The Brain and Lupus: 2010 Update

Neuropsychiatric manifestations of lupus include headache, cognitive dysfunction, mood disorders, cerebrovascular events (i.e., stroke), seizures, polyneuropathy, anxiety, and psychosis. It’s difficult, however, for clinicians to know what is caused by lupus and what may have existed before lupus or despite lupus.

What is important, said John Hanly, MD, of Dalhousie University in Halifax, Nova Scotia, Canada, is teasing out those symptoms that began before the lupus diagnosis (i.e., migraines) and those that are likely related to the lupus or its treatment, i.e., stroke. He and his colleagues published a seminal paper on the topic in 2007 in which they assessed 572 patients recently diagnosed with lupus. They found that about a third had at least one neuropsychiatric event, with 10% exhibiting more than one. Events attributed to lupus occurred in 6% to 12% of patients (depending on how the association was determined). No matter what caused the patients’ neuropsychiatric event, however, all demonstrated reduced quality of life and increased organ damage compared to a similar cohort with no neuropsychiatric events.^xv

There are likely numerous underlying causes of these events, Dr. Hanly said, including the effect of lupus on blood vessels (which can affect blood flow to the brain); autoantibodies and inflammatory mediators. For instance, some studies show that injecting autoantibodies into the brain leads to memory deficits, seizures, and neuropathological changes. It is possible that the blood/brain barrier that typically protects the brain against such invasion is weaker in patients with lupus, enabling certain autoantibodies to penetrate into the brain.

Other than aspirin or other antithrombotic therapies to prevent stroke, only symptomatic therapies are available for most neuropsychiatric indications, including anticonvulsants, anti-psychotics, anxiolytics, and immunosuppression to reduce inflammation, all with mixed evidence as to their benefits. Rituximab is being tried in some centers to treat neuropsychiatric lupus, he said, and while the evidence is “not robust... it is the best we have at this stage.”

Key point: Whether depression, anxiety, cognitive problems, or other neuropsychiatric conditions are caused by lupus or result from other issues, they should be treated aggressively given their effect on quality of life and overall disease status.

More information about lupus and treatment advances can be found by visiting www.lupusresearch.org.

The 2010 American College of Rheumatology Meeting Special Report was made possible in part by generous support from Biogen Idec, Genentech and Johnson & Johnson.

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