Magazine article Clinical Psychiatry News

Neuropsychiatric SLE May Get Tighter Definition

Magazine article Clinical Psychiatry News

Neuropsychiatric SLE May Get Tighter Definition

Article excerpt

SNOWMASS, COLO. -- The pendulum appears to be swinging away from the broad definition of neuropsychi-atric systemic lupus erythematosus advocated by the American College of Rheumatology in a landmark 1999 report in favor of a much more restrictive set of manifestations, according to Dr. W.Joseph McCune.

The ACR list of 19 neuropsychiatric syndromes attributable to SLE includes headache, mood disorders, cognitive dysfunction, and anxiety disorders (Arthritis Rheum. 1999;42:599-608). The problem is that these features are quite common among individuals without SLE, and attributing them to lupus activity can result in overestimation of the prevalence of neuropsychiatric SLE and overtreatment of lupus, he said at the meeting.

The ACR case definitions have resulted in a great expansion of the perceived incidence and prevalence of neuropsychiatric lupus. But last year, a European League Against Rheumatism consensus statement on neu-ropsychiatric SLE suggested that the sweeping ACR conception goes too far, noted Dr. McCune, who is professor of internal medicine at the University of Michigan, Ann Arbor.

The EULAR report concluded that excluding headache, mood disorders, anxiety disorders, mild cognitive dysfunction, and polyneuropathy without electromyographic confirmation from the ACR list of manifestations of neuropsychiatric SLE would reduce the reported frequency of neuropsychiatric lupus by half while doubling the specificity of the ACR nomenclature from 46% to 93% (Ann. Rheum. Dis. 2010;69:2074-82).

The EULAR report identified three risk factors consistently associated with roughly a fivefold increased likelihood that a neuropsychiatric symptom is actually attributable to the patient's lupus rather than to a secondary cause such as comorbid hypertension, infection, or cardiac vegetations.

These risk factors are generalized SLE activity; a moderate to high titer of antiphospholipid antibodies, which particularly predispose to lupus as the primary cause in cases involving seizures, cerebrovascular disease, or chorea; and previous neuropsychiatric SLE manifestations, which greatly in crease the likelihood that seizures or cognitive dysfunction in a lupus patient are actually due to the SLE. An other key point made in the EULAR consensus statement was that 50%-60% of neuropsychiatric SLE events occur at the onset of lupus or within the first year afterward.

"That means one has to be alert to the possibility that someone who presents with an incompletely developed syndrome may ultimately turn out to have lupus," Dr. …

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