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Pasoto SG, Villamarín LEB, de Vinci Kanda Kupa L, Deveza GBH, Ribeiro CT, Emi Aikawa N, Leon EP, de Oliveira Martins VA, Silva CA, Bonfa E. Assessment of hydroxychloroquine blood levels in Sjögren's disease patients: drug adherence and clinical associations. Rheumatol Int 2024; 44:1305-1315. [PMID: 38294544 DOI: 10.1007/s00296-024-05545-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 01/18/2024] [Indexed: 02/01/2024]
Abstract
Hydroxychloroquine (HCQ) has been used to treat Sjögren's disease (SjD) patients. However, there are no studies evaluating drug adherence through HCQ blood levels, pharmacy refill (PR) and medication adherence questionnaires. The relationship of HCQ blood levels with glandular/extraglandular disease parameters was also poorly assessed. This cross-sectional observational study included 74 adult SjD patients, who were receiving a stable HCQ dose (4-5.5 mg/kg/day, actual weight) for at least 3 months before study inclusion. HCQ blood levels were quantified by high-performance liquid chromatography coupled to mass spectrometry. Adherence was assessed by PR and Medida de Adesão aos Tratamentos (MAT) questionnaire. The following parameters were evaluated: Xerostomia Inventory, Ocular Surface Disease Index, EULAR (European League Against Rheumatism) Sjögren's Syndrome Disease Activity Index, EULAR Sjögren's Syndrome Patient Reported Index, Schirmer's I test and non-stimulated/stimulated salivary flow rates. HCQ blood levels were 775.3(25.0-2,568.6)ng/mL. Eleven patients (14.9%) had HCQ blood levels < 200ng/mL (non-adherent group); 11(14.9%), 200-499ng/mL (sub-therapeutic levels group); and 52(70.2%), ≥ 500ng/mL (adherent group). PR classified incorrectly all non-adherent/sub-therapeutic patients and 2/52(3.9%) adherent patients. Using MAT, the overall misclassification was 24/52(46.2%) in the adherent group, and were correctly identified 9/11(81.8%) patients in non-adherent and 7/11(63.6%) in sub-therapeutic groups. MAT sensitivity and specificity to identify non-adherent/sub-therapeutic patients were 72.7% and 53.9%, respectively. The three groups were comparable regarding glandular/extraglandular disease parameters (p > 0.05). The assessment of HCQ blood levels is a promising tool for evaluating drug adherence in SjD. This is particularly crucial as one-third of patients exhibited non-adherence/sub-therapeutic levels, and neither PR nor MAT reliably identified these patients.
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Affiliation(s)
- Sandra Gofinet Pasoto
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil.
- Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Arnaldo, 455, 3o andar (Disciplina de Reumatologia), sala 3192, São Paulo, 01246-903, SP, Brazil.
| | | | - Léonard de Vinci Kanda Kupa
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Giordano Bruno Henriques Deveza
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Carolina Torres Ribeiro
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Nádia Emi Aikawa
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
- Pediatric Rheumatology Unit, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Elaine Pires Leon
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | | | - Clovis Artur Silva
- Pediatric Rheumatology Unit, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Eloisa Bonfa
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
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Rúa-Figueroa Í, Salman-Monte TC, Pego Reigosa JM, Galindo Izquierdo M, Díez Álvarez E, Fernández-Nebro A, Román Ivorra JA, Calvo Penades I, Artaraz Beobide J, Calvo Alén J. Multidisciplinary consensus on the use of hydroxychloroquine in patients with systemic lupus erythematosus. REUMATOLOGIA CLINICA 2024; 20:312-319. [PMID: 38991825 DOI: 10.1016/j.reumae.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 03/12/2024] [Accepted: 03/21/2024] [Indexed: 07/13/2024]
Abstract
BACKGROUND Hydroxychloroquine (HCQ) is the first-line treatment for systemic lupus erythematosus (SLE); however, there is heterogeneity in its clinical use. This consensus aims to bridge the gap in SLE treatment by providing practical and valuable recommendations for health professionals. METHODS The methodology used is based on a systematic literature review and a nominal group technique (NGT). A ten-member scientific committee formulated eight clinically relevant questions. First, a systematic review was conducted to identify the available evidence, which the scientific committee evaluated to developed recommendations based on their expertise, achieving consensus through NGT. RESULTS 1673 titles and abstracts were screened, and 43 studies were included for meeting the inclusion criteria. The scientific committee established 11 recommendations for HCQ use in initiation, maintenance, and monitoring, considering benefits and potential adverse effects of HCQ. Unanimous agreement was achieved on all recommendations. CONCLUSIONS The available evidence supports HCQ's effectiveness and safety for SLE. Individualized assessment of the initial HCQ dose is important, especially in situations requiring dose reduction or discontinuation. This risk-benefit assessment, specifically focusing on the balance between retinal toxicity and the risk of SLE relapse, should guide decisions regarding medication withdrawal, considering disease activity, risk factors, and HCQ potential benefits. Close monitoring is essential for optimal disease management and minimize potential risks, such as QT prolongation or retinal toxicity.
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Affiliation(s)
- Íñigo Rúa-Figueroa
- Rheumatology Department, Gran Canaria University Hospital Doctor Negrin, Las Palmas de Gran Canaria, Spain
| | | | - José María Pego Reigosa
- Rheumatology Department, University Hospital of Vigo, IRIDIS-VIGO Group (Investigation in Rheumatology and Immune-Mediated Diseases), Galicia South Health Research Institute (IISGS), Vigo, Spain
| | | | | | - Antonio Fernández-Nebro
- Biomedical Research Institute of Malaga (IBIMA) - Plataforma Bionand, UGC of Rheumatology, Regional University Hospital of Malaga, Department of Medicine and Dermatology, University of Malaga, Malaga, Spain
| | | | | | - Joseba Artaraz Beobide
- Department of Ophthalmology, BioCruces Bizkaia Health Research Institute, Cruces University Hospital, Barakaldo, Spain
| | - Jaime Calvo Alén
- Rheumatology Department, Araba University Hospital, Vitoria, Spain; Research Institute BIOARABA, Spain; País Vasco University, Spain.
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Emamikia S, Gomez A, Ådahl T, von Perner G, Enman Y, Chatzidionysiou K, Arkema EV, Parodis I. Factors associated with non-adherence to medications in systemic lupus erythematosus: Results from a Swedish survey. Lupus 2024; 33:615-628. [PMID: 38545763 PMCID: PMC11015713 DOI: 10.1177/09612033241242692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 03/05/2024] [Indexed: 04/13/2024]
Abstract
OBJECTIVE To identify determinants of medication non-adherence in a Swedish population of systemic lupus erythematosus (SLE). METHODS Patients with SLE from Karolinska and Örebro University Hospitals participated in a survey-based cross-sectional study. Demographics, disease activity, organ damage, HRQoL (LupusQol, EQ-5D-5 L), medication non-adherence (<80% on CQR-19 or MASRI) and beliefs about medicines (BMQ) were registered. MASRI was used to report adherence to different drugs/drug classes, categorised into (i) antimalarial agents (AMA), (ii) glucocorticoids and (iii) other SLE medications. Multivariable logistic regression adjusted for age, sex, disease activity and organ damage. RESULTS Among 205 respondents, the median age was 52.0 years (IQR: 34.0-70.0), 86.3% were women, 66.8% were non-adherent to their medications according to CQR-19, and 6.6% and 6.3% were non-adherent to AMA and glucocorticoids, respectively, according to MASRI. Positive beliefs about glucocorticoids (OR; 95% CI: 0.77; 0.59-0.99; p = .039) and medications overall (0.71; 0.52-0.97; p = .029) were protective against non-adherence to glucocorticoids. Anxiety/depression (3.09; 1.12-8.54; p = .029), medication concerns (1.12; 1.05-1.20; p < .001) and belief that medications are overused (1.30; 1.15-1.46; p < .001) or harmful (1.36; 1.19-1.56; p < .001) were associated with medication non-adherence (CQR-19); beliefs in the necessity of medications (0.73; 0.65-0.82; p < .001) and positive beliefs in medications were protective (0.72; 0.60-0.86; p < .001). No associations were found between other investigated factors and medication non-adherence. CONCLUSIONS Beliefs about medications were a major determinant of medication non-adherence. Patient education may help alleviate the negative impact of misinformation/unawareness on adherence.
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Affiliation(s)
- Sharzad Emamikia
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Alvaro Gomez
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Theodor Ådahl
- Department of Rheumatology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Gunilla von Perner
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Yvonne Enman
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Katerina Chatzidionysiou
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Elizabeth V. Arkema
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Ioannis Parodis
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
- Department of Rheumatology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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Walhelm T, Wirestam L, Enman Y, Parodis I, Sjöwall C. Factors Associated with Survival and Discontinuation of Anti-Malarial Agents in Systemic Lupus Erythematosus: Results from a Tertiary Swedish Referral Centre. J Clin Med 2024; 13:1485. [PMID: 38592294 PMCID: PMC10934232 DOI: 10.3390/jcm13051485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 02/08/2024] [Accepted: 02/29/2024] [Indexed: 04/10/2024] Open
Abstract
Background: Antimalarial agents (AMAs) are cornerstone drugs in the treatment of systemic lupus erythematosus (SLE), and their use has established benefits, such as improved prognosis and decelerated accrual of organ damage. The aim of this study was to investigate the frequency of discontinuation of AMAs and associated factors in a Swedish SLE population. Methods: We retrieved data from a regional SLE register where all patients fulfilled the 1982 ACR and/or the 2012 SLICC classification criteria. A total of 328 subjects were included in the analysis. Results: Altogether, 92.4% (303/328) had been prescribed AMAs at some point during their disease. At the last available visit, 67.7% (222/328) were currently prescribed AMAs. Among individuals who had discontinued use, 24.7% (20/81) had developed a contraindication. Side effects were also common reasons for discontinuation (n = 38); gastrointestinal symptoms (52.6%, 20/38) were most common. Patients who discontinued had accrued more organ damage at the last visit (mean SDI: 2.9; SD: 2.8) compared with those still on AMAs (mean SDI: 1.4; SD: 1.8; p = 0.001). Conclusions: Most patients had been exposed to AMAs, but 25% discontinued therapy. Among side effects leading to discontinuation, >50% were gastrointestinal, calling for adequate gastroprotection towards drug retention and prevention of organ damage progression.
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Affiliation(s)
- Tomas Walhelm
- Division of Inflammation and Infection/Rheumatology, Department of Biomedical and Clinical Sciences, Linköping University, SE-581 83 Linköping, Sweden;
| | - Lina Wirestam
- Division of Inflammation and Infection/Rheumatology, Department of Biomedical and Clinical Sciences, Linköping University, SE-581 83 Linköping, Sweden;
| | - Yvonne Enman
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, SE-171 77 Stockholm, Sweden; (Y.E.); (I.P.)
| | - Ioannis Parodis
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, SE-171 77 Stockholm, Sweden; (Y.E.); (I.P.)
- Department of Gastroenterology, Dermatology and Rheumatology, Karolinska University Hospital, SE-171 64 Stockholm, Sweden
- Department of Rheumatology, Faculty of Medicine and Health, Örebro University, SE-701 82 Örebro, Sweden
| | - Christopher Sjöwall
- Division of Inflammation and Infection/Rheumatology, Department of Biomedical and Clinical Sciences, Linköping University, SE-581 83 Linköping, Sweden;
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Garg S, Chewning B, Hutson P, Astor BC, Bartels CM. Reference Range of Hydroxychloroquine Blood Levels That Can Reduce Odds of Active Lupus and Prevent Flares. Arthritis Care Res (Hoboken) 2024; 76:241-250. [PMID: 37667434 DOI: 10.1002/acr.25228] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 08/04/2023] [Accepted: 08/31/2023] [Indexed: 09/06/2023]
Abstract
OBJECTIVE Recent data show that lower hydroxychloroquine (HCQ) doses are associated with a two- to six-fold higher risk of lupus flares. Thus, establishing an effective reference range of HCQ blood levels with upper and lower bounds for efficacy may support individualizing HCQ dosing to prevent flares. METHODS HCQ levels in whole blood and Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) were measured during the baseline visit and again during a standard of care routine follow-up visit. Active cross-sectional lupus at baseline was defined as SLEDAI ≥6; a within subject flare was defined as a subsequent three-point increase in SLEDAI with clinical symptoms requiring therapy change. We examined associations between active lupus and HCQ blood levels at baseline and flares and HCQ levels during 6 to 12-month routine lupus follow-up visits using mixed regression analysis. RESULTS Among 158 baseline patient visits, 19% had active lupus. Odds of active lupus were 71% lower in patients with levels within a 750 to 1,200 ng/mL range (adjusted odds ratio 0.29, 95% confidence interval 0.08-0.96). Using convenience sampling strategy during a pandemic, we longitudinally followed 42 patients. Among those patients, 17% flared during their follow-up visit. Maintaining HCQ levels within 750 to 1,200 ng/mL reduced the odds of a flare by 26% over a nine-month median follow-up. CONCLUSION An effective reference range of HCQ blood levels, 750 to 1,200 ng/mL, was associated with 71% lower odds of active lupus, and maintaining levels within this range reduced odds of flares by 26%. These findings could guide clinicians to individualize HCQ doses to maintain HCQ levels within this range to maximize efficacy.
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Affiliation(s)
- Shivani Garg
- University of Wisconsin School of Medicine and Public Health, Madison
| | | | - Paul Hutson
- University of Wisconsin School of Pharmacy, Madison
| | - Brad C Astor
- University of Wisconsin School of Medicine and Public Health, Madison
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Nguyen Y, Blanchet B, Urowitz MB, Hanly JG, Gordon C, Bae S, Romero‐Diaz J, Sanchez‐Guerrero J, Clarke AE, Bernatsky S, Wallace DJ, Isenberg DA, Rahman A, Merrill JT, Fortin PR, Gladman DD, Bruce IN, Petri M, Ginzler EM, Dooley MA, Ramsey‐Goldman R, Manzi S, Jönsen A, Alarcón GS, Van Vollenhoven RF, Aranow C, Le Guern V, Mackay M, Ruiz‐Irastorza G, Lim SS, Inanc M, Kalunian KC, Jacobsen S, Peschken CA, Kamen DL, Askanase A, Buyon J, Costedoat‐Chalumeau N. Association Between Severe Nonadherence to Hydroxychloroquine and Systemic Lupus Erythematosus Flares, Damage, and Mortality in 660 Patients From the SLICC Inception Cohort. Arthritis Rheumatol 2023; 75:2195-2206. [PMID: 37459273 PMCID: PMC10792124 DOI: 10.1002/art.42645] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 06/05/2023] [Accepted: 06/29/2023] [Indexed: 11/15/2023]
Abstract
OBJECTIVE The goals of this study were to assess the associations of severe nonadherence to hydroxychloroquine (HCQ), objectively assessed by HCQ serum levels, and risks of systemic lupus erythematosus (SLE) flares, damage, and mortality rates over five years of follow-up. METHODS The Systemic Lupus International Collaborating Clinics (SLICC) Inception Cohort is an international multicenter initiative (33 centers throughout 11 countries). The serum of patients prescribed HCQ for at least three months at enrollment were analyzed. Severe nonadherence was defined by a serum HCQ level <106 ng/mL or <53 ng/mL for HCQ doses of 400 or 200 mg/day, respectively. Associations with the risk of a flare (defined as a Systemic Lupus Erythematosus Disease Activity Index 2000 increase ≥4 points, initiation of prednisone or immunosuppressive drugs, or new renal involvement) were studied with logistic regression, and associations with damage (first SLICC/American College of Rheumatology Damage Index [SDI] increase ≥1 point) and mortality with separate Cox proportional hazard models. RESULTS Of the 1,849 cohort participants, 660 patients (88% women) were included. Median (interquartile range) serum HCQ was 388 ng/mL (244-566); 48 patients (7.3%) had severe HCQ nonadherence. No covariates were clearly associated with severe nonadherence, which was, however, independently associated with both flare (odds ratio 3.38; 95% confidence interval [CI] 1.80-6.42) and an increase in the SDI within each of the first three years (hazard ratio [HR] 1.92 at three years; 95% CI 1.05-3.50). Eleven patients died within five years, including 3 with severe nonadherence (crude HR 5.41; 95% CI 1.43-20.39). CONCLUSION Severe nonadherence was independently associated with the risks of an SLE flare in the following year, early damage, and five-year mortality.
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Affiliation(s)
- Yann Nguyen
- National Referral Centre for Rare Autoimmune and Systemic Diseases, Hôpital Cochin, AP‐HP Centre and Université Paris Cité and Centre de Recherche en Epidémiologie et Statistiques (CRESS), Unité Inserm 1153, Université de Paris CitéParisFrance
| | - Benoît Blanchet
- Biologie du médicament‐Toxicologie, AP‐HP Centre–Hôpital Cochin, Université Paris Cité, and UMR8038 CNRS, U1268 INSERM, Université Paris Cité, PRES Sorbonne Paris Cité, CARPEMParisFrance
| | | | - John G. Hanly
- Queen Elizabeth II Health Sciences Centre and Dalhousie UniversityHalifaxNova ScotiaCanada
| | - Caroline Gordon
- Institute of Inflammation and Ageing, University of BirminghamBirminghamUnited Kingdom
| | - Sang‐Cheol Bae
- Hanyang University Hospital for Rheumatic Diseases, Hanyang University Institute for Rheumatology, and Hanyang University Institute of Bioscience and BiotechnologySeoulKorea
| | | | | | - Ann E. Clarke
- Cumming School of MedicineUniversity of CalgaryCalgaryAlbertaCanada
| | | | | | | | | | | | | | - Dafna D. Gladman
- Toronto Western Hospital, University of TorontoTorontoOntarioCanada
| | - Ian N. Bruce
- NIHR Manchester Biomedical Research Centre, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Center and Centre for Epidemiology Versus Arthritis, The University of ManchesterManchesterUK
| | - Michelle Petri
- Johns Hopkins University School of MedicineBaltimoreMaryland
| | | | - Mary Anne Dooley
- Thurston Arthritis Research Center, University of North CarolinaChapel Hill
| | | | - Susan Manzi
- Allegheny Health NetworkPittsburghPennsylvania
| | | | | | | | - Cynthia Aranow
- Feinstein Institute for Medical ResearchManhassetNew York
| | - Véronique Le Guern
- National Referral Centre for Rare Autoimmune and Systemic Diseases, Hôpital Cochin, AP‐HP Centre, Université Paris CitéParisFrance
| | - Meggan Mackay
- Feinstein Institute for Medical ResearchManhassetNew York
| | | | - S. Sam Lim
- Emory University School of MedicineAtlantaGeorgia
| | | | | | - Søren Jacobsen
- Rigshospitalet, Copenhagen University HospitalCopenhagenDenmark
| | | | | | - Anca Askanase
- Hospital for Joint Diseases and, Seligman Centre for Advanced Therapeutics, New York UniversityNew York City
| | - Jill Buyon
- New York University School of MedicineNew York City
| | - Nathalie Costedoat‐Chalumeau
- National Referral Centre for Rare Autoimmune and Systemic Diseases, Hôpital Cochin, AP‐HP Centre and Université Paris Cité and Centre de Recherche en Epidémiologie et Statistiques (CRESS), Unité Inserm 1153, Université de Paris CitéParisFrance
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David T, Su L, Cheng Y, Gordon C, Parker B, Isenberg D, Reynolds JA, Bruce IN. Predictors of British Isles Lupus Assessment Group-based outcomes in patients with systemic lupus erythematosus: Analysis from the Systemic Lupus International Collaborating Clinics Inception Cohort. Lupus 2023:9612033231183273. [PMID: 37463793 PMCID: PMC7614893 DOI: 10.1177/09612033231183273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
BACKGROUND We aimed to identify factors associated with a significant reduction in SLE disease activity over 12 months assessed by the BILAG Index. METHODS In an international SLE cohort, we studied patients from their 'inception enrolment' visit. We also defined an 'active disease' cohort of patients who had active disease similar to that needed for enrolment into clinical trials. Outcomes at 12 months were; Major Clinical Response (MCR: reduction to classic BILAG C in all domains, steroid dose of ≤7.5 mg and SLEDAI ≤ 4) and 'Improvement' (reduction to ≤1B score in previously active organs; no new BILAG A/B; stable or reduced steroid dose; no increase in SLEDAI). Univariate and multivariate logistic regression with Least Absolute Shrinkage and Selection Operator (LASSO) and cross-validation in randomly split samples were used to build prediction models. RESULTS 'Inception enrolment' (n = 1492) and 'active disease' (n = 924) patients were studied. Models for MCR performed well (ROC AUC = .777 and .732 in the inception enrolment and active disease cohorts, respectively). Models for Improvement performed poorly (ROC AUC = .574 in the active disease cohort). MCR in both cohorts was associated with anti-malarial use and inversely associated with active disease at baseline (BILAG or SLEDAI) scores, BILAG haematological A/B scores, higher steroid dose and immunosuppressive use. CONCLUSION Baseline predictors of response in SLE can help identify patients in clinic who are less likely to respond to standard therapy. They are also important as stratification factors when designing clinical trials in order to better standardize overall usual care response rates.
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Affiliation(s)
- Trixy David
- The Kellgren Centre for Rheumatology, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Li Su
- MRC Biostatistics Unit, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Yafeng Cheng
- MRC Biostatistics Unit, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Caroline Gordon
- Rheumatology Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Benjamin Parker
- The Kellgren Centre for Rheumatology, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - David Isenberg
- Centre for Rheumatology, Division of Medicine, University College London, London, UK
| | - John A Reynolds
- Rheumatology Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
- Rheumatology Department, City Hospital, Sandwell and West Birmingham NHS Trust, Birmingham, UK
| | - Ian N Bruce
- The Kellgren Centre for Rheumatology, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
- Centre for Musculoskeletal Research, The University of Manchester, Faculty of Biology Medicine and Health, Manchester Academic Health Science Centre, Manchester, UK
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Fasano S, Messiniti V, Iudici M, Coscia MA, Ciccia F. Hydroxychloroquine daily dose, hydroxychloroquine blood levels and the risk of flares in patients with systemic lupus erythematosus. Lupus Sci Med 2023; 10:10/1/e000841. [PMID: 36631164 PMCID: PMC9835942 DOI: 10.1136/lupus-2022-000841] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 01/04/2023] [Indexed: 01/13/2023]
Abstract
BACKGROUND Recent guidelines for SLE recommend using a hydroxychloroquine (HCQ) dose less than 5.0 mg/kg/day to reduce the risk of retinopathy. To determine if this dose reduction would have an impact on the clinical course of SLE, we compared flare incidence in a cohort of patients with SLE treated with two different oral HCQ dosages (≤5 mg/kg/day or >5 mg/kg/day). As a secondary analysis, we compared HCQ blood levels between the two different oral dosages, and evaluated the frequency of non-adherence in patients with SLE treated with HCQ. METHODS We identified a cohort of patients with SLE taking HCQ for at least 6 months and followed for 24 months. At study entry and 6 months later, a blood venous sample was taken to measure HCQ blood levels by liquid chromatography. Incidence of new SLE flares after recruitment was put in relation to daily HCQ dose and mean HCQ blood levels. Cox regression analysis served to identify factors associated with SLE flares. RESULTS 83 patients were enrolled. We observed 11 (16%) flares that developed in mean 14.8 months of follow-up. The difference in terms of flare rate and mean HCQ blood levels between the two oral dosages was not statistically significant. There was a trend (p=0.08) for high HCQ dose being associated with a lower flare rate. At Cox analysis, higher HCQ blood levels and older age at baseline were protective against flare occurrence, while concomitant immunosuppressant therapy showed significant positive association. HCQ blood levels did not correlate with prescribed HCQ dose. CONCLUSION Patients with low oral HCQ dosage tend to have more flares, although the difference was not statistically significant. Higher HCQ blood levels were protective against flare occurrence. The risks and benefits must be balanced in choosing HCQ dose.
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Affiliation(s)
- Serena Fasano
- Rheumatology Unit, Department of Precision Medicine, University of Campania, "Luigi Vanvitelli", Naples, Italy
| | - Valentina Messiniti
- Rheumatology Unit, Department of Precision Medicine, University of Campania, "Luigi Vanvitelli", Naples, Italy
| | - Michele Iudici
- Department of Internal Medicine Specialties, Geneva University Hospitals, Geneva, Switzerland
| | - Melania Alessia Coscia
- Rheumatology Unit, Department of Precision Medicine, University of Campania, "Luigi Vanvitelli", Naples, Italy
| | - Francesco Ciccia
- Rheumatology Unit, Department of Precision Medicine, University of Campania, "Luigi Vanvitelli", Naples, Italy
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Sun K, Coles TM, Voils CI, Anderson DR, Eudy AM, Sadun RE, Rogers JL, Criscione-Schreiber LG, Doss J, Maheswaranathan M, Clowse MEB. Development and Initial Validation of a Systemic Lupus Erythematosus-Specific Measure of the Extent of and Reasons for Medication Nonadherence. J Rheumatol 2022; 49:1341-1348. [PMID: 36243406 PMCID: PMC9722566 DOI: 10.3899/jrheum.220399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Medication nonadherence is common in patients with systemic lupus erythematosus (SLE) and negatively affects outcomes. To better recognize and address nonadherence in this population, there is a need for an easily implementable tool with interpretable scores. Domains of Subjective Extent of Nonadherence (DOSE-Nonadherence) is a measure that captures both extent of and reasons for nonadherence. We refined and evaluated DOSE-Nonadherence for patients with SLE. METHODS We refined the reasons for the nonadherence domain of DOSE-Nonadherence through rheumatologist feedback and patient cognitive interviewing. We then administered the refined instrument to patients prescribed oral SLE medications and compared the results to the Beliefs About Medicines Questionnaire (BMQ), the Medication Adherence Self-Report Inventory (MASRI), medication possession ratios (MPRs), and hydroxychloroquine (HCQ) blood levels using Pearson correlations. RESULTS Five rheumatologists provided feedback; 16 patients (median age 43 yrs, 100% female, 50% Black) participated in cognitive interviews and 128 (median age 49 yrs, 95% female, 49% Black, 88% on antimalarials, and 59% on immunosuppressants) completed the refined instrument. Items assessing extent of nonadherence produced reliable scores (α 0.89) and identified 47% as nonadherent. They showed convergent validity with MASRI (r = -0.57), HCQ blood levels (r = -0.55), to a lesser extent MPRs (r = -0.34 to -0.40), and discriminant validity with BMQ domains (r = -0.27 to 0.32). Nonadherent patients reported on average 3.5 adherence barriers, the most common being busyness/forgetting (62%), physical fatigue (38%), and pill fatigue (33%). CONCLUSION Our results support the reliability and validity of DOSE-Nonadherence for SLE medications. This refined instrument, DOSE-Nonadherence-SLE, can be used to identify, rigorously study, and guide adherence intervention development in SLE.
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Affiliation(s)
- Kai Sun
- K. Sun, MD, D.R. Anderson, MD, PhD, A.M. Eudy, PhD, J.L. Rogers, MD, L.G. Criscione-Schreiber, MD, MEd, J. Doss, MD, MPH, M. Maheswaranathan, MD, M.E.B. Clowse, MD, MPH, Division of Rheumatology and Immunology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina;
| | - Theresa M Coles
- T.M. Coles, PhD, Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Corrine I Voils
- C.I. Voils, PhD, William S Middleton Memorial Veterans Hospital and Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin
| | - D Ryan Anderson
- K. Sun, MD, D.R. Anderson, MD, PhD, A.M. Eudy, PhD, J.L. Rogers, MD, L.G. Criscione-Schreiber, MD, MEd, J. Doss, MD, MPH, M. Maheswaranathan, MD, M.E.B. Clowse, MD, MPH, Division of Rheumatology and Immunology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Amanda M Eudy
- K. Sun, MD, D.R. Anderson, MD, PhD, A.M. Eudy, PhD, J.L. Rogers, MD, L.G. Criscione-Schreiber, MD, MEd, J. Doss, MD, MPH, M. Maheswaranathan, MD, M.E.B. Clowse, MD, MPH, Division of Rheumatology and Immunology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Rebecca E Sadun
- R.E. Sadun, MD, PhD, Division of Rheumatology and Immunology, Department of Medicine, and Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jennifer L Rogers
- K. Sun, MD, D.R. Anderson, MD, PhD, A.M. Eudy, PhD, J.L. Rogers, MD, L.G. Criscione-Schreiber, MD, MEd, J. Doss, MD, MPH, M. Maheswaranathan, MD, M.E.B. Clowse, MD, MPH, Division of Rheumatology and Immunology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Lisa G Criscione-Schreiber
- K. Sun, MD, D.R. Anderson, MD, PhD, A.M. Eudy, PhD, J.L. Rogers, MD, L.G. Criscione-Schreiber, MD, MEd, J. Doss, MD, MPH, M. Maheswaranathan, MD, M.E.B. Clowse, MD, MPH, Division of Rheumatology and Immunology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Jayanth Doss
- K. Sun, MD, D.R. Anderson, MD, PhD, A.M. Eudy, PhD, J.L. Rogers, MD, L.G. Criscione-Schreiber, MD, MEd, J. Doss, MD, MPH, M. Maheswaranathan, MD, M.E.B. Clowse, MD, MPH, Division of Rheumatology and Immunology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Mithu Maheswaranathan
- K. Sun, MD, D.R. Anderson, MD, PhD, A.M. Eudy, PhD, J.L. Rogers, MD, L.G. Criscione-Schreiber, MD, MEd, J. Doss, MD, MPH, M. Maheswaranathan, MD, M.E.B. Clowse, MD, MPH, Division of Rheumatology and Immunology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Megan E B Clowse
- K. Sun, MD, D.R. Anderson, MD, PhD, A.M. Eudy, PhD, J.L. Rogers, MD, L.G. Criscione-Schreiber, MD, MEd, J. Doss, MD, MPH, M. Maheswaranathan, MD, M.E.B. Clowse, MD, MPH, Division of Rheumatology and Immunology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
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11
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Semo-Oz R, Wagner-Weiner L, Edens C, Zic C, One K, Saad N, Tesher M. Adherence to medication by adolescents and young adults with childhood-onset systemic lupus erythematosus. Lupus 2022; 31:1508-1515. [DOI: 10.1177/09612033221115974] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background: Approximately 20% of all cases systemic lupus erythematous (SLE) are juvenile onset. Children and adolescents with SLE usually present with more severe illness and have a higher mortality rate compared to adults with SLE. Adherence to medications in children and adolescents has a major impact on disease control as well as short- and long-term outcomes. Improved understanding of adherence rates, risk factors for non-adherence, and barriers to adherence are essential in order to increase patient adherence with medication regimens. The aim of our study was to evaluate adherence to medications among children and young adults with pediatric-onset SLE and identify barriers for non-adherence by utilizing several adherence evaluation methods. Methods: Adherence to medications of patients aged 12–25, with childhood-onset SLE was assessed as follows: (1). The brief medication questionnaire (BMQ): self-report tool for screening adherence and barriers to adherence. (2). Mycophenolic acid (MPA) serum level. (3). Medication possession ratio (MPR): data assessing 90-day refills and dispense prior to patient’s enrollment was collected. Results: Of the 38 patients who were enrolled in the study, 65% were found to be non-adherent according to at least 1 measurement method. Forty-four percent of patients were found to be non-adherent based on the self-reported questionnaire (BMQ). Of those taking MMF, 33% had an MPA level < 1 mcg/mL and were defined as non-adherent. Seventeen percent of patients were found to be non-adherent according to pharmacy refills rate. Forty-six percent of patients stated that their medications caused side effects, 33% of patients indicated difficulty remembering to take the medications, and 25% reported difficulty paying for medications. The disease activity index (SLEDAI) score of the “adherent group” at diagnosis was significantly lower compared to the “non-adherent” group. Patients with private insurance had more access barriers to obtaining medications compared to patients with public insurance. Conclusion: Non-adherence to medications is highly prevalent among cSLE patients. Higher SLEDAI score is a risk factor for non-adherence. Adherence to medications should be routinely evaluated among adolescence and young adults with cSLE and barriers to adherence need to be addressed to decrease morbidity and improve patient outcomes.
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Affiliation(s)
- Rotem Semo-Oz
- Section of Pediatric Rheumatology, University of Chicago Medical Center, Chicago, IL, USA
- Department B/Pediatric Rheumatology, Edmond and Lily Safra Children’s Hospital, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Linda Wagner-Weiner
- Section of Pediatric Rheumatology, University of Chicago Medical Center, Chicago, IL, USA
| | - Cuoghi Edens
- Sections of Rheumatology and Pediatric Rheumatology, Departments of Internal Medicine and Pediatrics, University of Chicago Medical Center, Chicago, IL, USA
| | - Carolyn Zic
- Section of Pediatric Rheumatology, University of Chicago Medical Center, Chicago, IL, USA
| | - Karen One
- Section of Pediatric Rheumatology, University of Chicago Medical Center, Chicago, IL, USA
| | - Nadine Saad
- Division of Pediatric Rheumatology, Hospital for Special Surgery, New York, NY, USA
| | - Melissa Tesher
- Section of Pediatric Rheumatology, University of Chicago Medical Center, Chicago, IL, USA
- Pediatric Rheumatology Clinic, C. S. Mott Children’s Hospital, Ann Arbor, MI, USA
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12
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Garg S, Chewning B, Gazeley D, Gomez S, Kaitz N, Weber AC, Rosenthal A, Bartels C. Patient and healthcare team recommended medication adherence strategies for hydroxychloroquine: results of a qualitative study informing intervention development. Lupus Sci Med 2022; 9:9/1/e000720. [PMID: 35914839 PMCID: PMC9345084 DOI: 10.1136/lupus-2022-000720] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 07/19/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Patients identified as black and from disadvantaged backgrounds have a twofold higher hydroxychloroquine (HCQ) non-adherence, which contributes to worse lupus outcomes and disparities. Yet, most adherence interventions lack tailored strategies for racially and socioeconomically diverse patients who face unique challenges with HCQ. We aimed to examine a broadly representative group of patients with SLE and physician perspectives on HCQ adherence and adherence strategies to redesign an adherence intervention. METHODS We conducted four virtual focus groups (90 min each) with 11 racially and socioeconomically diverse patients with SLE recruited from two health systems. Additionally, we hosted two focus group meetings with nine healthcare advisors. In focus groups, patients: (1) shared their perspectives on using HCQ; (2) shared concerns leading to non-adherence; (3) discussed strategies to overcome concerns; (4) prioritised strategies from the most to least valuable to inform an adherence intervention. In two separate focus groups, healthcare advisors gave feedback to optimise an adherence intervention. Using content analysis, we analysed transcripts to redesign our adherence intervention. RESULTS Worry about side effects was the most common barrier phrase mentioned by patients. Key themes among patients' concerns about HCQ included: information gaps, logistical barriers, misbeliefs and medication burden. Finally, patients suggested adherence strategies and ranked those most valuable including co-pay assistance, personal reminders, etc. Patient and healthcare advisors informed designing a laminate version of an adherence intervention to link each barrier category with four to six patient-recommended adherence strategies. CONCLUSION We developed a patient stakeholder-informed and healthcare stakeholder-informed tailored intervention that will target non-adherence at the individual patient level.
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Affiliation(s)
- Shivani Garg
- Department of Medicine, Division of Rheumatology, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Betty Chewning
- Department of Pharmacy, University of Wisconsin-Madison School of Pharmacy, Madison, Wisconsin, USA
| | - David Gazeley
- Department of Medicine, Rheumatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Shelby Gomez
- Department of Pharmacy, University of Wisconsin-Madison School of Pharmacy, Madison, Wisconsin, USA
| | - Noah Kaitz
- Department of Pharmacy, University of Wisconsin-Madison School of Pharmacy, Madison, Wisconsin, USA
| | - Amanda C Weber
- Department of Medicine, Division of Rheumatology, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Ann Rosenthal
- Department of Medicine, Division of Rheumatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Christie Bartels
- Department of Medicine, Division of Rheumatology, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
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13
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Clowse MEB, Eudy AM, Balevic S, Sanders-Schmidler G, Kosinski A, Fischer-Betz R, Gladman DD, Molad Y, Nalli C, Mokbel A, Tincani A, Urowitz M, Bay C, van Noord M, Petri M. Hydroxychloroquine in the pregnancies of women with lupus: a meta-analysis of individual participant data. Lupus Sci Med 2022; 9:9/1/e000651. [PMID: 35318256 PMCID: PMC8935175 DOI: 10.1136/lupus-2021-000651] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 02/26/2022] [Indexed: 11/21/2022]
Abstract
Objective Multiple guidelines recommend continuing hydroxychloroquine (HCQ) for SLE during pregnancy based on observational data. The goal of this individual patient data meta-analysis was to identify the potential benefits and harms of HCQ use within lupus pregnancies. Methods Eligible studies included prospectively collected pregnancies in women with lupus. After a systematic literature search, seven datasets meeting inclusion criteria were obtained. Pregnancy outcomes and lupus activity were compared for pregnancies with a visit in the first trimester in women who did or did not take HCQ throughout pregnancy. Birth defects were not systematically collected. This analysis was conducted in each dataset, and results were aggregated to provide a pooled OR. Results Seven cohorts provided 938 pregnancies in 804 women. After selecting one pregnancy per patient with a first trimester visit, 668 pregnancies were included; 63% took HCQ throughout pregnancy. Compared with pregnancies without HCQ, those with HCQ had lower odds of highly active lupus, but did not have different odds of fetal loss, preterm delivery or pre-eclampsia. Among women with low lupus activity, HCQ reduced the odds of preterm delivery. Conclusions This large study of prospectively-collected lupus pregnancies demonstrates a decrease in lupus activity among woman who continue HCQ through pregnancy and no harm to pregnancy outcomes. Like all studies of HCQ in lupus pregnancy, this study is confounded by indication and non-adherence. As this study confirms the safety of HCQ and diminished SLE activity with use, it is consistent with current recommendations to continue HCQ throughout pregnancy.
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Affiliation(s)
| | - Amanda M Eudy
- Medicine, Duke University, Durham, North Carolina, USA
| | - Stephen Balevic
- Rheumatology and Clinical Immunology, Duke University, Durham, North Carolina, USA.,The Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Gillian Sanders-Schmidler
- Duke-Margolis Center for Health Policy, Duke Clinical Research Institute and Department of Population Health Sciences, Duke University, Durham, North Carolina, USA
| | - Andrzej Kosinski
- Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
| | | | - Dafna D Gladman
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Yair Molad
- Rheumtology, Beilinson Hospital, Rabin Medical Center, Petach Tikva, Israel
| | - Cecilia Nalli
- Rheumatology and Clinical Immunology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | | | - Angela Tincani
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Murray Urowitz
- Center for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital, University of Toronto, Lupus Clinic, Toronto, Ontario, Canada
| | | | - Megan van Noord
- Library, University of California Davis, Davis, California, USA
| | - Michelle Petri
- Rheumatology, Johns Hopkins University, Baltimore, Maryland, USA
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14
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Daftarian N, Lima A, Marozoff S, Ojo D, Levasseur SD, Maberley DAL, Hoens A, Esdaile J, Dawes M, Aviña-Zubieta JA, Adante B, Bhui RD, Bhui SB, Butler M, Chui L, Erasmus M, Etminan M, Godinho D, Hay E, Hollands H, Hoonjan M, Joe A, Lukaris A, Mammo Z, Navajas E, Pakzad-Vaezi K, Sanmugasunderam S, Shojania K. RetINal Toxicity And HydroxyChloroquine Therapy (INTACT): protocol for a prospective population-based cohort study. BMJ Open 2022; 12:e053852. [PMID: 35177450 PMCID: PMC8860004 DOI: 10.1136/bmjopen-2021-053852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
PURPOSE Hydroxychloroquine (HCQ) is an important medication for patients with systemic lupus erythematosus (SLE), rheumatoid arthritis (RA) and other rheumatic diseases. Although it is well-tolerated and cost-effective, the risk of HCQ retinal toxicity is of increasing concern. The aim of this study is to re-examine the HCQ retinal toxicity incidence rate, risk factors and clinical course after discontinuation. METHODS We designed a prospective population-based cohort study in adult patients with SLE or RA, currently receiving HCQ for five or more years, who are residents of British Columbia (BC), Canada. Based on administrative data, we identified 5508 eligible participants (1346 SLE and 4162 RA). They will participate in annual or biannual retinal screening over 5 years in alignment with the recently revised American Academy of Ophthalmology guidelines. To standardise procedures for retinal screening, imaging, diagnostic criteria, severity staging and data transfer, a consensus meeting was convened in December 2019 with participation of BC retinal specialists and the research team. Agreement was attained on: use of spectral domain-optical coherence tomography as the primary objective screening modality; classification of images into categories of normal, equivocal or abnormal; and transferring the equivocal and abnormal images plus corresponding subjective test results via cloud-based server from each clinic to a reading centre. Confirmation of HCQ retinal toxicity diagnoses and severity staging will be performed by three independent and masked reviewers. The incidence of HCQ retinal toxicity will be calculated, accounting for the competing risk of death. Hazard ratios for each risk factor will be calculated for the risk of HCQ retinopathy, after adjusting for confounders. We will also estimate the risk of HCQ retinal toxicity progression over 5 years. ETHICS AND DISSEMINATION This study has received approval from the University of British Columbia Clinical Research Ethics Board (H20-00736) and the Vancouver Coastal Health Research Institute.
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Affiliation(s)
- Narsis Daftarian
- Arthritis Research Canada, Vancouver, British Columbia, Canada
- Experimental Medicine, Department of Medicine, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Adriana Lima
- Arthritis Research Canada, Vancouver, British Columbia, Canada
| | - Shelby Marozoff
- Arthritis Research Canada, Vancouver, British Columbia, Canada
| | - Dami Ojo
- Arthritis Research Canada, Vancouver, British Columbia, Canada
| | - Steve D Levasseur
- Department of Ophthalmology and Visual Sciences, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - David A L Maberley
- Department of Ophthalmology and Visual Sciences, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Alison Hoens
- Department of Physical Therapy, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
- Centre for Clinical Epidemiology & Evaluation, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - John Esdaile
- Arthritis Research Canada, Vancouver, British Columbia, Canada
- Division of Rheumatology, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Martin Dawes
- Department of Family Practice, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - J Antonio Aviña-Zubieta
- Arthritis Research Canada, Vancouver, British Columbia, Canada
- Division of Rheumatology, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Beatrice Adante
- Department of Ophthalmology and Visual Sciences, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Ravinder Dennis Bhui
- Department of Ophthalmology and Visual Sciences, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Suruchi B Bhui
- Department of Ophthalmology and Visual Sciences, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Michael Butler
- Department of Ophthalmology and Visual Sciences, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Lica Chui
- Department of Ophthalmology and Visual Sciences, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Murray Erasmus
- Department of Ophthalmology and Visual Sciences, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
- Faculty of Medicine, University of Victoria Island Medical Program, Victoria, British Columbia, Canada
| | - Mahyar Etminan
- Departments of Ophthalmology and Visual Sciences, Pharmacology and Medicine, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Derek Godinho
- Department of Ophthalmology and Visual Sciences, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Elizabeth Hay
- Department of Ophthalmology and Visual Sciences, Nanaimo Regional General Hospital, Nanaimo, British Columbia, Canada
| | - Hussein Hollands
- Department of Ophthalmology and Visual Sciences, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Malvinder Hoonjan
- Department of Ophthalmology and Visual Sciences, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Aaron Joe
- Kelowna General Hospital, Kelowna, British Columbia, Canada
| | - Andrew Lukaris
- Department of Ophthalmology and Visual Sciences, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Zaid Mammo
- Department of Ophthalmology and Visual Sciences, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Eduardo Navajas
- Department of Ophthalmology and Visual Sciences, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Kaivon Pakzad-Vaezi
- Department of Ophthalmology and Visual Sciences, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Suren Sanmugasunderam
- Department of Ophthalmology and Visual Sciences, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Kam Shojania
- Arthritis Research Canada, Vancouver, British Columbia, Canada
- Division of Rheumatology, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
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15
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Pirri S, Talarico R, Marinello D, Turchetti G, Mosca M. A systematic literature review of existing tools used to assess medication adherence in connective tissue diseases: the state of the art for the future development of co-designed measurement tools. Reumatismo 2021; 73. [PMID: 34814655 DOI: 10.4081/reumatismo.2021.1418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 09/18/2021] [Indexed: 11/23/2022] Open
Abstract
Lack of medication adherence is frequent in chronic connective tissue diseases and is associated with poorer health outcomes, low quality of life and economic loss. This research is based on a systematic literature search and aims to identify the surveys and tools used for the assessment of medication adherence in patients with connective tissue diseases (CTDs) and in particular the tools co-designed with patients. A systematic literature review was performed in PubMed and Embase databases searching for studies concerning the application of surveys or tools designed for medication adherence assessment. A specific analysis was also performed to identify which of these existing tools were developed in co-design with patients affected by CTDs. 1958 references were identified, and 31 studies were finally included. Systemic lupus erythematosus was the most investigated disease, followed by the Behçet's disease. The tools used to assess adherence in CTDs were, in most cases, valid and useful. However, the results showed a certain degree of heterogeneity among the studies and the medication adherence assessment and measurement tools adopted, which were mostly based on selfreported questionnaire. No co-designed tools with patients were found. Low- and non-adherence were explored in some CTDs with valid and useful tools, while other CTDs still need to be assessed. Therefore, more efforts should be made to better understand the specific reasons for the low- and non-adherence in CTDs patients.
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Affiliation(s)
- S Pirri
- Institute of Management, Scuola Superiore Sant'Anna, Pisa.
| | - R Talarico
- Rheumatology Unit, Azienda Ospedaliero Universitaria Pisana, Pisa.
| | - D Marinello
- Rheumatology Unit, Azienda Ospedaliero Universitaria Pisana, Pisa.
| | - G Turchetti
- Institute of Management, Scuola Superiore Sant'Anna, Pisa.
| | - M Mosca
- Rheumatology Unit, Azienda Ospedaliero Universitaria Pisana, Pisa.
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16
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Balevic SJ, Sagcal-Gironella ACP. Precision Medicine: Towards Individualized Dosing in Pediatric Rheumatology. Rheum Dis Clin North Am 2021; 48:305-330. [PMID: 34798954 DOI: 10.1016/j.rdc.2021.09.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Despite an increase in the number of available therapeutics, many children with rheumatic disease continue to experience active inflammatory disease and treatment failure. One reason for treatment failure is the lack of dosing paradigms to account for the wide between-patient variability in drug pharmacokinetics because of developmental changes or genetic polymorphisms that effect drug absorption, distribution, metabolism, and elimination. This review highlights several strategies to optimize dosing for biologic and nonbiologic disease-modifying antirheumatic drugs, including therapeutic drug monitoring, pharmacogenomics, and the use of pharmacokinetic/pharmacodynamic modeling.
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Affiliation(s)
- Stephen J Balevic
- Department of Pediatrics, Duke University, Durham, NC, USA; Duke Clinical Research Institute, Durham, NC, USA.
| | - Anna Carmela P Sagcal-Gironella
- Department of Pediatrics, Hackensack Meridian School of Medicine, Nutley, NJ, USA; Division of Pediatric Rheumatology, Joseph M. Sanzari Children's Hospital, 30 Prospect Avenue, WFAN 3rd Floor, Hackensack, NJ 07601, USA; K. HovnanianChildren's Hospital, Neptune, NJ, USA
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17
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Garg S, Unnithan R, Hansen KE, Costedoat-Chalumeau N, Bartels CM. Clinical Significance of Monitoring Hydroxychloroquine Levels in Patients With Systemic Lupus Erythematosus: A Systematic Review and Meta-Analysis. Arthritis Care Res (Hoboken) 2021; 73:707-716. [PMID: 32004406 DOI: 10.1002/acr.24155] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 01/21/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Despite the pivotal role that hydroxychloroquine (HCQ) plays in treating systemic lupus erythematosus (SLE), less than 50% of patients take HCQ as prescribed. Measurement of HCQ blood levels can help clinicians distinguish nonadherence versus lack of efficacy of HCQ. Our objective was to systematically review publications and perform a meta-analysis to examine the correlation between HCQ levels and 1) nonadherence and 2) Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) scores, in SLE. METHODS A comprehensive search was performed. We included observational and interventional studies that measured HCQ levels and assessed adherence or SLEDAI scores in adults with SLE. Forest plots compared pooled estimates of correlations between HCQ levels and reported nonadherence or SLEDAI scores. RESULTS Among 604 studies screened, 17 were reviewed. We found 3-times higher odds of reported nonadherence in patients with low HCQ levels (odds ratio 2.95 [95% confidence interval (95% CI) 1.63, 5.35], P < 0.001). The mean SLEDAI score was 3.14 points higher in groups with below-threshold HCQ levels on a priori analysis (δ = 3.14 [95% CI -0.05, 6.23], P = 0.053), and 1.4 points higher in groups with HCQ levels of <500 ng/ml (δ = 1.42 [95% CI 0.07, 2.76], P = 0.039). Among 1,223 patients, those with HCQ levels ≥750 ng/ml had a 58% lower risk of active disease, and their SLEDAI score was 3.2 points lower. CONCLUSION We found a strong association between low HCQ levels and reported nonadherence. Our results suggest that HCQ levels of ≥750 ng/ml might be a potential therapeutic target.
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Affiliation(s)
- Shivani Garg
- University of Wisconsin School of Medicine and Public Health, Madison
| | - Rachna Unnithan
- University of Wisconsin School of Medicine and Public Health, Madison
| | - Karen E Hansen
- University of Wisconsin School of Medicine and Public Health, Madison
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Lenfant T, Salah S, Leroux G, Bousquet E, Le Guern V, Chasset F, Francès C, Morel N, Chezel J, Papo T, Cacoub P, Mouthon L, Guettrot-Imbert G, Cohen P, Régent A, Mauget-Faÿsse M, Piette JC, Jallouli M, Costedoat-Chalumeau N. Risk factors for hydroxychloroquine retinopathy in systemic lupus erythematosus: a case-control study with hydroxychloroquine blood-level analysis. Rheumatology (Oxford) 2021; 59:3807-3816. [PMID: 32442312 PMCID: PMC8186841 DOI: 10.1093/rheumatology/keaa157] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 03/05/2020] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE HCQ is an essential medication in SLE, proven to lengthen survival and reduce flares. Its use, however, is limited by its rare but severe ophthalmological complications. Here, we aimed to analyse factors associated with HCQ retinopathy including HCQ blood levels. METHODS This case-control study compared SLE patients with and without HCQ retinopathy, defined by abnormal results for at least two of the following ophthalmological tests: automated visual fields, spectral-domain optical coherence tomography (SD-OCT), multifocal electroretinogram (mfERG) and fundus autofluorescence. We compared clinical and laboratory findings to assess risk factors for HCQ retinopathy. RESULTS The study included 23 patients with confirmed retinopathy (cases) and 547 controls. In the univariate analysis, age (P < 0.001), height (P = 0.045), creatinine clearance (P < 0.001), haemoglobin concentration (P = 0.01), duration of HCQ intake, (P < 0.001), higher cumulative HCQ dose (P < 0.001) and geographical origin (West Indies and sub-Saharan Africa) (P = 0.007) were associated with the risk of retinopathy, while HCQ blood levels were not. In the multivariate analysis, only cumulative dose (P = 0.016), duration of intake (P = 0.039), creatinine clearance (P = 0.002) and geographical origin (P < 0.0001, odds ratio 8.7) remained significantly associated with retinopathy. CONCLUSION SLE patients on HCQ should be closely monitored for retinopathy, especially those from the West Indies or sub-Saharan Africa, or with renal insufficiency, longer HCQ intake or a high cumulative dose. Although reducing the daily dose of HCQ in patients with persistently high HCQ blood levels seems logical, these concentrations were not associated with retinopathy in this study with controls adherent to treatment.
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Affiliation(s)
- Tiphaine Lenfant
- Department of Internal Medicine, Centre de Référence Maladies Auto-Immunes et Systémiques Rares d'Ile de France, Cochin Hospital, APHP
| | - Sawsen Salah
- Department of Ophthalmology, Ophtalmopôle, Cochin Hospital, APHP
| | - Gaëlle Leroux
- Department of Internal Medicine and Clinical Immunology, Centre de Référence Maladies Auto-Immunes et Systémiques Rares de l'île de France, Pitié-Salpêtrière University Hospital, APHP
| | - Elodie Bousquet
- Department of Ophthalmology, Ophtalmopôle, Cochin Hospital, APHP.,Faculty of Medicine, Université de Paris
| | - Véronique Le Guern
- Department of Internal Medicine, Centre de Référence Maladies Auto-Immunes et Systémiques Rares d'Ile de France, Cochin Hospital, APHP
| | - François Chasset
- Department of Dermatology and Allergology, Tenon Hospital, APHP.,Faculty of Medicine, Sorbonne University
| | - Camille Francès
- Department of Dermatology and Allergology, Tenon Hospital, APHP
| | - Nathalie Morel
- Department of Internal Medicine, Centre de Référence Maladies Auto-Immunes et Systémiques Rares d'Ile de France, Cochin Hospital, APHP
| | - Julie Chezel
- Department of Internal Medicine, Bichat-Claude Bernard Hospital, APHP
| | - Thomas Papo
- Faculty of Medicine, Université de Paris.,Department of Internal Medicine, Bichat-Claude Bernard Hospital, APHP
| | - Patrice Cacoub
- Department of Internal Medicine and Clinical Immunology, Centre de Référence Maladies Auto-Immunes et Systémiques Rares de l'île de France, Pitié-Salpêtrière University Hospital, APHP.,Faculty of Medicine, Sorbonne University.,INSERM, UMR_S 959.,Paris CNRS, FRE3632
| | - Luc Mouthon
- Department of Internal Medicine, Centre de Référence Maladies Auto-Immunes et Systémiques Rares d'Ile de France, Cochin Hospital, APHP.,Faculty of Medicine, Université de Paris.,INSERM U1016, Équipe Neutrophiles et Vascularites, Institut Cochin
| | - Gaëlle Guettrot-Imbert
- Department of Internal Medicine, Centre de Référence Maladies Auto-Immunes et Systémiques Rares d'Ile de France, Cochin Hospital, APHP
| | - Pascal Cohen
- Department of Internal Medicine, Centre de Référence Maladies Auto-Immunes et Systémiques Rares d'Ile de France, Cochin Hospital, APHP
| | - Alexis Régent
- Department of Internal Medicine, Centre de Référence Maladies Auto-Immunes et Systémiques Rares d'Ile de France, Cochin Hospital, APHP.,Faculty of Medicine, Université de Paris
| | - Martine Mauget-Faÿsse
- Clinical Investigative Platform, Rothschild Ophthalmologic Foundation Hospital, Paris, France
| | - Jean-Charles Piette
- Department of Internal Medicine and Clinical Immunology, Centre de Référence Maladies Auto-Immunes et Systémiques Rares de l'île de France, Pitié-Salpêtrière University Hospital, APHP
| | - Moez Jallouli
- Department of Internal Medicine, Hédi Chaker Sfax Hospital, Sfax, Tunisia
| | - Nathalie Costedoat-Chalumeau
- Department of Internal Medicine, Centre de Référence Maladies Auto-Immunes et Systémiques Rares d'Ile de France, Cochin Hospital, APHP.,Faculty of Medicine, Université de Paris.,Center for Epidemiology and Statistics, Sorbonne Paris Cité (CRESS), INSERM U1153, Paris, France
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Piga M, Arnaud L. The Main Challenges in Systemic Lupus Erythematosus: Where Do We Stand? J Clin Med 2021; 10:E243. [PMID: 33440874 PMCID: PMC7827672 DOI: 10.3390/jcm10020243] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 01/04/2021] [Accepted: 01/08/2021] [Indexed: 12/12/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is an immune-mediated multi-systemic disease characterized by a wide variability of clinical manifestations and a course frequently subject to unpredictable flares. Despite significant advances in the understanding of the pathophysiology and optimization of medical care, patients with SLE still have significant mortality and carry a risk of progressive organ damage accrual and reduced health-related quality of life. New tools allow earlier classification of SLE, whereas tailored early intervention and treatment strategies targeted to clinical remission or low disease activity could offer the opportunity to reduce damage, thus improving long-term outcomes. Nevertheless, the early diagnosis of SLE is still an unmet need for many patients. Further disentangling the SLE susceptibility and complex pathogenesis will allow to identify more accurate biomarkers and implement new ways to measure disease activity. This could represent a major step forward to find new trials modalities for developing new drugs, optimizing the use of currently available therapeutics and minimizing glucocorticoids. Preventing and treating comorbidities in SLE, improving the management of hard-to-treat manifestations including management of SLE during pregnancy are among the remaining major unmet needs. This review provides insights and a research agenda for the main challenges in SLE.
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Affiliation(s)
- Matteo Piga
- Rheumatology Unit, AOU University Clinic and University of Cagliari, 09042 Cagliari, Italy;
| | - Laurent Arnaud
- Service de Rhumatologie, Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, 67000 Strasbourg, France
- Centre National de Références des Maladies Systémiques et Auto-immunes Rares Est Sud-Ouest (RESO), 67000 Strasbourg, France
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Adherence to hydroxychloroquine in patients with systemic lupus: Contrasting results and weak correlation between assessment tools. Joint Bone Spine 2020; 87:603-610. [PMID: 32438061 DOI: 10.1016/j.jbspin.2020.04.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Accepted: 04/24/2020] [Indexed: 01/11/2023]
Abstract
OBJECTIVES Hydroxychloroquine (HCQ) is an anchor drug in the treatment of systemic lupus erythematosus (SLE). Adherence to HCQ is key for efficacy. Inaccurate evaluation of adherence could lead to non-justified switch to more expensive or less tolerated drugs. METHODS Severe non-adherence rate to HCQ was estimated in a sample of SLE patients during a routine visit using blood HCQ concentration<200μg/L. Adherence was assessesd by the Medication Adherence Self-Report Inventory (MASRI)<80/100, 8-item Morisky Medication Adherence Scale (MMAS-8) ≤6/8, Health Care Provider (HCP) visual analog scale (VAS)<80/100. Same procedures were to be repeated during a further routine visit 6 to 12 months later. We described agreement and correlations between tools and compared severely non-adherent patients and others on their characteristics. RESULTS The study involved 158 patients (86.1% females) aged 42.2±12.6 years treated with HCQ for 9.6±6.9 years. Blood HCQ concentration (mean±standard deviation) was 1046±662μg/L at visit 1 and 855±577μg/L at visit 2. At visit 1, the non-adherence rate varied from 3.2% (blood HCQ level<200μg/L) to 7.7% (MASRI), 12.4% (HCP-VAS) or 32.5% (MMAS-8). 37.8% of patients met at least one of the definitions of non-adherence. Patients' characteristics including SLE activity, damage and quality of life were similar between severely non-adherent patients and others. Correlations between blood HCQ-concentration and self-questionnaires were weak (r<0.25) and agreement between methods was poor. CONCLUSION Blood HCQ concentration<200μg/L reveals severe non-adherence. Combining blood HCQ concentration with MASRI and MMAS-8 may help to better identify non-adherence in SLE. Agreement between methods was poor and correlations with HCQ level and SLE activity were weak.
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Balevic SJ, Hornik CP, Green TP, Clowse MEB, Gonzalez D, Maharaj AR, Schanberg LE, Eudy AM, Swamy GK, Hughes BL, Cohen-Wolkowiez M. Hydroxychloroquine in Patients with Rheumatic Disease Complicated by COVID-19: Clarifying Target Exposures and the Need for Clinical Trials. J Rheumatol 2020; 47:jrheum.200493. [PMID: 32393664 PMCID: PMC7655510 DOI: 10.3899/jrheum.200493] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To characterize hydroxychloroquine (HCQ) exposure in patients with rheumatic disease receiving longterm HCQ compared to target concentrations with reported antiviral activity against the coronavirus disease 2019 caused by SARS-CoV-2 (COVID-19). METHODS We evaluated total HCQ concentrations in serum and plasma from published literature values, frozen serum samples from a pediatric systemic lupus erythematosus trial, and simulated concentrations using a published pharmacokinetic model during pregnancy. For each source, we compared observed or predicted HCQ concentrations to target concentrations with reported antiviral activity against SARS-CoV-2. RESULTS The average total serum/plasma HCQ concentrations were below the lowest SARS-CoV-2 target of 0.48 mg/l in all studies. Assuming the highest antiviral target exposure (total plasma concentration of 4.1 mg/l), all studies had about one-tenth the necessary concentration for in vitro viral inhibition. Pharmacokinetic model simulations confirmed that pregnant adults receiving common dosing for rheumatic diseases did not achieve target exposures; however, the models predict that a dosage of 600 mg once a day during pregnancy would obtain the lowest median target exposure for most patients after the first dose. CONCLUSION We found that the average patient receiving treatment with HCQ for rheumatic diseases, including children and non-pregnant/pregnant adults, are unlikely to achieve total serum or plasma concentrations shown to inhibit SARS-CoV-2 in vitro. Nevertheless, patients receiving HCQ long term may have tissue concentrations far exceeding that of serum/plasma. Because the therapeutic window for HCQ in the setting of SARS-CoV-2 is unknown, well-designed clinical trials that include patients with rheumatic disease are urgently needed to characterize the efficacy, safety, and target exposures for HCQ.
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Affiliation(s)
- Stephen J Balevic
- From the Department of Rheumatology and Immunology, Duke University School of Medicine, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA; Department of Pediatrics, and the Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Duke University School of Medicine, Durham, North Carolina, USA; Department of Pediatrics, Northwestern University, Feinberg School of Medicine, Evanston, Illinois, USA; Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA. This study was supported by the Rheumatology Research Foundation's Scientist Development Award, the Thrasher Research Fund, the Childhood Arthritis and Rheumatology Research Alliance/Arthritis Foundation, the Derfner Foundation, NIGMS/NICHD (2T32GM086330-06), NICHD (5R01-HD076676-04, HHSN275201000003I), and a Duke Health/Private Diagnostic Clinic ENABLE grant. The Atherosclerosis Prevention in Pediatric Lupus Erythematosus [APPLE (ClinicalTrials. gov: NCT00065806)] trial is supported by the US National Institutes of Health (NIH) National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) contract N01-AR-2-2265, the Edna and Fred L. Mandel Jr. Center for Hypertension and Atherosclerosis, and Pfizer, which provided atorvastatin and matching placebo. S.J.B. receives support from the NIH (5R01-HD076676-04, 1R01HD083003-01, HHSN275201000003I, HHSN275201800003I, HHSN272201500006I 5U24-TR001608-03), the US Food and Drug Administration (5U18FD006298-03), the Patient-Centered Outcomes Research Institute (PCORI), the Rheumatology Research Foundation's Scientist Development Award, the Thrasher Research Fund, and the Childhood Arthritis and Rheumatology Research Alliance/Arthritis Foundation. C.P.H. receives salary support for research from the National Institute for Child Health and Human Development (NICHD; 1K23HD090239; R13HD102136), National Heart Lung and Blood Institute (R61/R33HL147833), FDA (1R01-FD006099, PI: Laughon; and 5U18-FD006298, PI: Benjamin), the US government for his work in pediatric clinical pharmacology (Government Contract HHSN275201800003I, PI: Benjamin under the Best Pharmaceuticals for Children Act), the nonprofit Burrhoughs Wellcome Fund, and other sponsors for drug development in adults and children (dcri.org/about-us/ conflict-of-interest). D.G. receives support for research from the Eunice Kennedy Shriver NICHD (5R01HD096435). A.M. receives research support from the Thrasher Research Fund (www.thrasherresearch.org). L.E.S. receives support for research from the NIH (U19AR069522), PCORI (8177), and the Childhood Arthritis and Rheumatology Research Alliance. She is on the Data Safety Monitoring Board for investigational product trials for UCB (Cimzia) and Sanofi (sarilumab). Sanofi is a maker of hydroxychloroquine. Samples used in this publication were collected as part of NIH/NIAMS (N01-AR-2-2265). A.M.E. receives support from the NIH National Center for Advancing Translational Sciences. G.K.S. receives support for research from the NIH (UG1 HD068258‑06, HHSN272201300017I, 1UL1TR002553-01, R21AI132677) and the Centers for Disease Control and Prevention (200-2012-53663). She chairs an Independent Data Monitoring Committee for GlaxoSmithKline (RSV vaccine trials). M.C.W. receives support for research from the NIH (1R01-HD076676‑01A1 and 1K24-AI143971), National Institute of Allergy and Infectious Diseases (HHSN272201500006I and HHSN272201300017I), NICHD (HHSN275201000003I), FDA (5U18-FD006298), and the industry for drug development in adults and children. S.J. Balevic, MD, MHS, Department of Rheumatology and Immunology, and Department of Pediatrics, Duke University School of Medicine, and Duke Clinical Research Institute; C.P. Hornik, MD, PhD, Duke Clinical Research Institute, and Department of Pediatrics, Duke University School of Medicine; T.P. Green, MD, MS, Department of Pediatrics, Northwestern University, Feinberg School of Medicine; M.E. Clowse, MD, MPH, Department of Rheumatology and Immunology, Duke University School of Medicine; D. Gonzalez, PharmD, PhD, Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill; A.R. Maharaj, PhD, Duke Clinical Research Institute; L.E. Schanberg, MD, Duke Clinical Research Institute, and Department of Pediatrics, Duke University School of Medicine; A.M. Eudy, PhD, Department of Rheumatology and Immunology, Duke University School of Medicine; G.K. Swamy, MD, Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Duke University School of Medicine; B.L. Hughes, MD, MSc, Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Duke University School of Medicine; M. Cohen-Wolkowiez, MD, PhD, Duke Clinical Research Institute, and Department of Pediatrics, Duke University School of Medicine. Address correspondence to Dr. S.J. Balevic, Department of Rheumatology and Immunology, Duke University School of Medicine, 2301 Erwin Road, CHC, T-Level, Durham, North Carolina 27710, USA. E-mail: . Full Release Article. For details see Reprints and Permissions at jrheum. org. Accepted for publication May 14, 2019
| | - Christoph P Hornik
- From the Department of Rheumatology and Immunology, Duke University School of Medicine, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA; Department of Pediatrics, and the Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Duke University School of Medicine, Durham, North Carolina, USA; Department of Pediatrics, Northwestern University, Feinberg School of Medicine, Evanston, Illinois, USA; Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA. This study was supported by the Rheumatology Research Foundation's Scientist Development Award, the Thrasher Research Fund, the Childhood Arthritis and Rheumatology Research Alliance/Arthritis Foundation, the Derfner Foundation, NIGMS/NICHD (2T32GM086330-06), NICHD (5R01-HD076676-04, HHSN275201000003I), and a Duke Health/Private Diagnostic Clinic ENABLE grant. The Atherosclerosis Prevention in Pediatric Lupus Erythematosus [APPLE (ClinicalTrials. gov: NCT00065806)] trial is supported by the US National Institutes of Health (NIH) National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) contract N01-AR-2-2265, the Edna and Fred L. Mandel Jr. Center for Hypertension and Atherosclerosis, and Pfizer, which provided atorvastatin and matching placebo. S.J.B. receives support from the NIH (5R01-HD076676-04, 1R01HD083003-01, HHSN275201000003I, HHSN275201800003I, HHSN272201500006I 5U24-TR001608-03), the US Food and Drug Administration (5U18FD006298-03), the Patient-Centered Outcomes Research Institute (PCORI), the Rheumatology Research Foundation's Scientist Development Award, the Thrasher Research Fund, and the Childhood Arthritis and Rheumatology Research Alliance/Arthritis Foundation. C.P.H. receives salary support for research from the National Institute for Child Health and Human Development (NICHD; 1K23HD090239; R13HD102136), National Heart Lung and Blood Institute (R61/R33HL147833), FDA (1R01-FD006099, PI: Laughon; and 5U18-FD006298, PI: Benjamin), the US government for his work in pediatric clinical pharmacology (Government Contract HHSN275201800003I, PI: Benjamin under the Best Pharmaceuticals for Children Act), the nonprofit Burrhoughs Wellcome Fund, and other sponsors for drug development in adults and children (dcri.org/about-us/ conflict-of-interest). D.G. receives support for research from the Eunice Kennedy Shriver NICHD (5R01HD096435). A.M. receives research support from the Thrasher Research Fund (www.thrasherresearch.org). L.E.S. receives support for research from the NIH (U19AR069522), PCORI (8177), and the Childhood Arthritis and Rheumatology Research Alliance. She is on the Data Safety Monitoring Board for investigational product trials for UCB (Cimzia) and Sanofi (sarilumab). Sanofi is a maker of hydroxychloroquine. Samples used in this publication were collected as part of NIH/NIAMS (N01-AR-2-2265). A.M.E. receives support from the NIH National Center for Advancing Translational Sciences. G.K.S. receives support for research from the NIH (UG1 HD068258‑06, HHSN272201300017I, 1UL1TR002553-01, R21AI132677) and the Centers for Disease Control and Prevention (200-2012-53663). She chairs an Independent Data Monitoring Committee for GlaxoSmithKline (RSV vaccine trials). M.C.W. receives support for research from the NIH (1R01-HD076676‑01A1 and 1K24-AI143971), National Institute of Allergy and Infectious Diseases (HHSN272201500006I and HHSN272201300017I), NICHD (HHSN275201000003I), FDA (5U18-FD006298), and the industry for drug development in adults and children. S.J. Balevic, MD, MHS, Department of Rheumatology and Immunology, and Department of Pediatrics, Duke University School of Medicine, and Duke Clinical Research Institute; C.P. Hornik, MD, PhD, Duke Clinical Research Institute, and Department of Pediatrics, Duke University School of Medicine; T.P. Green, MD, MS, Department of Pediatrics, Northwestern University, Feinberg School of Medicine; M.E. Clowse, MD, MPH, Department of Rheumatology and Immunology, Duke University School of Medicine; D. Gonzalez, PharmD, PhD, Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill; A.R. Maharaj, PhD, Duke Clinical Research Institute; L.E. Schanberg, MD, Duke Clinical Research Institute, and Department of Pediatrics, Duke University School of Medicine; A.M. Eudy, PhD, Department of Rheumatology and Immunology, Duke University School of Medicine; G.K. Swamy, MD, Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Duke University School of Medicine; B.L. Hughes, MD, MSc, Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Duke University School of Medicine; M. Cohen-Wolkowiez, MD, PhD, Duke Clinical Research Institute, and Department of Pediatrics, Duke University School of Medicine. Address correspondence to Dr. S.J. Balevic, Department of Rheumatology and Immunology, Duke University School of Medicine, 2301 Erwin Road, CHC, T-Level, Durham, North Carolina 27710, USA. E-mail: . Full Release Article. For details see Reprints and Permissions at jrheum. org. Accepted for publication May 14, 2019
| | - Thomas P Green
- From the Department of Rheumatology and Immunology, Duke University School of Medicine, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA; Department of Pediatrics, and the Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Duke University School of Medicine, Durham, North Carolina, USA; Department of Pediatrics, Northwestern University, Feinberg School of Medicine, Evanston, Illinois, USA; Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA. This study was supported by the Rheumatology Research Foundation's Scientist Development Award, the Thrasher Research Fund, the Childhood Arthritis and Rheumatology Research Alliance/Arthritis Foundation, the Derfner Foundation, NIGMS/NICHD (2T32GM086330-06), NICHD (5R01-HD076676-04, HHSN275201000003I), and a Duke Health/Private Diagnostic Clinic ENABLE grant. The Atherosclerosis Prevention in Pediatric Lupus Erythematosus [APPLE (ClinicalTrials. gov: NCT00065806)] trial is supported by the US National Institutes of Health (NIH) National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) contract N01-AR-2-2265, the Edna and Fred L. Mandel Jr. Center for Hypertension and Atherosclerosis, and Pfizer, which provided atorvastatin and matching placebo. S.J.B. receives support from the NIH (5R01-HD076676-04, 1R01HD083003-01, HHSN275201000003I, HHSN275201800003I, HHSN272201500006I 5U24-TR001608-03), the US Food and Drug Administration (5U18FD006298-03), the Patient-Centered Outcomes Research Institute (PCORI), the Rheumatology Research Foundation's Scientist Development Award, the Thrasher Research Fund, and the Childhood Arthritis and Rheumatology Research Alliance/Arthritis Foundation. C.P.H. receives salary support for research from the National Institute for Child Health and Human Development (NICHD; 1K23HD090239; R13HD102136), National Heart Lung and Blood Institute (R61/R33HL147833), FDA (1R01-FD006099, PI: Laughon; and 5U18-FD006298, PI: Benjamin), the US government for his work in pediatric clinical pharmacology (Government Contract HHSN275201800003I, PI: Benjamin under the Best Pharmaceuticals for Children Act), the nonprofit Burrhoughs Wellcome Fund, and other sponsors for drug development in adults and children (dcri.org/about-us/ conflict-of-interest). D.G. receives support for research from the Eunice Kennedy Shriver NICHD (5R01HD096435). A.M. receives research support from the Thrasher Research Fund (www.thrasherresearch.org). L.E.S. receives support for research from the NIH (U19AR069522), PCORI (8177), and the Childhood Arthritis and Rheumatology Research Alliance. She is on the Data Safety Monitoring Board for investigational product trials for UCB (Cimzia) and Sanofi (sarilumab). Sanofi is a maker of hydroxychloroquine. Samples used in this publication were collected as part of NIH/NIAMS (N01-AR-2-2265). A.M.E. receives support from the NIH National Center for Advancing Translational Sciences. G.K.S. receives support for research from the NIH (UG1 HD068258‑06, HHSN272201300017I, 1UL1TR002553-01, R21AI132677) and the Centers for Disease Control and Prevention (200-2012-53663). She chairs an Independent Data Monitoring Committee for GlaxoSmithKline (RSV vaccine trials). M.C.W. receives support for research from the NIH (1R01-HD076676‑01A1 and 1K24-AI143971), National Institute of Allergy and Infectious Diseases (HHSN272201500006I and HHSN272201300017I), NICHD (HHSN275201000003I), FDA (5U18-FD006298), and the industry for drug development in adults and children. S.J. Balevic, MD, MHS, Department of Rheumatology and Immunology, and Department of Pediatrics, Duke University School of Medicine, and Duke Clinical Research Institute; C.P. Hornik, MD, PhD, Duke Clinical Research Institute, and Department of Pediatrics, Duke University School of Medicine; T.P. Green, MD, MS, Department of Pediatrics, Northwestern University, Feinberg School of Medicine; M.E. Clowse, MD, MPH, Department of Rheumatology and Immunology, Duke University School of Medicine; D. Gonzalez, PharmD, PhD, Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill; A.R. Maharaj, PhD, Duke Clinical Research Institute; L.E. Schanberg, MD, Duke Clinical Research Institute, and Department of Pediatrics, Duke University School of Medicine; A.M. Eudy, PhD, Department of Rheumatology and Immunology, Duke University School of Medicine; G.K. Swamy, MD, Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Duke University School of Medicine; B.L. Hughes, MD, MSc, Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Duke University School of Medicine; M. Cohen-Wolkowiez, MD, PhD, Duke Clinical Research Institute, and Department of Pediatrics, Duke University School of Medicine. Address correspondence to Dr. S.J. Balevic, Department of Rheumatology and Immunology, Duke University School of Medicine, 2301 Erwin Road, CHC, T-Level, Durham, North Carolina 27710, USA. E-mail: . Full Release Article. For details see Reprints and Permissions at jrheum. org. Accepted for publication May 14, 2019
| | - Megan E B Clowse
- From the Department of Rheumatology and Immunology, Duke University School of Medicine, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA; Department of Pediatrics, and the Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Duke University School of Medicine, Durham, North Carolina, USA; Department of Pediatrics, Northwestern University, Feinberg School of Medicine, Evanston, Illinois, USA; Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA. This study was supported by the Rheumatology Research Foundation's Scientist Development Award, the Thrasher Research Fund, the Childhood Arthritis and Rheumatology Research Alliance/Arthritis Foundation, the Derfner Foundation, NIGMS/NICHD (2T32GM086330-06), NICHD (5R01-HD076676-04, HHSN275201000003I), and a Duke Health/Private Diagnostic Clinic ENABLE grant. The Atherosclerosis Prevention in Pediatric Lupus Erythematosus [APPLE (ClinicalTrials. gov: NCT00065806)] trial is supported by the US National Institutes of Health (NIH) National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) contract N01-AR-2-2265, the Edna and Fred L. Mandel Jr. Center for Hypertension and Atherosclerosis, and Pfizer, which provided atorvastatin and matching placebo. S.J.B. receives support from the NIH (5R01-HD076676-04, 1R01HD083003-01, HHSN275201000003I, HHSN275201800003I, HHSN272201500006I 5U24-TR001608-03), the US Food and Drug Administration (5U18FD006298-03), the Patient-Centered Outcomes Research Institute (PCORI), the Rheumatology Research Foundation's Scientist Development Award, the Thrasher Research Fund, and the Childhood Arthritis and Rheumatology Research Alliance/Arthritis Foundation. C.P.H. receives salary support for research from the National Institute for Child Health and Human Development (NICHD; 1K23HD090239; R13HD102136), National Heart Lung and Blood Institute (R61/R33HL147833), FDA (1R01-FD006099, PI: Laughon; and 5U18-FD006298, PI: Benjamin), the US government for his work in pediatric clinical pharmacology (Government Contract HHSN275201800003I, PI: Benjamin under the Best Pharmaceuticals for Children Act), the nonprofit Burrhoughs Wellcome Fund, and other sponsors for drug development in adults and children (dcri.org/about-us/ conflict-of-interest). D.G. receives support for research from the Eunice Kennedy Shriver NICHD (5R01HD096435). A.M. receives research support from the Thrasher Research Fund (www.thrasherresearch.org). L.E.S. receives support for research from the NIH (U19AR069522), PCORI (8177), and the Childhood Arthritis and Rheumatology Research Alliance. She is on the Data Safety Monitoring Board for investigational product trials for UCB (Cimzia) and Sanofi (sarilumab). Sanofi is a maker of hydroxychloroquine. Samples used in this publication were collected as part of NIH/NIAMS (N01-AR-2-2265). A.M.E. receives support from the NIH National Center for Advancing Translational Sciences. G.K.S. receives support for research from the NIH (UG1 HD068258‑06, HHSN272201300017I, 1UL1TR002553-01, R21AI132677) and the Centers for Disease Control and Prevention (200-2012-53663). She chairs an Independent Data Monitoring Committee for GlaxoSmithKline (RSV vaccine trials). M.C.W. receives support for research from the NIH (1R01-HD076676‑01A1 and 1K24-AI143971), National Institute of Allergy and Infectious Diseases (HHSN272201500006I and HHSN272201300017I), NICHD (HHSN275201000003I), FDA (5U18-FD006298), and the industry for drug development in adults and children. S.J. Balevic, MD, MHS, Department of Rheumatology and Immunology, and Department of Pediatrics, Duke University School of Medicine, and Duke Clinical Research Institute; C.P. Hornik, MD, PhD, Duke Clinical Research Institute, and Department of Pediatrics, Duke University School of Medicine; T.P. Green, MD, MS, Department of Pediatrics, Northwestern University, Feinberg School of Medicine; M.E. Clowse, MD, MPH, Department of Rheumatology and Immunology, Duke University School of Medicine; D. Gonzalez, PharmD, PhD, Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill; A.R. Maharaj, PhD, Duke Clinical Research Institute; L.E. Schanberg, MD, Duke Clinical Research Institute, and Department of Pediatrics, Duke University School of Medicine; A.M. Eudy, PhD, Department of Rheumatology and Immunology, Duke University School of Medicine; G.K. Swamy, MD, Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Duke University School of Medicine; B.L. Hughes, MD, MSc, Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Duke University School of Medicine; M. Cohen-Wolkowiez, MD, PhD, Duke Clinical Research Institute, and Department of Pediatrics, Duke University School of Medicine. Address correspondence to Dr. S.J. Balevic, Department of Rheumatology and Immunology, Duke University School of Medicine, 2301 Erwin Road, CHC, T-Level, Durham, North Carolina 27710, USA. E-mail: . Full Release Article. For details see Reprints and Permissions at jrheum. org. Accepted for publication May 14, 2019
| | - Daniel Gonzalez
- From the Department of Rheumatology and Immunology, Duke University School of Medicine, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA; Department of Pediatrics, and the Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Duke University School of Medicine, Durham, North Carolina, USA; Department of Pediatrics, Northwestern University, Feinberg School of Medicine, Evanston, Illinois, USA; Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA. This study was supported by the Rheumatology Research Foundation's Scientist Development Award, the Thrasher Research Fund, the Childhood Arthritis and Rheumatology Research Alliance/Arthritis Foundation, the Derfner Foundation, NIGMS/NICHD (2T32GM086330-06), NICHD (5R01-HD076676-04, HHSN275201000003I), and a Duke Health/Private Diagnostic Clinic ENABLE grant. The Atherosclerosis Prevention in Pediatric Lupus Erythematosus [APPLE (ClinicalTrials. gov: NCT00065806)] trial is supported by the US National Institutes of Health (NIH) National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) contract N01-AR-2-2265, the Edna and Fred L. Mandel Jr. Center for Hypertension and Atherosclerosis, and Pfizer, which provided atorvastatin and matching placebo. S.J.B. receives support from the NIH (5R01-HD076676-04, 1R01HD083003-01, HHSN275201000003I, HHSN275201800003I, HHSN272201500006I 5U24-TR001608-03), the US Food and Drug Administration (5U18FD006298-03), the Patient-Centered Outcomes Research Institute (PCORI), the Rheumatology Research Foundation's Scientist Development Award, the Thrasher Research Fund, and the Childhood Arthritis and Rheumatology Research Alliance/Arthritis Foundation. C.P.H. receives salary support for research from the National Institute for Child Health and Human Development (NICHD; 1K23HD090239; R13HD102136), National Heart Lung and Blood Institute (R61/R33HL147833), FDA (1R01-FD006099, PI: Laughon; and 5U18-FD006298, PI: Benjamin), the US government for his work in pediatric clinical pharmacology (Government Contract HHSN275201800003I, PI: Benjamin under the Best Pharmaceuticals for Children Act), the nonprofit Burrhoughs Wellcome Fund, and other sponsors for drug development in adults and children (dcri.org/about-us/ conflict-of-interest). D.G. receives support for research from the Eunice Kennedy Shriver NICHD (5R01HD096435). A.M. receives research support from the Thrasher Research Fund (www.thrasherresearch.org). L.E.S. receives support for research from the NIH (U19AR069522), PCORI (8177), and the Childhood Arthritis and Rheumatology Research Alliance. She is on the Data Safety Monitoring Board for investigational product trials for UCB (Cimzia) and Sanofi (sarilumab). Sanofi is a maker of hydroxychloroquine. Samples used in this publication were collected as part of NIH/NIAMS (N01-AR-2-2265). A.M.E. receives support from the NIH National Center for Advancing Translational Sciences. G.K.S. receives support for research from the NIH (UG1 HD068258‑06, HHSN272201300017I, 1UL1TR002553-01, R21AI132677) and the Centers for Disease Control and Prevention (200-2012-53663). She chairs an Independent Data Monitoring Committee for GlaxoSmithKline (RSV vaccine trials). M.C.W. receives support for research from the NIH (1R01-HD076676‑01A1 and 1K24-AI143971), National Institute of Allergy and Infectious Diseases (HHSN272201500006I and HHSN272201300017I), NICHD (HHSN275201000003I), FDA (5U18-FD006298), and the industry for drug development in adults and children. S.J. Balevic, MD, MHS, Department of Rheumatology and Immunology, and Department of Pediatrics, Duke University School of Medicine, and Duke Clinical Research Institute; C.P. Hornik, MD, PhD, Duke Clinical Research Institute, and Department of Pediatrics, Duke University School of Medicine; T.P. Green, MD, MS, Department of Pediatrics, Northwestern University, Feinberg School of Medicine; M.E. Clowse, MD, MPH, Department of Rheumatology and Immunology, Duke University School of Medicine; D. Gonzalez, PharmD, PhD, Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill; A.R. Maharaj, PhD, Duke Clinical Research Institute; L.E. Schanberg, MD, Duke Clinical Research Institute, and Department of Pediatrics, Duke University School of Medicine; A.M. Eudy, PhD, Department of Rheumatology and Immunology, Duke University School of Medicine; G.K. Swamy, MD, Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Duke University School of Medicine; B.L. Hughes, MD, MSc, Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Duke University School of Medicine; M. Cohen-Wolkowiez, MD, PhD, Duke Clinical Research Institute, and Department of Pediatrics, Duke University School of Medicine. Address correspondence to Dr. S.J. Balevic, Department of Rheumatology and Immunology, Duke University School of Medicine, 2301 Erwin Road, CHC, T-Level, Durham, North Carolina 27710, USA. E-mail: . Full Release Article. For details see Reprints and Permissions at jrheum. org. Accepted for publication May 14, 2019
| | - Anil R Maharaj
- From the Department of Rheumatology and Immunology, Duke University School of Medicine, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA; Department of Pediatrics, and the Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Duke University School of Medicine, Durham, North Carolina, USA; Department of Pediatrics, Northwestern University, Feinberg School of Medicine, Evanston, Illinois, USA; Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA. This study was supported by the Rheumatology Research Foundation's Scientist Development Award, the Thrasher Research Fund, the Childhood Arthritis and Rheumatology Research Alliance/Arthritis Foundation, the Derfner Foundation, NIGMS/NICHD (2T32GM086330-06), NICHD (5R01-HD076676-04, HHSN275201000003I), and a Duke Health/Private Diagnostic Clinic ENABLE grant. The Atherosclerosis Prevention in Pediatric Lupus Erythematosus [APPLE (ClinicalTrials. gov: NCT00065806)] trial is supported by the US National Institutes of Health (NIH) National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) contract N01-AR-2-2265, the Edna and Fred L. Mandel Jr. Center for Hypertension and Atherosclerosis, and Pfizer, which provided atorvastatin and matching placebo. S.J.B. receives support from the NIH (5R01-HD076676-04, 1R01HD083003-01, HHSN275201000003I, HHSN275201800003I, HHSN272201500006I 5U24-TR001608-03), the US Food and Drug Administration (5U18FD006298-03), the Patient-Centered Outcomes Research Institute (PCORI), the Rheumatology Research Foundation's Scientist Development Award, the Thrasher Research Fund, and the Childhood Arthritis and Rheumatology Research Alliance/Arthritis Foundation. C.P.H. receives salary support for research from the National Institute for Child Health and Human Development (NICHD; 1K23HD090239; R13HD102136), National Heart Lung and Blood Institute (R61/R33HL147833), FDA (1R01-FD006099, PI: Laughon; and 5U18-FD006298, PI: Benjamin), the US government for his work in pediatric clinical pharmacology (Government Contract HHSN275201800003I, PI: Benjamin under the Best Pharmaceuticals for Children Act), the nonprofit Burrhoughs Wellcome Fund, and other sponsors for drug development in adults and children (dcri.org/about-us/ conflict-of-interest). D.G. receives support for research from the Eunice Kennedy Shriver NICHD (5R01HD096435). A.M. receives research support from the Thrasher Research Fund (www.thrasherresearch.org). L.E.S. receives support for research from the NIH (U19AR069522), PCORI (8177), and the Childhood Arthritis and Rheumatology Research Alliance. She is on the Data Safety Monitoring Board for investigational product trials for UCB (Cimzia) and Sanofi (sarilumab). Sanofi is a maker of hydroxychloroquine. Samples used in this publication were collected as part of NIH/NIAMS (N01-AR-2-2265). A.M.E. receives support from the NIH National Center for Advancing Translational Sciences. G.K.S. receives support for research from the NIH (UG1 HD068258‑06, HHSN272201300017I, 1UL1TR002553-01, R21AI132677) and the Centers for Disease Control and Prevention (200-2012-53663). She chairs an Independent Data Monitoring Committee for GlaxoSmithKline (RSV vaccine trials). M.C.W. receives support for research from the NIH (1R01-HD076676‑01A1 and 1K24-AI143971), National Institute of Allergy and Infectious Diseases (HHSN272201500006I and HHSN272201300017I), NICHD (HHSN275201000003I), FDA (5U18-FD006298), and the industry for drug development in adults and children. S.J. Balevic, MD, MHS, Department of Rheumatology and Immunology, and Department of Pediatrics, Duke University School of Medicine, and Duke Clinical Research Institute; C.P. Hornik, MD, PhD, Duke Clinical Research Institute, and Department of Pediatrics, Duke University School of Medicine; T.P. Green, MD, MS, Department of Pediatrics, Northwestern University, Feinberg School of Medicine; M.E. Clowse, MD, MPH, Department of Rheumatology and Immunology, Duke University School of Medicine; D. Gonzalez, PharmD, PhD, Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill; A.R. Maharaj, PhD, Duke Clinical Research Institute; L.E. Schanberg, MD, Duke Clinical Research Institute, and Department of Pediatrics, Duke University School of Medicine; A.M. Eudy, PhD, Department of Rheumatology and Immunology, Duke University School of Medicine; G.K. Swamy, MD, Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Duke University School of Medicine; B.L. Hughes, MD, MSc, Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Duke University School of Medicine; M. Cohen-Wolkowiez, MD, PhD, Duke Clinical Research Institute, and Department of Pediatrics, Duke University School of Medicine. Address correspondence to Dr. S.J. Balevic, Department of Rheumatology and Immunology, Duke University School of Medicine, 2301 Erwin Road, CHC, T-Level, Durham, North Carolina 27710, USA. E-mail: . Full Release Article. For details see Reprints and Permissions at jrheum. org. Accepted for publication May 14, 2019
| | - Laura E Schanberg
- From the Department of Rheumatology and Immunology, Duke University School of Medicine, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA; Department of Pediatrics, and the Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Duke University School of Medicine, Durham, North Carolina, USA; Department of Pediatrics, Northwestern University, Feinberg School of Medicine, Evanston, Illinois, USA; Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA. This study was supported by the Rheumatology Research Foundation's Scientist Development Award, the Thrasher Research Fund, the Childhood Arthritis and Rheumatology Research Alliance/Arthritis Foundation, the Derfner Foundation, NIGMS/NICHD (2T32GM086330-06), NICHD (5R01-HD076676-04, HHSN275201000003I), and a Duke Health/Private Diagnostic Clinic ENABLE grant. The Atherosclerosis Prevention in Pediatric Lupus Erythematosus [APPLE (ClinicalTrials. gov: NCT00065806)] trial is supported by the US National Institutes of Health (NIH) National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) contract N01-AR-2-2265, the Edna and Fred L. Mandel Jr. Center for Hypertension and Atherosclerosis, and Pfizer, which provided atorvastatin and matching placebo. S.J.B. receives support from the NIH (5R01-HD076676-04, 1R01HD083003-01, HHSN275201000003I, HHSN275201800003I, HHSN272201500006I 5U24-TR001608-03), the US Food and Drug Administration (5U18FD006298-03), the Patient-Centered Outcomes Research Institute (PCORI), the Rheumatology Research Foundation's Scientist Development Award, the Thrasher Research Fund, and the Childhood Arthritis and Rheumatology Research Alliance/Arthritis Foundation. C.P.H. receives salary support for research from the National Institute for Child Health and Human Development (NICHD; 1K23HD090239; R13HD102136), National Heart Lung and Blood Institute (R61/R33HL147833), FDA (1R01-FD006099, PI: Laughon; and 5U18-FD006298, PI: Benjamin), the US government for his work in pediatric clinical pharmacology (Government Contract HHSN275201800003I, PI: Benjamin under the Best Pharmaceuticals for Children Act), the nonprofit Burrhoughs Wellcome Fund, and other sponsors for drug development in adults and children (dcri.org/about-us/ conflict-of-interest). D.G. receives support for research from the Eunice Kennedy Shriver NICHD (5R01HD096435). A.M. receives research support from the Thrasher Research Fund (www.thrasherresearch.org). L.E.S. receives support for research from the NIH (U19AR069522), PCORI (8177), and the Childhood Arthritis and Rheumatology Research Alliance. She is on the Data Safety Monitoring Board for investigational product trials for UCB (Cimzia) and Sanofi (sarilumab). Sanofi is a maker of hydroxychloroquine. Samples used in this publication were collected as part of NIH/NIAMS (N01-AR-2-2265). A.M.E. receives support from the NIH National Center for Advancing Translational Sciences. G.K.S. receives support for research from the NIH (UG1 HD068258‑06, HHSN272201300017I, 1UL1TR002553-01, R21AI132677) and the Centers for Disease Control and Prevention (200-2012-53663). She chairs an Independent Data Monitoring Committee for GlaxoSmithKline (RSV vaccine trials). M.C.W. receives support for research from the NIH (1R01-HD076676‑01A1 and 1K24-AI143971), National Institute of Allergy and Infectious Diseases (HHSN272201500006I and HHSN272201300017I), NICHD (HHSN275201000003I), FDA (5U18-FD006298), and the industry for drug development in adults and children. S.J. Balevic, MD, MHS, Department of Rheumatology and Immunology, and Department of Pediatrics, Duke University School of Medicine, and Duke Clinical Research Institute; C.P. Hornik, MD, PhD, Duke Clinical Research Institute, and Department of Pediatrics, Duke University School of Medicine; T.P. Green, MD, MS, Department of Pediatrics, Northwestern University, Feinberg School of Medicine; M.E. Clowse, MD, MPH, Department of Rheumatology and Immunology, Duke University School of Medicine; D. Gonzalez, PharmD, PhD, Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill; A.R. Maharaj, PhD, Duke Clinical Research Institute; L.E. Schanberg, MD, Duke Clinical Research Institute, and Department of Pediatrics, Duke University School of Medicine; A.M. Eudy, PhD, Department of Rheumatology and Immunology, Duke University School of Medicine; G.K. Swamy, MD, Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Duke University School of Medicine; B.L. Hughes, MD, MSc, Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Duke University School of Medicine; M. Cohen-Wolkowiez, MD, PhD, Duke Clinical Research Institute, and Department of Pediatrics, Duke University School of Medicine. Address correspondence to Dr. S.J. Balevic, Department of Rheumatology and Immunology, Duke University School of Medicine, 2301 Erwin Road, CHC, T-Level, Durham, North Carolina 27710, USA. E-mail: . Full Release Article. For details see Reprints and Permissions at jrheum. org. Accepted for publication May 14, 2019
| | - Amanda M Eudy
- From the Department of Rheumatology and Immunology, Duke University School of Medicine, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA; Department of Pediatrics, and the Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Duke University School of Medicine, Durham, North Carolina, USA; Department of Pediatrics, Northwestern University, Feinberg School of Medicine, Evanston, Illinois, USA; Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA. This study was supported by the Rheumatology Research Foundation's Scientist Development Award, the Thrasher Research Fund, the Childhood Arthritis and Rheumatology Research Alliance/Arthritis Foundation, the Derfner Foundation, NIGMS/NICHD (2T32GM086330-06), NICHD (5R01-HD076676-04, HHSN275201000003I), and a Duke Health/Private Diagnostic Clinic ENABLE grant. The Atherosclerosis Prevention in Pediatric Lupus Erythematosus [APPLE (ClinicalTrials. gov: NCT00065806)] trial is supported by the US National Institutes of Health (NIH) National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) contract N01-AR-2-2265, the Edna and Fred L. Mandel Jr. Center for Hypertension and Atherosclerosis, and Pfizer, which provided atorvastatin and matching placebo. S.J.B. receives support from the NIH (5R01-HD076676-04, 1R01HD083003-01, HHSN275201000003I, HHSN275201800003I, HHSN272201500006I 5U24-TR001608-03), the US Food and Drug Administration (5U18FD006298-03), the Patient-Centered Outcomes Research Institute (PCORI), the Rheumatology Research Foundation's Scientist Development Award, the Thrasher Research Fund, and the Childhood Arthritis and Rheumatology Research Alliance/Arthritis Foundation. C.P.H. receives salary support for research from the National Institute for Child Health and Human Development (NICHD; 1K23HD090239; R13HD102136), National Heart Lung and Blood Institute (R61/R33HL147833), FDA (1R01-FD006099, PI: Laughon; and 5U18-FD006298, PI: Benjamin), the US government for his work in pediatric clinical pharmacology (Government Contract HHSN275201800003I, PI: Benjamin under the Best Pharmaceuticals for Children Act), the nonprofit Burrhoughs Wellcome Fund, and other sponsors for drug development in adults and children (dcri.org/about-us/ conflict-of-interest). D.G. receives support for research from the Eunice Kennedy Shriver NICHD (5R01HD096435). A.M. receives research support from the Thrasher Research Fund (www.thrasherresearch.org). L.E.S. receives support for research from the NIH (U19AR069522), PCORI (8177), and the Childhood Arthritis and Rheumatology Research Alliance. She is on the Data Safety Monitoring Board for investigational product trials for UCB (Cimzia) and Sanofi (sarilumab). Sanofi is a maker of hydroxychloroquine. Samples used in this publication were collected as part of NIH/NIAMS (N01-AR-2-2265). A.M.E. receives support from the NIH National Center for Advancing Translational Sciences. G.K.S. receives support for research from the NIH (UG1 HD068258‑06, HHSN272201300017I, 1UL1TR002553-01, R21AI132677) and the Centers for Disease Control and Prevention (200-2012-53663). She chairs an Independent Data Monitoring Committee for GlaxoSmithKline (RSV vaccine trials). M.C.W. receives support for research from the NIH (1R01-HD076676‑01A1 and 1K24-AI143971), National Institute of Allergy and Infectious Diseases (HHSN272201500006I and HHSN272201300017I), NICHD (HHSN275201000003I), FDA (5U18-FD006298), and the industry for drug development in adults and children. S.J. Balevic, MD, MHS, Department of Rheumatology and Immunology, and Department of Pediatrics, Duke University School of Medicine, and Duke Clinical Research Institute; C.P. Hornik, MD, PhD, Duke Clinical Research Institute, and Department of Pediatrics, Duke University School of Medicine; T.P. Green, MD, MS, Department of Pediatrics, Northwestern University, Feinberg School of Medicine; M.E. Clowse, MD, MPH, Department of Rheumatology and Immunology, Duke University School of Medicine; D. Gonzalez, PharmD, PhD, Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill; A.R. Maharaj, PhD, Duke Clinical Research Institute; L.E. Schanberg, MD, Duke Clinical Research Institute, and Department of Pediatrics, Duke University School of Medicine; A.M. Eudy, PhD, Department of Rheumatology and Immunology, Duke University School of Medicine; G.K. Swamy, MD, Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Duke University School of Medicine; B.L. Hughes, MD, MSc, Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Duke University School of Medicine; M. Cohen-Wolkowiez, MD, PhD, Duke Clinical Research Institute, and Department of Pediatrics, Duke University School of Medicine. Address correspondence to Dr. S.J. Balevic, Department of Rheumatology and Immunology, Duke University School of Medicine, 2301 Erwin Road, CHC, T-Level, Durham, North Carolina 27710, USA. E-mail: . Full Release Article. For details see Reprints and Permissions at jrheum. org. Accepted for publication May 14, 2019
| | - Geeta K Swamy
- From the Department of Rheumatology and Immunology, Duke University School of Medicine, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA; Department of Pediatrics, and the Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Duke University School of Medicine, Durham, North Carolina, USA; Department of Pediatrics, Northwestern University, Feinberg School of Medicine, Evanston, Illinois, USA; Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA. This study was supported by the Rheumatology Research Foundation's Scientist Development Award, the Thrasher Research Fund, the Childhood Arthritis and Rheumatology Research Alliance/Arthritis Foundation, the Derfner Foundation, NIGMS/NICHD (2T32GM086330-06), NICHD (5R01-HD076676-04, HHSN275201000003I), and a Duke Health/Private Diagnostic Clinic ENABLE grant. The Atherosclerosis Prevention in Pediatric Lupus Erythematosus [APPLE (ClinicalTrials. gov: NCT00065806)] trial is supported by the US National Institutes of Health (NIH) National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) contract N01-AR-2-2265, the Edna and Fred L. Mandel Jr. Center for Hypertension and Atherosclerosis, and Pfizer, which provided atorvastatin and matching placebo. S.J.B. receives support from the NIH (5R01-HD076676-04, 1R01HD083003-01, HHSN275201000003I, HHSN275201800003I, HHSN272201500006I 5U24-TR001608-03), the US Food and Drug Administration (5U18FD006298-03), the Patient-Centered Outcomes Research Institute (PCORI), the Rheumatology Research Foundation's Scientist Development Award, the Thrasher Research Fund, and the Childhood Arthritis and Rheumatology Research Alliance/Arthritis Foundation. C.P.H. receives salary support for research from the National Institute for Child Health and Human Development (NICHD; 1K23HD090239; R13HD102136), National Heart Lung and Blood Institute (R61/R33HL147833), FDA (1R01-FD006099, PI: Laughon; and 5U18-FD006298, PI: Benjamin), the US government for his work in pediatric clinical pharmacology (Government Contract HHSN275201800003I, PI: Benjamin under the Best Pharmaceuticals for Children Act), the nonprofit Burrhoughs Wellcome Fund, and other sponsors for drug development in adults and children (dcri.org/about-us/ conflict-of-interest). D.G. receives support for research from the Eunice Kennedy Shriver NICHD (5R01HD096435). A.M. receives research support from the Thrasher Research Fund (www.thrasherresearch.org). L.E.S. receives support for research from the NIH (U19AR069522), PCORI (8177), and the Childhood Arthritis and Rheumatology Research Alliance. She is on the Data Safety Monitoring Board for investigational product trials for UCB (Cimzia) and Sanofi (sarilumab). Sanofi is a maker of hydroxychloroquine. Samples used in this publication were collected as part of NIH/NIAMS (N01-AR-2-2265). A.M.E. receives support from the NIH National Center for Advancing Translational Sciences. G.K.S. receives support for research from the NIH (UG1 HD068258‑06, HHSN272201300017I, 1UL1TR002553-01, R21AI132677) and the Centers for Disease Control and Prevention (200-2012-53663). She chairs an Independent Data Monitoring Committee for GlaxoSmithKline (RSV vaccine trials). M.C.W. receives support for research from the NIH (1R01-HD076676‑01A1 and 1K24-AI143971), National Institute of Allergy and Infectious Diseases (HHSN272201500006I and HHSN272201300017I), NICHD (HHSN275201000003I), FDA (5U18-FD006298), and the industry for drug development in adults and children. S.J. Balevic, MD, MHS, Department of Rheumatology and Immunology, and Department of Pediatrics, Duke University School of Medicine, and Duke Clinical Research Institute; C.P. Hornik, MD, PhD, Duke Clinical Research Institute, and Department of Pediatrics, Duke University School of Medicine; T.P. Green, MD, MS, Department of Pediatrics, Northwestern University, Feinberg School of Medicine; M.E. Clowse, MD, MPH, Department of Rheumatology and Immunology, Duke University School of Medicine; D. Gonzalez, PharmD, PhD, Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill; A.R. Maharaj, PhD, Duke Clinical Research Institute; L.E. Schanberg, MD, Duke Clinical Research Institute, and Department of Pediatrics, Duke University School of Medicine; A.M. Eudy, PhD, Department of Rheumatology and Immunology, Duke University School of Medicine; G.K. Swamy, MD, Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Duke University School of Medicine; B.L. Hughes, MD, MSc, Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Duke University School of Medicine; M. Cohen-Wolkowiez, MD, PhD, Duke Clinical Research Institute, and Department of Pediatrics, Duke University School of Medicine. Address correspondence to Dr. S.J. Balevic, Department of Rheumatology and Immunology, Duke University School of Medicine, 2301 Erwin Road, CHC, T-Level, Durham, North Carolina 27710, USA. E-mail: . Full Release Article. For details see Reprints and Permissions at jrheum. org. Accepted for publication May 14, 2019
| | - Brenna L Hughes
- From the Department of Rheumatology and Immunology, Duke University School of Medicine, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA; Department of Pediatrics, and the Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Duke University School of Medicine, Durham, North Carolina, USA; Department of Pediatrics, Northwestern University, Feinberg School of Medicine, Evanston, Illinois, USA; Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA. This study was supported by the Rheumatology Research Foundation's Scientist Development Award, the Thrasher Research Fund, the Childhood Arthritis and Rheumatology Research Alliance/Arthritis Foundation, the Derfner Foundation, NIGMS/NICHD (2T32GM086330-06), NICHD (5R01-HD076676-04, HHSN275201000003I), and a Duke Health/Private Diagnostic Clinic ENABLE grant. The Atherosclerosis Prevention in Pediatric Lupus Erythematosus [APPLE (ClinicalTrials. gov: NCT00065806)] trial is supported by the US National Institutes of Health (NIH) National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) contract N01-AR-2-2265, the Edna and Fred L. Mandel Jr. Center for Hypertension and Atherosclerosis, and Pfizer, which provided atorvastatin and matching placebo. S.J.B. receives support from the NIH (5R01-HD076676-04, 1R01HD083003-01, HHSN275201000003I, HHSN275201800003I, HHSN272201500006I 5U24-TR001608-03), the US Food and Drug Administration (5U18FD006298-03), the Patient-Centered Outcomes Research Institute (PCORI), the Rheumatology Research Foundation's Scientist Development Award, the Thrasher Research Fund, and the Childhood Arthritis and Rheumatology Research Alliance/Arthritis Foundation. C.P.H. receives salary support for research from the National Institute for Child Health and Human Development (NICHD; 1K23HD090239; R13HD102136), National Heart Lung and Blood Institute (R61/R33HL147833), FDA (1R01-FD006099, PI: Laughon; and 5U18-FD006298, PI: Benjamin), the US government for his work in pediatric clinical pharmacology (Government Contract HHSN275201800003I, PI: Benjamin under the Best Pharmaceuticals for Children Act), the nonprofit Burrhoughs Wellcome Fund, and other sponsors for drug development in adults and children (dcri.org/about-us/ conflict-of-interest). D.G. receives support for research from the Eunice Kennedy Shriver NICHD (5R01HD096435). A.M. receives research support from the Thrasher Research Fund (www.thrasherresearch.org). L.E.S. receives support for research from the NIH (U19AR069522), PCORI (8177), and the Childhood Arthritis and Rheumatology Research Alliance. She is on the Data Safety Monitoring Board for investigational product trials for UCB (Cimzia) and Sanofi (sarilumab). Sanofi is a maker of hydroxychloroquine. Samples used in this publication were collected as part of NIH/NIAMS (N01-AR-2-2265). A.M.E. receives support from the NIH National Center for Advancing Translational Sciences. G.K.S. receives support for research from the NIH (UG1 HD068258‑06, HHSN272201300017I, 1UL1TR002553-01, R21AI132677) and the Centers for Disease Control and Prevention (200-2012-53663). She chairs an Independent Data Monitoring Committee for GlaxoSmithKline (RSV vaccine trials). M.C.W. receives support for research from the NIH (1R01-HD076676‑01A1 and 1K24-AI143971), National Institute of Allergy and Infectious Diseases (HHSN272201500006I and HHSN272201300017I), NICHD (HHSN275201000003I), FDA (5U18-FD006298), and the industry for drug development in adults and children. S.J. Balevic, MD, MHS, Department of Rheumatology and Immunology, and Department of Pediatrics, Duke University School of Medicine, and Duke Clinical Research Institute; C.P. Hornik, MD, PhD, Duke Clinical Research Institute, and Department of Pediatrics, Duke University School of Medicine; T.P. Green, MD, MS, Department of Pediatrics, Northwestern University, Feinberg School of Medicine; M.E. Clowse, MD, MPH, Department of Rheumatology and Immunology, Duke University School of Medicine; D. Gonzalez, PharmD, PhD, Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill; A.R. Maharaj, PhD, Duke Clinical Research Institute; L.E. Schanberg, MD, Duke Clinical Research Institute, and Department of Pediatrics, Duke University School of Medicine; A.M. Eudy, PhD, Department of Rheumatology and Immunology, Duke University School of Medicine; G.K. Swamy, MD, Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Duke University School of Medicine; B.L. Hughes, MD, MSc, Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Duke University School of Medicine; M. Cohen-Wolkowiez, MD, PhD, Duke Clinical Research Institute, and Department of Pediatrics, Duke University School of Medicine. Address correspondence to Dr. S.J. Balevic, Department of Rheumatology and Immunology, Duke University School of Medicine, 2301 Erwin Road, CHC, T-Level, Durham, North Carolina 27710, USA. E-mail: . Full Release Article. For details see Reprints and Permissions at jrheum. org. Accepted for publication May 14, 2019
| | - Michael Cohen-Wolkowiez
- From the Department of Rheumatology and Immunology, Duke University School of Medicine, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA; Department of Pediatrics, and the Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Duke University School of Medicine, Durham, North Carolina, USA; Department of Pediatrics, Northwestern University, Feinberg School of Medicine, Evanston, Illinois, USA; Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA. This study was supported by the Rheumatology Research Foundation's Scientist Development Award, the Thrasher Research Fund, the Childhood Arthritis and Rheumatology Research Alliance/Arthritis Foundation, the Derfner Foundation, NIGMS/NICHD (2T32GM086330-06), NICHD (5R01-HD076676-04, HHSN275201000003I), and a Duke Health/Private Diagnostic Clinic ENABLE grant. The Atherosclerosis Prevention in Pediatric Lupus Erythematosus [APPLE (ClinicalTrials. gov: NCT00065806)] trial is supported by the US National Institutes of Health (NIH) National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) contract N01-AR-2-2265, the Edna and Fred L. Mandel Jr. Center for Hypertension and Atherosclerosis, and Pfizer, which provided atorvastatin and matching placebo. S.J.B. receives support from the NIH (5R01-HD076676-04, 1R01HD083003-01, HHSN275201000003I, HHSN275201800003I, HHSN272201500006I 5U24-TR001608-03), the US Food and Drug Administration (5U18FD006298-03), the Patient-Centered Outcomes Research Institute (PCORI), the Rheumatology Research Foundation's Scientist Development Award, the Thrasher Research Fund, and the Childhood Arthritis and Rheumatology Research Alliance/Arthritis Foundation. C.P.H. receives salary support for research from the National Institute for Child Health and Human Development (NICHD; 1K23HD090239; R13HD102136), National Heart Lung and Blood Institute (R61/R33HL147833), FDA (1R01-FD006099, PI: Laughon; and 5U18-FD006298, PI: Benjamin), the US government for his work in pediatric clinical pharmacology (Government Contract HHSN275201800003I, PI: Benjamin under the Best Pharmaceuticals for Children Act), the nonprofit Burrhoughs Wellcome Fund, and other sponsors for drug development in adults and children (dcri.org/about-us/ conflict-of-interest). D.G. receives support for research from the Eunice Kennedy Shriver NICHD (5R01HD096435). A.M. receives research support from the Thrasher Research Fund (www.thrasherresearch.org). L.E.S. receives support for research from the NIH (U19AR069522), PCORI (8177), and the Childhood Arthritis and Rheumatology Research Alliance. She is on the Data Safety Monitoring Board for investigational product trials for UCB (Cimzia) and Sanofi (sarilumab). Sanofi is a maker of hydroxychloroquine. Samples used in this publication were collected as part of NIH/NIAMS (N01-AR-2-2265). A.M.E. receives support from the NIH National Center for Advancing Translational Sciences. G.K.S. receives support for research from the NIH (UG1 HD068258‑06, HHSN272201300017I, 1UL1TR002553-01, R21AI132677) and the Centers for Disease Control and Prevention (200-2012-53663). She chairs an Independent Data Monitoring Committee for GlaxoSmithKline (RSV vaccine trials). M.C.W. receives support for research from the NIH (1R01-HD076676‑01A1 and 1K24-AI143971), National Institute of Allergy and Infectious Diseases (HHSN272201500006I and HHSN272201300017I), NICHD (HHSN275201000003I), FDA (5U18-FD006298), and the industry for drug development in adults and children. S.J. Balevic, MD, MHS, Department of Rheumatology and Immunology, and Department of Pediatrics, Duke University School of Medicine, and Duke Clinical Research Institute; C.P. Hornik, MD, PhD, Duke Clinical Research Institute, and Department of Pediatrics, Duke University School of Medicine; T.P. Green, MD, MS, Department of Pediatrics, Northwestern University, Feinberg School of Medicine; M.E. Clowse, MD, MPH, Department of Rheumatology and Immunology, Duke University School of Medicine; D. Gonzalez, PharmD, PhD, Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill; A.R. Maharaj, PhD, Duke Clinical Research Institute; L.E. Schanberg, MD, Duke Clinical Research Institute, and Department of Pediatrics, Duke University School of Medicine; A.M. Eudy, PhD, Department of Rheumatology and Immunology, Duke University School of Medicine; G.K. Swamy, MD, Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Duke University School of Medicine; B.L. Hughes, MD, MSc, Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Duke University School of Medicine; M. Cohen-Wolkowiez, MD, PhD, Duke Clinical Research Institute, and Department of Pediatrics, Duke University School of Medicine. Address correspondence to Dr. S.J. Balevic, Department of Rheumatology and Immunology, Duke University School of Medicine, 2301 Erwin Road, CHC, T-Level, Durham, North Carolina 27710, USA. E-mail: . Full Release Article. For details see Reprints and Permissions at jrheum. org. Accepted for publication May 14, 2019
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Feldman CH, Collins J, Zhang Z, Xu C, Subramanian SV, Kawachi I, Solomon DH, Costenbader KH. Azathioprine and Mycophenolate Mofetil Adherence Patterns and Predictors Among Medicaid Beneficiaries With Systemic Lupus Erythematosus. Arthritis Care Res (Hoboken) 2020; 71:1419-1424. [PMID: 30354025 DOI: 10.1002/acr.23792] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 10/16/2018] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Azathioprine (AZA) and mycophenolate mofetil (MMF) are immunosuppressants frequently used in the treatment of moderate-to-severe systemic lupus erythematosus (SLE). We studied longitudinal patterns and predictors of adherence to AZA and MMF in a nationwide US SLE cohort. METHODS In the Medicaid Analytic eXtract (2000-2010) database, we identified patients with SLE who initiated AZA or MMF (no use in the prior 6 months) with ≥12 months of continuous follow-up. We dichotomized adherence at 80%, with ≥24 of 30 days per month considered adherent. We used group-based trajectory models to estimate monthly adherence patterns and multivariable multinomial logistic regression to determine the association between demographic, SLE and utilization-related predictors, and the odds ratios (OR) of belonging to a nonadherent versus the adherent trajectory, separately for AZA and MMF. RESULTS We identified 2,309 AZA initiators and 2,070 MMF initiators with SLE. Four-group trajectory models classified 17% of AZA and 21% of MMF initiators as adherent. AZA and MMF nonadherers followed similar trajectory patterns. African American race (OR 1.67 [95% confidence interval (95% CI) 1.20-2.31]) and Hispanic ethnicity (OR 1.58 [95% CI 1.06-2.35]) increased odds of AZA nonadherence; there were no significant associations between race/ethnicity and MMF nonadherence. Male sex and polypharmacy were associated with lower odds of nonadherence to both medications; lupus nephritis was associated with lower odds of nonadherence to MMF (OR 0.74 [95% CI 0.55-0.99]). CONCLUSION Adherence to AZA or MMF over the first year of use was rare. Race, sex, and lupus nephritis were modestly associated with adherence, but the magnitude, direction, and significance of predictors differed by medication, suggesting the complexity of predicting adherence behavior.
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Affiliation(s)
| | | | - Zhi Zhang
- Brigham and Women's Hospital, Boston, Massachusetts
| | - Chang Xu
- Brigham and Women's Hospital, Boston, Massachusetts
| | - S V Subramanian
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Ichiro Kawachi
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts
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Gandelman JS, Khan OA, Shuey MM, Neal JE, McNeer E, Dickson A, Barnado A, Wang L, Anandi P, Dupont WD, Stein CM, Chung CP. Increased Incidence of Resistant Hypertension in Patients With Systemic Lupus Erythematosus: A Retrospective Cohort Study. Arthritis Care Res (Hoboken) 2020; 72:534-543. [PMID: 30875459 PMCID: PMC6745299 DOI: 10.1002/acr.23880] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 03/05/2019] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To compare the risk of resistant hypertension (RHTN) in patients with systemic lupus erythematosus (SLE) and in controls without SLE, and to define factors associated with RHTN in patients with SLE. METHODS We studied 1,044 patients with SLE and 5,241 control subjects using de-identified electronic health records from a tertiary care center. SLE was defined as ≥4 International Classification of Diseases, Ninth Revision codes for SLE and antinuclear antibody titer ≥1:160. RHTN was defined as uncontrolled blood pressure on 3 antihypertensive medications or requiring 4 or more antihypertensives to attain control. First, we compared the risk of RHTN between groups. Second, we examined the association between RHTN and all-cause mortality in patients with SLE. RESULTS RHTN was nearly twice as prevalent in patients with SLE compared to control subjects (10.2% and 5.3%, respectively), with an incidence rate of 10.2 versus 6.1 cases per 1,000 person-years of observation (hazard ratio [HR] 1.72 [95% confidence interval 1.28-2.30]; P < 0.001, adjusted for age, sex, race, baseline end-stage renal disease [ESRD], creatinine, and calendar year). In patients with SLE, we found associations between RHTN and black race, lower renal function, hypercholesterolemia, and increased inflammatory markers. RHTN was associated with a significantly higher mortality risk (HR 2.91, P = 0.0005) after adjustment for age, sex, race, calendar year, creatinine, baseline ESRD, and number of visits. CONCLUSION Patients with SLE have a higher risk of RHTN compared to frequency-matched controls, independent of multiple covariates. RHTN is an important comorbidity for clinicians to recognize in SLE, because it is associated with a higher risk of mortality.
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Affiliation(s)
| | - Omair A Khan
- Vanderbilt University Medical Center, Nashville, Tennessee
| | | | | | | | - Alyson Dickson
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - April Barnado
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Li Wang
- Vanderbilt University Medical Center, Nashville, Tennessee
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Mechanisms of action of hydroxychloroquine and chloroquine: implications for rheumatology. Nat Rev Rheumatol 2020; 16:155-166. [PMID: 32034323 DOI: 10.1038/s41584-020-0372-x] [Citation(s) in RCA: 797] [Impact Index Per Article: 199.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2020] [Indexed: 12/15/2022]
Abstract
Despite widespread clinical use of antimalarial drugs such as hydroxychloroquine and chloroquine in the treatment of rheumatoid arthritis (RA), systemic lupus erythematosus (SLE) and other inflammatory rheumatic diseases, insights into the mechanism of action of these drugs are still emerging. Hydroxychloroquine and chloroquine are weak bases and have a characteristic 'deep' volume of distribution and a half-life of around 50 days. These drugs interfere with lysosomal activity and autophagy, interact with membrane stability and alter signalling pathways and transcriptional activity, which can result in inhibition of cytokine production and modulation of certain co-stimulatory molecules. These modes of action, together with the drug's chemical properties, might explain the clinical efficacy and well-known adverse effects (such as retinopathy) of these drugs. The unknown dose-response relationships of these drugs and the lack of definitions of the minimum dose needed for clinical efficacy and what doses are toxic pose challenges to clinical practice. Further challenges include patient non-adherence and possible context-dependent variations in blood drug levels. Available mechanistic data give insights into the immunomodulatory potency of hydroxychloroquine and provide the rationale to search for more potent and/or selective inhibitors.
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25
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Petri M, Elkhalifa M, Li J, Magder LS, Goldman DW. Hydroxychloroquine Blood Levels Predict Hydroxychloroquine Retinopathy. Arthritis Rheumatol 2020; 72:448-453. [PMID: 31532077 DOI: 10.1002/art.41121] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 09/12/2019] [Indexed: 01/03/2023]
Abstract
OBJECTIVE In 2016, the American Academy of Ophthalmology (AAO) changed the recommended daily dose of hydroxychloroquine (HCQ) from 6.5 mg/kg to <5 mg/kg. However, it is not clear that the lower prescribed dose of HCQ will have the same efficacy for systemic lupus erythematosus (SLE) activity or the same role in protecting against cardiovascular risk factors and thrombosis. This study was undertaken to address the frequency of HCQ retinopathy and the role of HCQ blood levels in identifying those individuals who are at a greater future risk of retinopathy. METHODS HCQ blood levels in 537 patients with SLE from a large clinical cohort were repeatedly measured, and patients were tested for HCQ retinopathy. We assessed the risk of retinopathy according to clinical characteristics and blood levels of HCQ. RESULTS The overall frequency of retinopathy was 4.3% (23 of 537 patients). There was a 1% risk of retinopathy in the first 5 years of HCQ treatment, 1.8% from 6 to 10 years, 3.3% from 11 to 15 years, 11.5% from 16 to 20 years, and 8.0% after 21 years of use. We found that older age (P < 0.0001), higher body mass index (P for trend = 0.0160), and longer duration of HCQ intake (P = 0.0024 and P for trend = 0.0006) were associated with a higher risk of HCQ toxicity. Higher blood levels of HCQ predicted later HCQ retinopathy (P = 0.0124 and P = 0.0340 for mean and maximum HCQ blood levels, respectively). CONCLUSION Our data prove the utility of assessing blood levels of HCQ in the prediction of retinopathy. This would allow clinicians to either decrease the dose or increase monitoring in those patients with high HCQ blood levels.
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Affiliation(s)
- Michelle Petri
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Jessica Li
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Daniel W Goldman
- Johns Hopkins University School of Medicine, Baltimore, Maryland
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Geraldino-Pardilla L, Perel-Winkler A, Miceli J, Neville K, Danias G, Nguyen S, Dervieux T, Kapoor T, Giles J, Askanase A. Association between hydroxychloroquine levels and disease activity in a predominantly Hispanic systemic lupus erythematosus cohort. Lupus 2019; 28:862-867. [PMID: 31122136 DOI: 10.1177/0961203319851558] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Hydroxychloroquine (HCQ) is a key therapy in systemic lupus erythematosus (SLE). Medication non-adherence is reported in up to 80% of lupus patients and results in increased morbidity, mortality, and health care utilization. HCQ levels are a sensitive and reliable method to assess medication adherence. Our study evaluated the role of HCQ level measurement in routine clinical care and its association with disease activity in a predominantly Hispanic population. METHODS SLE patients from the Columbia University Lupus cohort treated with HCQ for ≥ 6 months and reporting medication adherence were included. HCQ levels were measured by whole blood high performance liquid chromatography. Non-adherence was defined as an HCQ level <500 ng/ml. The association between HCQ levels and disease activity measured by Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K) was evaluated. RESULTS One hundred and eight patients were enrolled; the median age was 38 years, 91% were female, and 63% were Hispanic. The median SLEDAI-2K was 4.3 (0-20). Forty-one percent of patients had an HCQ level <500 ng/ml consistent with non-adherence, of which 19% had undetectable levels. A higher SLEDAI-2K score was associated with low HCQ levels (p = 0.003). This association remained significant after adjusting for depression (p = 0.0007). CONCLUSION HCQ levels < 500 ng/ml were associated with higher disease activity and accounted for 32% of the SLEDAI-2K variability. HCQ blood measurement is a simple and reliable method to evaluate medication adherence in SLE. Reasons for non-adherence (levels < 500 ng/ml) should be further explored and addressed.
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Affiliation(s)
- L Geraldino-Pardilla
- 1 Division of Rheumatology, Columbia University College of Physicians and Surgeons, and New York Presbyterian Hospital, New York, USA
| | - A Perel-Winkler
- 1 Division of Rheumatology, Columbia University College of Physicians and Surgeons, and New York Presbyterian Hospital, New York, USA
| | - J Miceli
- 1 Division of Rheumatology, Columbia University College of Physicians and Surgeons, and New York Presbyterian Hospital, New York, USA
| | - K Neville
- 1 Division of Rheumatology, Columbia University College of Physicians and Surgeons, and New York Presbyterian Hospital, New York, USA
| | - G Danias
- 1 Division of Rheumatology, Columbia University College of Physicians and Surgeons, and New York Presbyterian Hospital, New York, USA
| | - S Nguyen
- 1 Division of Rheumatology, Columbia University College of Physicians and Surgeons, and New York Presbyterian Hospital, New York, USA
| | | | - T Kapoor
- 1 Division of Rheumatology, Columbia University College of Physicians and Surgeons, and New York Presbyterian Hospital, New York, USA
| | - J Giles
- 1 Division of Rheumatology, Columbia University College of Physicians and Surgeons, and New York Presbyterian Hospital, New York, USA
| | - A Askanase
- 1 Division of Rheumatology, Columbia University College of Physicians and Surgeons, and New York Presbyterian Hospital, New York, USA
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Ntatsaki E, Vassiliou VS, Velo-Garcia A, Salama AD, Isenberg DA. Renal transplantation for lupus nephritis: non-adherence and graft survival. Lupus 2019; 28:651-657. [PMID: 30982400 DOI: 10.1177/0961203319842641] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Poor adherence to immunosuppressive treatment is common in patients with systemic lupus erythematosus and may identify those with lupus nephritis (LN) who have a poorer prognosis. Non-adherence has also been reported to be a potential adverse outcome predictor in renal transplantation (rTp). We investigated whether non-adherence is associated with increased rTp graft rejection and/or failure in patients with LN. METHODS Patients with LN undergoing rTp in two major London hospitals were retrospectively included. Medical and electronic records were reviewed for documented concerns of non-adherence as well as laboratory biochemical drug levels. The role of non-adherence and other potential predictors of graft rejection/failure including demographics, comorbidities, age at systemic lupus erythematosus and LN diagnosis, type of LN, time on dialysis prior to rTp and medication use were investigated using logistic regression. RESULTS Out of 361 patients with LN, 40 had rTp. During a median follow-up of 8.7 years, 17/40 (42.5%) of these patients had evidence of non-adherence. A total of 12 (30.0%) patients experienced graft rejection or failure or both. In the adherent group 2/23 (8.7%) had graft rejection, whilst in the non-adherent this rose to 5/17 (29.4%, p = 0.11). Graft failure was seen in 5/23 (21.7%) patients from the adherent group and 4/17 (23.5%) in the non-adherent group ( p = 0.89). Non-adherent patients had a trend towards increased graft rejection, hazard ratio 4.38, 95% confidence interval = 0.73-26.12, p = 0.11. Patients who spent more time on dialysis prior to rTp were more likely to be adherent to medication, p = 0.01. CONCLUSION Poor adherence to immunosuppressive therapy is common and has been shown to associate with a trend towards increased graft failure in patients with LN requiring rTp. This is the first paper to report that shorter periods on dialysis prior to transplantation might lead to increased non-adherence in lupus patients.
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Affiliation(s)
- E Ntatsaki
- 1 Centre for Rheumatology, Division of Medicine, University College London, London, United Kingdom.,2 Rheumatology Department, Ipswich Hospital, Ipswich, United Kingdom
| | - V S Vassiliou
- 3 Norwich Medical School, University of East Anglia, Norwich, United Kingdom.,4 Department of Medicine, Imperial College London, London, United Kingdom
| | - A Velo-Garcia
- 1 Centre for Rheumatology, Division of Medicine, University College London, London, United Kingdom.,5 Internal Medicine Department, University Hospital Complex of Pontevedra, Pontevedra, Spain
| | - A D Salama
- 6 Centre for Nephrology, University College London, London, United Kingdom
| | - D A Isenberg
- 1 Centre for Rheumatology, Division of Medicine, University College London, London, United Kingdom
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Balevic SJ, Green TP, Clowse MEB, Eudy AM, Schanberg LE, Cohen-Wolkowiez M. Pharmacokinetics of Hydroxychloroquine in Pregnancies with Rheumatic Diseases. Clin Pharmacokinet 2019; 58:525-533. [PMID: 30255310 PMCID: PMC6397666 DOI: 10.1007/s40262-018-0712-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Hydroxychloroquine is an oral drug prescribed to pregnant women with rheumatic disease to reduce disease activity and prevent flares. Physiologic changes during pregnancy may substantially alter drug pharmacokinetics. However, the effect of pregnancy on hydroxychloroquine disposition and the potential need for dose adjustment remains virtually unknown. METHODS We performed a population-pharmacokinetic analysis using samples from the Duke Autoimmunity in Pregnancy Registry from 2013 to 2016. We measured hydroxychloroquine concentration using high-performance liquid chromatography/tandem mass spectrometry and analyzed data using non-linear mixed-effect modeling. We calculated differences between pregnancy and postpartum empirical Bayesian estimates using paired t tests. We computed steady-state concentration profiles for hydroxychloroquine during pregnancy and postpartum using individual clinical data and empirical Bayesian estimates developed from the final pharmacokinetic model. RESULTS We obtained 145 serum samples from 50 patients, 25 of whom had paired pregnancy and postpartum specimens. Five subjects had average concentrations (pregnancy and postpartum) < 100 ng/mL, consistent with medication non-adherence, and were excluded. The population estimated apparent volume of distribution was 1850 L/70 kg and estimated apparent clearance was 51 L/h. Compared with postpartum, median apparent volume of distribution increased significantly during pregnancy (p < 0.001), whereas apparent clearance and 24-h area under the curve did not change. CONCLUSIONS We developed a one-compartment population-pharmacokinetic model for hydroxychloroquine in pregnant women with rheumatic disease. Estimates for serum CL were within the expected range for plasma in non-pregnant adults. Because CL and 24-h area under the curve did not change during pregnancy compared with postpartum, our modeling in this small cohort does not support adjusting hydroxychloroquine dose during pregnancy.
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Affiliation(s)
- Stephen J Balevic
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA.
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA.
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA.
- Divisions of Adult and Pediatric Rheumatology, Duke University Medical Center, 2301 Erwin Road, Durham, NC, 27710, USA.
| | - Thomas P Green
- Department of Pediatrics, Northwestern University/Ann and Robert H. Lurie Children's Hospital, Chicago, IL, USA
| | - Megan E B Clowse
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Amanda M Eudy
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Laura E Schanberg
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Michael Cohen-Wolkowiez
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
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Liu LH, Fevrier HB, Goldfien R, Hemmerling A, Herrinton LJ. Understanding Nonadherence with Hydroxychloroquine Therapy in Systemic Lupus Erythematosus. J Rheumatol 2019; 46:1309-1315. [DOI: 10.3899/jrheum.180946] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/10/2019] [Indexed: 01/06/2023]
Abstract
Objective.Hydroxychloroquine (HCQ) is a cornerstone to managing systemic lupus erythematosus (SLE), yet adherence to medication is poor. We sought to measure the association of adherence with 5 “dimensions of adherence” as articulated by the World Health Organization for chronic conditions: the patient’s socioeconomic status, and patient-, condition-, therapy-, and healthcare system–related factors. Our longterm goal is to generate evidence to design effective interventions to increase adherence.Methods.The retrospective cohort study included Kaiser Permanente Northern California patients ≥ 18 years old during 2006–2014, with SLE and ≥ 2 consecutive prescriptions for HCQ. Adherence was calculated from the medication possession ratio and dichotomized as < 80% versus ≥ 80%. Predictor variables were obtained from the electronic medical record and census data. We used multivariable logistic regression to estimate adjusted OR and 95% CI.Results.The study included 1956 patients. Only 58% of patients had adherence ≥ 80%. In adjusted analyses, socioeconomic variables did not predict adherence. Increasing age (65–89 yrs compared with ≤ 39 yrs: OR 1.44, 95% CI 1.07–1.93), white race (p < 0.05), and the number of rheumatology visits in the year before baseline (≥ 3 compared with 0 or 1: OR 1.47, 95% CI 1.18–1.83) were positively associated with adherence. The rheumatologist and medical center providing care were not associated with adherence.Conclusion.At our setting, as in other settings, about half of patients with SLE were not adherent to HCQ therapy. Differences in adherence by race/ethnicity suggest the possibility of using tailored interventions to increase adherence. Qualitative research is needed to elucidate patient preferences for adherence support.
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Gatto M, Zen M, Iaccarino L, Doria A. New therapeutic strategies in systemic lupus erythematosus management. Nat Rev Rheumatol 2018; 15:30-48. [DOI: 10.1038/s41584-018-0133-2] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Bishnoi A, Vinay K, Handa S. Antimalarial resistance in lupus: a lesser-explored terrain. Lupus 2018; 28:145-146. [PMID: 30472916 DOI: 10.1177/0961203318815585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- A Bishnoi
- Department of Dermatology Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - K Vinay
- Department of Dermatology Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - S Handa
- Department of Dermatology Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Costedoat-Chalumeau N, Houssiau FA. Ustekinumab: a promising new drug for SLE? Lancet 2018; 392:1284-1286. [PMID: 30249508 DOI: 10.1016/s0140-6736(18)32330-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 09/14/2018] [Indexed: 12/27/2022]
Affiliation(s)
- Nathalie Costedoat-Chalumeau
- AP-HP, Cochin Hospital, Internal Medicine Department, Centre de référence maladies auto-immunes et systémiques rares, 75014 Paris, France; Université Paris Descartes-Sorbonne Paris Cité, Paris, France; INSERM U 1153, Center for Epidemiology and Statistics Sorbonne Paris Cité (CRESS), Paris, France.
| | - Frédéric A Houssiau
- Service de Rhumatologie, Cliniques Universitaires Saint-Luc, Brussels, Belgium; Pôle de Pathologies Rhumatismales Inflammatoires et Systémiques, Université Catholique de Louvain, Brussels, Belgium
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Balevic SJ, Cohen-Wolkowiez M, Eudy AM, Green TP, Schanberg LE, Clowse MEB. Hydroxychloroquine Levels throughout Pregnancies Complicated by Rheumatic Disease: Implications for Maternal and Neonatal Outcomes. J Rheumatol 2018; 46:57-63. [PMID: 30275257 DOI: 10.3899/jrheum.180158] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2018] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Pregnancies in women with active rheumatic disease often result in poor neonatal outcomes. Hydroxychloroquine (HCQ) reduces disease activity and flares; however, pregnancy causes significant physiologic changes that may alter HCQ levels and lead to therapeutic failure. Therefore, our objective was to evaluate HCQ concentrations during pregnancy and relate levels to outcomes. METHODS We performed an observational study of pregnant patients with rheumatic disease who were taking HCQ from a single center during 2013-2016. Serum samples were analyzed using high-performance liquid chromatography/mass spectrometry. Primary HCQ exposure was categorized as nontherapeutic (≤ 100 ng/ml) or therapeutic (> 100 ng/ml). Categorical outcomes were analyzed using Fisher's exact test and continuous outcomes using linear regression models, Wilcoxon signed-rank test, Kruskal-Wallis test, t test, and ANOVA. RESULTS We analyzed 145 samples from 50 patients with rheumatic disease, 56% of whom had systemic lupus erythematosus (SLE). HCQ concentration varied widely among individuals at each trimester. Mean physician's global assessment scores in patients with SLE were significantly higher in those with average drug levels ≤ 100 ng/ml compared to > 100 ng/ml (0.93 vs 0.32, p = 0.01). Of patients with SLE, 83% with average drug levels ≤ 100 ng/ml delivered prematurely (n = 6), compared to only 21% with average levels > 100 ng/ml (n = 19; p = 0.01). HCQ levels were not associated with prematurity or disease activity in non-SLE patients. CONCLUSION With both high and low HCQ levels associated with preterm birth and disease activity in SLE, further study is necessary to understand HCQ disposition throughout pregnancy and to clarify the relationship between drug levels and outcomes.
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Affiliation(s)
- Stephen J Balevic
- From the departments of Internal Medicine and Pediatrics, Duke University, and Duke Clinical Research Institute, Durham, North Carolina; Department of Pediatrics, Children's Hospital of Chicago, Chicago, Illinois, USA. .,S.J. Balevic, MD, MHS, Assistant Professor, departments of Internal Medicine and Pediatrics, Duke University Medical Center and Duke Clinical Research Institute; M. Cohen-Wolkowiez, MD, PhD, Professor, Department of Pediatrics, Duke University Medical Center and Duke Clinical Research Institute; A.M. Eudy, PhD, Postdoctoral Fellow, Department of Internal Medicine, Duke University Medical Center; T.P. Green, MD, Professor and Chair, Department of Pediatrics, Children's Hospital of Chicago; L.E. Schanberg, MD, Professor, Department of Pediatrics, Duke University Medical Center; M.E. Clowse, MD, MPH, Associate Professor, Department of Internal Medicine, Duke University Medical Center.
| | - Michael Cohen-Wolkowiez
- From the departments of Internal Medicine and Pediatrics, Duke University, and Duke Clinical Research Institute, Durham, North Carolina; Department of Pediatrics, Children's Hospital of Chicago, Chicago, Illinois, USA.,S.J. Balevic, MD, MHS, Assistant Professor, departments of Internal Medicine and Pediatrics, Duke University Medical Center and Duke Clinical Research Institute; M. Cohen-Wolkowiez, MD, PhD, Professor, Department of Pediatrics, Duke University Medical Center and Duke Clinical Research Institute; A.M. Eudy, PhD, Postdoctoral Fellow, Department of Internal Medicine, Duke University Medical Center; T.P. Green, MD, Professor and Chair, Department of Pediatrics, Children's Hospital of Chicago; L.E. Schanberg, MD, Professor, Department of Pediatrics, Duke University Medical Center; M.E. Clowse, MD, MPH, Associate Professor, Department of Internal Medicine, Duke University Medical Center
| | - Amanda M Eudy
- From the departments of Internal Medicine and Pediatrics, Duke University, and Duke Clinical Research Institute, Durham, North Carolina; Department of Pediatrics, Children's Hospital of Chicago, Chicago, Illinois, USA.,S.J. Balevic, MD, MHS, Assistant Professor, departments of Internal Medicine and Pediatrics, Duke University Medical Center and Duke Clinical Research Institute; M. Cohen-Wolkowiez, MD, PhD, Professor, Department of Pediatrics, Duke University Medical Center and Duke Clinical Research Institute; A.M. Eudy, PhD, Postdoctoral Fellow, Department of Internal Medicine, Duke University Medical Center; T.P. Green, MD, Professor and Chair, Department of Pediatrics, Children's Hospital of Chicago; L.E. Schanberg, MD, Professor, Department of Pediatrics, Duke University Medical Center; M.E. Clowse, MD, MPH, Associate Professor, Department of Internal Medicine, Duke University Medical Center
| | - Thomas P Green
- From the departments of Internal Medicine and Pediatrics, Duke University, and Duke Clinical Research Institute, Durham, North Carolina; Department of Pediatrics, Children's Hospital of Chicago, Chicago, Illinois, USA.,S.J. Balevic, MD, MHS, Assistant Professor, departments of Internal Medicine and Pediatrics, Duke University Medical Center and Duke Clinical Research Institute; M. Cohen-Wolkowiez, MD, PhD, Professor, Department of Pediatrics, Duke University Medical Center and Duke Clinical Research Institute; A.M. Eudy, PhD, Postdoctoral Fellow, Department of Internal Medicine, Duke University Medical Center; T.P. Green, MD, Professor and Chair, Department of Pediatrics, Children's Hospital of Chicago; L.E. Schanberg, MD, Professor, Department of Pediatrics, Duke University Medical Center; M.E. Clowse, MD, MPH, Associate Professor, Department of Internal Medicine, Duke University Medical Center
| | - Laura E Schanberg
- From the departments of Internal Medicine and Pediatrics, Duke University, and Duke Clinical Research Institute, Durham, North Carolina; Department of Pediatrics, Children's Hospital of Chicago, Chicago, Illinois, USA.,S.J. Balevic, MD, MHS, Assistant Professor, departments of Internal Medicine and Pediatrics, Duke University Medical Center and Duke Clinical Research Institute; M. Cohen-Wolkowiez, MD, PhD, Professor, Department of Pediatrics, Duke University Medical Center and Duke Clinical Research Institute; A.M. Eudy, PhD, Postdoctoral Fellow, Department of Internal Medicine, Duke University Medical Center; T.P. Green, MD, Professor and Chair, Department of Pediatrics, Children's Hospital of Chicago; L.E. Schanberg, MD, Professor, Department of Pediatrics, Duke University Medical Center; M.E. Clowse, MD, MPH, Associate Professor, Department of Internal Medicine, Duke University Medical Center
| | - Megan E B Clowse
- From the departments of Internal Medicine and Pediatrics, Duke University, and Duke Clinical Research Institute, Durham, North Carolina; Department of Pediatrics, Children's Hospital of Chicago, Chicago, Illinois, USA.,S.J. Balevic, MD, MHS, Assistant Professor, departments of Internal Medicine and Pediatrics, Duke University Medical Center and Duke Clinical Research Institute; M. Cohen-Wolkowiez, MD, PhD, Professor, Department of Pediatrics, Duke University Medical Center and Duke Clinical Research Institute; A.M. Eudy, PhD, Postdoctoral Fellow, Department of Internal Medicine, Duke University Medical Center; T.P. Green, MD, Professor and Chair, Department of Pediatrics, Children's Hospital of Chicago; L.E. Schanberg, MD, Professor, Department of Pediatrics, Duke University Medical Center; M.E. Clowse, MD, MPH, Associate Professor, Department of Internal Medicine, Duke University Medical Center
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Hsu CY, Lin YS, Cheng TT, Syu YJ, Lin MS, Lin HF, Su YJ, Chen YC, Chen JF, Chen TH. Adherence to hydroxychloroquine improves long-term survival of patients with systemic lupus erythematosus. Rheumatology (Oxford) 2018; 57:1743-1751. [DOI: 10.1093/rheumatology/key167] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Indexed: 11/12/2022] Open
Affiliation(s)
- Chung-Yuan Hsu
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine Kaohsiung, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yu-Sheng Lin
- Division of Cardiology, Chang Gung Memorial Hospital, Chiayi, Taiwan
- School of Traditional Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan County, Taiwan
| | - Tien-Tsai Cheng
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine Kaohsiung, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | | | - Ming-Shyan Lin
- Division of Cardiology, Chang-Gung Memorial Hospital, Yunlin, Taiwan
| | | | - Yu-Jih Su
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine Kaohsiung, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Ying-Chou Chen
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine Kaohsiung, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Jia-Feng Chen
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine Kaohsiung, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Tien-Hsing Chen
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Keelung, Taiwan
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