velop. Therefore, symptoms, and their severity and gravity, vary greatly from person to person. Lupus can be quite mild, or it can be devastating, disabling, or fatal. For example, in people who have antibodies that affect only the skin, the skin symptoms may be mild-protecting the skin from sunlight may even prevent them or they may be severe and disfiguring.

Because symptoms vary greatly, lupus may resemble many other diseases. For example, the connective tissue of joints is commonly affected in lupus, and the arthritis that results may resemble rheumatoid arthritis. Lupus may resemble epilepsy or some psychologic disorders when the brain is affected.

Although lupus can be chronic and ongoing, it usually flares up intermittently. What triggers a flare-up of lupus in people who are predisposed to it often isn't known, although sunlight seems to be one factor.

Lupus may begin with a fever. A high fever can occur abruptly, or episodes of fever and a generally sick feeling (malaise) can come and go, sometimes for years. About 90 percent of people with lupus have joint inflammation, which ranges from intermittent mild aches to severe arthritis in several joints. Years of joint symptoms may precede other symptoms. In fact, many people who have lupus recall having growing pains as children. Long-standing joint inflammation can lead to deformity and permanent damage to the joint and surrounding tissue, but the bone doesn't erode as it does in rheumatoid arthritis.

Skin rashes are common, often occurring on the face, neck, upper chest, and elbows. The most characteristic is a red, butterfly shaped rash that appears across the bridge of the nose and on the cheeks. Circular, raised bumps may develop. These rashes rarely blister or become raw. Mouth sores are also common. Mottled, reddish purple areas may appear on the sides of the palms and on the fingers; swelling and redness may develop around the nails. Hair loss is common when the disease is active. In almost half the people who have lupus, the skin is highly sensitive to light; it may burn easily or a rash may develop after exposure to sunlight.

Occasionally, an inflammation develops and extra fluid accumulates in the membranes surrounding the lungs. This inflammation (pleurisy) can make deep breathing painful. Fluid may accumulate in the sac around the heart, resulting in pericarditis, which can cause severe, constant chest pain. Children, young adults, and blacks with lupus commonly develop swollen lymph nodes throughout the body, and about 10 percent of the people with lupus develop an enlarged spleen.

Sometimes the nervous system is affected, causing headaches, personality changes, seizures, and symptoms that resemble dementia, such as difficulty in thinking clearly. Strokes occur less often. Protein or red blood cells in the urine, detected by a laboratory test, indicate kidney damage caused by glomerulonephritis, an inflam-mation of the kidneys, which is a common consequence of lupus. If severe, progressive kidney disease develops, blood pressure can become dangerously high, and kidney failure, which may be fatal, can follow. Early detection and treatment of kidney damage in people who, have lupus reduces the incidence of severe kidney disease.

Diagnosis

Lupus is diagnosed mainly on the basis of its symptoms, particularly if they occur in a young woman. Because of the wide range of symptoms, distinguishing lupus from similar diseases can be difficult at first.

Laboratory tests can help confirm the diagnosis. A blood test can detect antinuclear antibodies, which are present in almost all people who have lupus. However, these antibodies also occur in other diseases. Therefore, if antinuclear antibodies are detected, a test for antibodies to double-stranded DNA is also performed. A high level of these antibodies is almost specific for lupus, but not all people who have lupus have these antibodies. Blood tests to measure complement levels (a group of proteins that are part of the immune system) and to detect other antibodies may be performed to predict the activity and course of the disease.

Kidney damage from lupus may be detected by blood and urine tests. Sometimes a biopsy of kidney tissue must be performed to help the doctor plan treatment.

Prognosis and Treatment

Because the course of lupus is unpredictable, the prognosis varies widely. The disease tends to be chronic and relapsing, often with symptom free periods that can last for years. Flare-ups rarely occur after menopause. The prognosis has improved markedly over the last two decades. Usually, if the initial inflammation is controlled, the long-term prognosis is good.

If the symptoms of lupus are caused by taking a drug, discontinuing the drug cures the lupus, although the recovery may take months.

Treatment depends on which organs are affected and whether the disease is mild or severe. Mild lupus is characterized by fever, arthritis, rash, mild heart and lung involvement, and headaches. Severe lupus may cause life-threatening blood disorders, massive heart and lung involve-ment, significant kidney damage, vasculitis of the arms and legs or gastrointestinal tract, or severe nervous system dysfunction.

Mild disease may require little or no treatment. Nonsteroidal anti-inflammatory drugs (NSAIDs) often can relieve joint pain. Aspirin is used in low doses if the person's blood has a tendency to clot, as happens in some people with lupus; doses that are too high can harm the liver. Hydroxychloroquine, chloroquine, or quinacrine, sometimes taken in combination, helps relieve joint and skin symptoms.

Severe disease is treated immediately with a corticos'teroid such as prednisone. The dose and duration of treatment depend on which organs are affected. Sometimes an immunosuppressive drug such as azathioprine or cyclophosphamide is given to suppress the body's autoimmune attack. The combination of a corticosteroid and an immunosuppressive drug is most often used for severe kidney or nervous system disease and vasculitis.

Once the initial inflammation is controlled, a doctor determines the dose that most effectively suppresses the inflammation over the long term. Usually, the dose of prednisone is gradually decreased when symptoms are controlled and laboratory test results improve. Relapses or flare-ups can occur during this process. For most peo-ple who have lupus, the dose of prednisone can eventually be decreased or discontinued.

Surgical procedures and pregnancy are more complicated for people who have lupus, and they require close medical supervision. Miscarriages and flare-ups after childbirth are common.

Source : Family Medicine.

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