If I Have Both Lupus and MS, How Does My Doctor Know What Treatment To Use?

Differentiating between Systemic Lupus Erythematosis (also called SLE or Lupus) and Multiple sclerosis can be very difficult. Both are essentially a clinical diagnosis, meaning there is no specific diagnostic test that differentiates between the two disorders.

The good news is that verifiable lupus probably involves the central nervous system in less than 5% of patients, despite prior studies suggesting a larger percentage of lupus patients with central nervous system involvement. In my experience most patients with well documented Lupus who also have a characteristic history, exam and diagnostic evaluation for MS have both disorders.

Similarities between Lupus and MS include the following:

1. Both tend to involve young woman more than men
2. Both can cause vague neurological symptoms like fatigue, forgetfulness, numbness and tingling sensations, and odd pains
3. Both can cause discrete neurological syndromes often associated with MS such as optic neuritis and transverse myelitis
4. Both can cause white spots on MRI scans
5. Both can cause abnormal spinal fluid findings particularly intrathecal (meaning within the spinal fluid) synthesis of immunuglobulin often associated with oligoclonal bands
6. Both are associated with elevated ANA (anti nuclear antibodies) although antibodies against  double stranded DNA (anti-dsDNA) are more specific for lupus
   

Differences between Lupus and MS mostly reflect a different pathogenic mechanism of tissue injury; specifically, MS symptoms are caused by inflammatory demyelination within the brain tissue whereas lupus symptoms involving the central nervous system are pathologically related to immune mediated injury to small blood vessels (the vessel lumen becomes narrow and can close off) supplying oxygen and nutrients to an area of the brain.

This difference is extremely important since the type of injury created by Lupus tends to be more severe with less recovery because the tissue is deprived of essential nutrients and oxygen (like a stroke), whereas significant recovery is more common in MS.

Specific things to look for to help differentiate the two conditions include:

Lupus eventually involves other parts of the body with symptoms like arthralgias, myalgias, a characteristic rash, livido reticularis, kidney, heart or pulmonary involvement

Lupus as well as neuromyelitis optica should be considered with any case of severe optic neuritis associated with little recovery or complete longitudinally extensive transverse myelitis

Lupus is less often associated with typical MS MRI findings likely periventricular and juxtacortical lesions but it can be difficult to separate the two by MRI

If the evidence supports a diagnosis of lupus or both lupus and MS, this will effect how you are treated. It is important to avoid interferons since there are a number of studies implicating type I interferon pathways (the type triggered by treatment with beta interferons or alpha interferons) in the cause of Lupus and anecdotal evidence of worsening lupus in MS patients treated with interferons.

In my opinion immunosuppressant and anti-CD20 therapy (rituximab) is the preferred option for these patients. The actual therapy recommended will depend on the situation but could include periodic steroids, azathioprine, mycophenolate, cyclophosphamide or rituximab. A newer therapy for MS called teriflunimide (Aubagio) could be strongly considered as well because of its mechanism of action. Many patients end up on combination therapies that may include Copaxone plus one of the agents previously mentioned.

Treatment of this small group of patients is guided primarily by experience with little evidence to support one or another approach. I would recommend discussing the options thoroughly with your doctor and finding a neurologist experienced in the management of these conditions with or without the assistance of a rheumatologist.

Rip Kinkel

---