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How effective is antimalarial therapy in patients with lupus?
Systemic lupus erythematosus (SLE) exacts a terrible toll. This disease causes a broad array of serious organ injuries, including kidney disease (leading to renal failure), serosal inflammation, joint swelling, CNS pathology (strokes, for instance), skin disease, and various other problems. Women-who constitute the majority of patients with SLE-may miscarry repeatedly as a result of antiphospholipid antibody syndrome. Although successful treatment of SLE can mitigate associated organ damage, patients may still experience life-threatening infections, malignancies, and atherosclerosis.
Sometimes the treatments for SLE can be proverbially worse than the disease itself: for example, cyclophosphamide is associated with cystitis. One class of drugs used to treat SLE, the antimalarials (hydroxychloroquine is the typical agent), is not as toxic as some of the immunosuppressants. Early studies attested to the benefits of hydroxychloroquine in preventing SLE flares.1 This month's "Top Paper" shows that hydroxychloroquine also has profound effects on the overall survival of persons with SLE.2
EFFECT OF ANTIMALARIALS ON SURVIVAL
The authors of the "Top Paper" alluded to a previous study that suggested antimalarials have a protective effect and increase survival in persons with SLE.3 They set out to determine the potential beneficial effect of at least 6 months of antimalarial therapy in patients with SLE. All patients received a diagnosis based on the American College of Rheumatology criteria and were categorized as taking or not taking antimalarials for at least 6 consecutive months. There were 1480 persons in the cohort, and 1141 had been taking antimalarials for an average of 48.5 months.
Mortality in antimalarial users was 4.4% compared with 11.5% in nonusers (P < .001). Breaking down the duration of antimalarial use demonstrated that administration for 6 to 11 months, 1 to 2 years, and more than 2 years was associated with mortality rates of 3.85, 2.7, and 0.54, respectively.2
It appears that not only do antimalarials have a protective effect for persons with SLE, but the longer they are used, the greater the protection. However, in this study, antimalarial use did not protect against mortality from cardiovascular causes.
ROLE OF PRIMARY CARE PRACTITIONERS
Although many of the medications used to treat SLE (such as mycophenolate mofetil and cyclophosphamide) are prescribed by subspecialists, primary care physicians still play an important role in the care of persons with SLE. We must ensure that these patients receive prophylaxis for osteoporosis while taking corticosteroids, as well as appropriate vaccinations, risk factor treatment (to achieve cholesterol and blood pressure targets), and malignancy screenings. In addition, the evidence now supports the use of antimalarials in all persons who have SLE.
The Canadian Hydroxychloroquine Study Group. A randomized study of the effect of withdrawing hydroxychloroquine sulfate in systemic lupus erythematosus.
N Engl J Med
Shinjo SK, Bonfá E, Wojdyla D, et al; Grupo Latino Americano de Estudio del Lupus Eritematoso (Gladel). Antimalarial treatment may have a time-dependent effect on lupus survival: data from a multinational Latin American inception cohort.
Ruiz-Irastorza G, Egurbide MV, Pijoan JI, et al. Effect of antimalarials on thrombosis and survival in patients with systemic lupus erythematosus.
Dr Rutecki reports that he has no relevant financial relationships to disclose.