[Safety management of the treatment with antimalarial drugs in rheumatology. Interdisciplinary recommendations based on a systematic literature search]

Hydroxychloroquine-induced generalized myopathy in a patient with lupus tumidus: a case report

A subtype of cutaneous lupus erythematosus known as lupus erythematosus tumidus (LET) is characterized by sun-exposed areas that typically display urticaria-like papules and plaques. For LET, systemic therapy with antimalarials - particularly hydroxychloroquine (HCQ) - is the first line of treatment. Even though the safety profile of these medications appears to be high, there have been very few reports of side effects in the literature, including hemolytic anemia, retinal toxicity, maculopapular rash, gastrointestinal disturbance, and blue-gray discoloration of the skin or mucous membranes. Here, we report a unique instance of a 46-year-old LET smoker who, following HCQ treatment, developed a generalized myopathy.

Assessment of interactions and dosage recommendations of synthetic DMARDs-Evidence-based and consensus-based recommendations based on a systematic literature search

Conventional synthetic (cs) and targeted synthetic (ts) disease-modifying antirheumatic drugs (DMARD) have potential interactions with a multitude of drugs. Furthermore, they sometimes have a lower therapeutic index, particularly in cases of limited organ functions. The aim of this work was to establish evidence-based recommendations on the therapeutic use of DMARDs in the context of drug interactions and dosage recommendations. A systematic literature search was carried out on the issue of drug interactions and dosages in cases of patients with limited kidney function and higher age and suffering from rheumatoid arthritis. A total of 2756 scientific publications were screened and 154 selected of which 68 were scrutinized in detail. Furthermore, the respective product information was also analyzed. A multitude of possible interactions of synthetic DMARDs with different drugs were detected, which were then assessed with respect to the clinical significance and consequences. A consensus process led to making recommendations with which the interactions were classified: A: dangerous combination, B: avoid combination (if possible, pausing DMARD treatment), C: possible combination requiring increased monitoring and potential adjustments in dosage and D: pharmacological interaction without relevance in DMARD standard doses. Apart from that dosage recommendations were established for each csDMARD and tsDMARD depending on kidney function and age. There are 3 primary recommendations and 11 core recommendations on interactions and dosages of csDMARDs and tsDMARDs meant as a practical help for therapeutic decision making and to improve safety in the treatment of rheumatoid arthritis.

[Assessment of interactions and dosage recommendations of synthetic DMARDs-Evidence-based and consensus-based recommendations based on a systematic literature search]

Conventional synthetic (cs) and targeted synthetic (ts) disease-modifying antirheumatic drugs (DMARD) have potential interactions with a multitude of drugs. Furthermore, they sometimes have a lower therapeutic index, particularly in cases of limited organ functions. The aim of this work was to establish evidence-based recommendations on the therapeutic use of DMARDs in the context of drug interactions and dosage recommendations. A systematic literature search was carried out on the issue of drug interactions and dosages in cases of patients with limited kidney function and higher age and suffering from rheumatoid arthritis. A total of 2756 scientific publications were screened and 154 selected of which 68 were scrutinized in detail. Furthermore, the respective specialist subject information was also analyzed. A multitude of possible interactions of synthetic DMARDs with different drugs were detected, which were then assessed with respect to the clinical significance and consequences. A consensus process led to making recommendations with which the interactions were classified: A: dangerous combination, B: avoid combination (if possible, pausing DMARD treatment), C: possible combination requiring increased monitoring and potential adjustments in dosage and D: pharmacological interaction without relevance in DMARD standard doses. Apart from that dosage recommendations were established for each csDMARD and tsDMARD depending on kidney function and age. There are 3 primary recommendations and 11 core recommendations on interactions and dosages of csDMARDs and tsDMARDs meant as a practical help for therapeutic decision making and to improve safety in the treatment of rheumatoid arthritis.

COVID-19 and immunological regulations - from basic and translational aspects to clinical implications

The COVID‐19 pandemic caused by SARS‐CoV‐2 has far‐reaching direct and indirect medical consequences. These include both the course and treatment of diseases. It is becoming increasingly clear that infections with SARS‐CoV‐2 can cause considerable immunological alterations, which particularly also affect pathogenetically and/or therapeutically relevant factors.

Against this background we summarize here the current state of knowledge on the interaction of SARS‐CoV‐2/COVID‐19 with mediators of the acute phase of inflammation (TNF, IL‐1, IL‐6), type 1 and type 17 immune responses (IL‐12, IL‐23, IL‐17, IL‐36), type 2 immune reactions (IL‐4, IL‐13, IL‐5, IL‐31, IgE), B‐cell immunity, checkpoint regulators (PD‐1, PD‐L1, CTLA4), and orally druggable signaling pathways (JAK, PDE4, calcineurin). In addition, we discuss in this context non‐specific immune modulation by glucocorticosteroids, methotrexate, antimalarial drugs, azathioprine, dapsone, mycophenolate mofetil and fumaric acid esters, as well as neutrophil granulocyte‐mediated innate immune mechanisms.

From these recent findings we derive possible implications for the therapeutic modulation of said immunological mechanisms in connection with SARS‐CoV‐2/COVID‐19. Although, of course, the greatest care should be taken with patients with immunologically mediated diseases or immunomodulating therapies, it appears that many treatments can also be carried out during the COVID‐19 pandemic; some even appear to alleviate COVID‐19.

COVID‐19 und Immunregulation – von grundlegenden und translationalen Aspekten zu klinischen Implikationen

Die durch SARS‐CoV‐2 verursachte Pandemie COVID‐19 hat weitreichende direkte und indirekte medizinische Folgen. Dazu gehören sowohl der Verlauf als auch die Behandlung vieler Krankheiten. Es wird immer deutlicher, dass Infektionen mit SARS‐CoV‐2 erhebliche immunologische Veränderungen verursachen können, die insbesondere auch pathogenetisch und/oder therapeutisch relevante Faktoren betreffen.

Vor diesem Hintergrund fassen wir hier den aktuellen Wissensstand zur Interaktion von SARS‐CoV‐2/COVID‐19 mit Mediatoren der akuten Phase der Entzündung (TNF, IL‐1, IL‐6), der Typ‐1‐ und Typ‐17‐Immunantwort (IL‐12, IL‐23, IL‐17, IL‐36), Typ‐2‐Immunreaktionen (IL‐4, IL‐13, IL‐5, IL‐31, IgE), B‐Zell‐Immunität, Checkpoint‐Regulatoren (PD‐1, PD‐L1, CTLA4) und Signalwegen, die durch oral applizierte Medikamente moduliert werden (JAK, PDE4, Calcineurin), zusammen. Darüber hinaus diskutieren wir in diesem Zusammenhang die unspezifische Immunmodulation durch Glukokortikosteroide, Methotrexat, Malariamittel, Azathioprin, Dapson, Mycophenolsäure‐Derivate und Fumarsäureester sowie angeborene Immunmechanismen neutrophiler Granulozyten.

Aus diesen neueren Erkenntnissen leiten wir mögliche Implikationen für die therapeutische Modulation der genannten immunologischen Mechanismen im Zusammenhang mit SARS‐CoV‐2/COVID‐19 ab. Obwohl natürlich bei Patienten mit immunologisch vermittelten Krankheiten oder immunmodulierenden Therapien größte Vorsicht geboten ist, scheint es, dass viele Behandlungen auch während der COVID‐19‐Pandemie durchgeführt werden können; einige scheinen COVID‐19 sogar zu lindern.

Treatment of COVID-19 in Pregnancy with Hydroxychloroquine and Azithromycin: a case report

The combination of hydroxychloroquine (HCQ) and azithromycin could represent a suitable treatment for SarS-CoV-2 positive pregnancies. The authors report one of the first cases of COVID-19 positive pregnant woman successfully treated with HCQ in April 2020. (www.actabiomedica.it)

Sicherheitsmanagement der Therapie mit Antimalariamitteln: was bedeuten die neuen Empfehlungen für die Praxis?

Antimalariamittel (AM) haben nach wie vor eine große Bedeutung in der Rheumatologie. Die aktualisierten Empfehlungen zum Sicherheitsmanagement mit AM wurden auf der Basis einer systematischen Literaturaturrecherche und im interdisziplinären Konsens erarbeitet. Verantwortlich war die Kommission Pharmakotherapie der Deutschen Gesellschaft für Rheumatologie. Um Nebenwirkungen frühzeitig zu entdecken, bzw. Komplikationen im Zusammenhang mit der AM-Therapie vorzubeugen, sind folgende Maßnahmen empfohlen: Die rheumatologische Therapie mit AM sollte mit Hydroxychloroquin (HCQ) erfolgen und die Dosis von 5 mg/kg Körpergewicht (KG) nicht übersteigen. In den ersten 6 Monaten der Therapie ist eine augenärztliche Untersuchung empfohlen. Risikofaktoren für die Entwicklung einer AM-induzierten Retinopathie sind vorbestehende Makulopathie, Niereninsuffizienz mit glomerulärer Filtrationsrate (GFR)< 60 ml/min, Tamoxifen-Begleittherapie, Tagesdosen HCQ > 5 mg/kg KG, sowie die Therapie mit Chloroquin (CQ). Bei Vorliegen von Risikofaktoren werden die weiteren Kontrolluntersuchungen einmal pro Jahr empfohlen, ansonsten erst ab dem fünften Jahr, dann ebenfalls jährlich. Die ophthalmologische Untersuchung sollte mindestens eine subjektive und eine objektive Methode beinhalten. Empfohlen wird jeweils das automatisierte Gesichtsfeld (aGF) und die optische Kohärenztomografie (OCT). In der aGF lassen bei einer AM-Retinopathie eine parafoveale Empfindlichkeitsabnahme und in der OCT eine umschriebene Verdünnung der Photorezeptorenschicht parafoveal sowie fokale Unterbrechung der Außensegmentstrukturlinie den Verdacht auf eine AM-Retinopathie zu. Zur Erkennung von Kardiomyopathie bzw. Myopathie wird zu Beginn und dann alle 3–6 Monate die Bestimmung von Creatinkinase (CK) und Laktatdehydrogenase (LDH) im Serum empfohlen. Ergänzend können bei Verdacht auf AM-induzierte Kardiomyopathie Troponin, brain natriuretic peptide (BNP), Elektrokardiogramm (EKG), sowie eine kardiale Magnetresonanztomografie (MRT) erwogen werden. Bei Verdacht auf AM-induzierte Myopathie ist die Muskelbiopsie mit elektronenmikroskopischer Untersuchung der Goldstandard. Die Behandlung mit HCQ verursacht bei Einnahme in der Schwangerschaft keine Fehlbildungen der ungeborenen Kinder und ist sowohl in der Schwangerschaft wie auch Stillzeit nach gegenwärtigem Wissenstand sicher. Die aktualisierten Empfehlungen zum Sicherheitsmanagement der Therapie mit AM enthalten strengere Dosisvorgaben, Definition für Risikofaktoren für AM-Retinopathie und geeignete ophthalmologische Untersuchungen, sowie Stratifizierung im Monitoring.

Is hydroxychloroquine beneficial for COVID-19 patients?

The outbreak of coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was first reported in December 2019. As similar cases rapidly emerged around the world1-3, the World Health Organization (WHO) declared a public health emergency of international concern on January 30, 2020 and pronounced the rapidly spreading coronavirus outbreak as a pandemic on March 11, 20204. The virus has reached almost all countries of the globe. As of June 3, 2020, the accumulated confirmed cases reached 6,479,405 with more than 383,013 deaths worldwide. The urgent and emergency care of COVID-19 patients calls for effective drugs, in addition to the beneficial effects of remdesivir5, to control the disease and halt the pandemic.

Hydroxychloroquine in Dermatology and Beyond: Recent Update

Hydroxychloroquine is one of the most frequently used drugs in dermatology with a wide variety of uses due to its immunomodulatory, anti-inflammatory, photoprotective, and metabolic actions and low side effect profile. Demonstration of its antiviral action in vitro has led to renewed interest by physicians worldwide during the ongoing coronavirus disease of 2019 (COVID-19) pandemic. Like its immunomodulatory action, its antiviral activity is also due to its ability to alkalinize the intracytoplasmic milieu, leading to disordered viral entry/fusion and deranged viral protein synthesis. However, randomized controlled trials are the need of the hour to conclusively determine its clinical efficacy in such infections. A review of the multitude of mechanisms of action, updated screening and monitoring guidelines, drug interactions, side effects, and its use in special populations is described.