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Kim YM, Sung JH, Cha HH, Oh SY. Hydroxychloroquine in obstetrics: potential implications of the prophylactic use of hydroxychloroquine for placental insufficiency during pregnancy. Obstet Gynecol Sci 2024; 67:143-152. [PMID: 38246692 PMCID: PMC10948207 DOI: 10.5468/ogs.23252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 11/20/2023] [Accepted: 11/22/2023] [Indexed: 01/23/2024] Open
Abstract
Proper placentation during early pregnancy is a key factor for maintaining a healthy pregnancy. Placental insufficiency leads to critical complications such as preeclampsia, fetal growth restriction, and fetal demise. These complications are often associated with pathological findings of restricted remodeling and obstructive lesions of the myometrial spiral arteries, which have high recurrence rates during subsequent pregnancies. Currently, there are no pharmacological interventions other than aspirin for the prevention of preeclampsia. Hydroxychloroquine (HCQ), a well-known antimalarial drug, reduces inflammatory and thrombotic changes in vessels. For decades, the use of HCQ for autoimmune diseases has resulted in the successful prevention of both arterial and venous thrombotic events and has been extended to the treatment of lupus and antiphospholipid antibody syndrome during pregnancy. HCQ reduces the risk of preeclampsia with lupus by up to 90%. Several recent studies have investigated whether HCQ improves pregnancy outcomes in women with a history of poor outcomes. In addition, in vitro and animal studies have demonstrated the beneficial effects of HCQ in improving endothelial dysfunction and alleviating hypertension and proteinuria. Therefore, we hypothesized that HCQ has the potential to attenuate the vascular inflammatory and thrombogenic pathways associated with placental insufficiency and conducted a multicenter clinical trial on the efficacy of combining aspirin with HCQ for pregnancies at high risk for preeclampsia in Korea. This study summarizes the potential effects of HCQ on pregnancies with placental insufficiency and the implications of HCQ treatment in the field of obstetrics.
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Affiliation(s)
- Yoo-Min Kim
- Department of Obstetrics and Gynecology, Chung-Ang University Gwangmyeong Hospital, Chung-Ang University School of Medicine, Seoul,
Korea
| | - Ji-Hee Sung
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul,
Korea
| | - Hyun-Hwa Cha
- Department of Obstetrics and Gynecology, Kyungpook National University Chilgok Hospital, Kyungpook National University School of Medicine, Daegu,
Korea
| | - Soo-Young Oh
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul,
Korea
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Eschbach J, Wagner A, Beahr C, Bekel A, Korganow AS, Quartier A, Peter JC, Eftekhari P. Drug upgrade: A complete methodology from old drug to new chemical entities using Nematic Protein Organization Technique. Drug Dev Res 2024; 85:e22151. [PMID: 38349254 DOI: 10.1002/ddr.22151] [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: 08/25/2023] [Revised: 11/27/2023] [Accepted: 01/03/2024] [Indexed: 02/15/2024]
Abstract
Drug repurposing is used to propose new therapeutic perspectives. Here, we introduce "Drug Upgrade", that is, characterizing the mode of action of an old drug to generate new chemical entities and new therapeutics. We proposed a novel methodology covering target identification to pharmacology validation. As an old drug, we chose hydroxychloroquine (HCQ) for its well-documented clinical efficacy in lupus and its side effect, retinal toxicity. Using the Nematic Protein Organization Technique (NPOT®) followed by liquid chromatography-tandem mass spectrometry analyses, we identified myeloperoxidase (MPO) and alpha-crystallin β chain (CRYAB) as primary and secondary targets to HCQ from lupus patients' peripheral blood mononuclear cells (PBMCs) and isolated human retinas. Surface plasmon resonance (SPR) and enzymatic assays confirmed the interaction of HCQ with MPO and CRYAB. We synthesized INS-072 a novel analog of HCQ that increased affinity for MPO and decreased binding to CRYAB compared to HCQ. INS-072 delayed cutaneous eruption significantly compared to HCQ in the murine MRL/lpr model of spontaneous lupus and prevents immune complex vasculitis in mice. In addition, long-term HCQ treatment caused retinal toxicity in mice, unlike INS-072. Our study illustrates a method of drug development, where new applications or improvements can be explored by fully characterizing the drug's mode of action.
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Affiliation(s)
| | - Alain Wagner
- Bio-Functional Chemistry (UMR 7199), Institut du Médicament de Strasbourg, Illkirch-Graffenstaden, France
- Strasbourg Drug Discovery and Development Institute (IMS), Strasbourg, France
| | - Corinne Beahr
- Bio-Functional Chemistry (UMR 7199), Institut du Médicament de Strasbourg, Illkirch-Graffenstaden, France
| | - Akkiz Bekel
- Inoviem Scientific, Illkirch-Graffenstaden, France
| | - Anne-Sophie Korganow
- Department of Clinical Immunology and Internal Medicine, National Reference Center for Systemic Autoimmune Diseases (CNR RESO), Tertiary Center for Primary Immunodeficiency, University Hospital and INSERM UMR 1109, Strasbourg, France
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Geevarghese A, Kaiser A, Patel S, Saxena A, Belmont MH, Modi YS. Hydroxychloroquine Screening Guidelines: Best Evidence, Controversies, and Future Areas of Research. Int Ophthalmol Clin 2024; 64:195-207. [PMID: 38146891 DOI: 10.1097/iio.0000000000000508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2023]
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Parakh S, Bhatt V, Das S, Chaturvedi A, Luthra G, Katoch D, Barman P, Jindal AK, Luthra S. Pediatric Lupus Retinopathy: A Rare Manifestation of a Grave Systemic Disorder. Cureus 2023; 15:e46616. [PMID: 37937017 PMCID: PMC10626398 DOI: 10.7759/cureus.46616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2023] [Indexed: 11/09/2023] Open
Abstract
We describe a rare case of pediatric systemic lupus erythematosus (pSLE) and its successful management. A nine-year-old female presented with bilateral diminution of vision, fever, and rash in the malar region, chest, abdomen, back, and arms for three months. Clinical examination and multimodal imaging revealed bilateral extensive retinal vasculitis with macular edema. Laboratory investigations revealed anemia, leucopenia, positive serum antinuclear antibody (ANA), and anti-extractable nuclear antigen (ENA) antibodies. A diagnosis of pediatric lupus retinopathy was made. Ocular and systemic manifestations responded well to intense systemic immunosuppression (pulse intravenous {IV} methylprednisolone, oral prednisolone and hydroxychloroquine {HCQ}, six cycles of IV cyclophosphamide, and oral azathioprine) along with topical steroids and laser photocoagulation, over the next 10 months. Though ocular manifestations are not a part of the diagnostic criteria for SLE, they may be markers of active systemic disease. Ophthalmologists and rheumatologists must treat this complex disease in tandem in order to provide optimum patient care.
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Affiliation(s)
| | | | | | | | | | - Deeksha Katoch
- Ophthalmology, Postgraduate Institute of Medical Education and Research, Chandigarh, IND
| | - Prabal Barman
- Pediatric Rheumatology, Postgraduate Institute of Medical Education and Research, Chandigarh, IND
| | - Ankur K Jindal
- Pediatric Rheumatology, Postgraduate Institute of Medical Education and Research, Chandigarh, IND
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Chen RI, Kuo BL, Kalur A, Muste JC, Deal C, Singh RP. Impact of an Electronic Decision Support Tool to Improve Ophthalmic Safety in Hydroxychloroquine Prescribing Practices. Ophthalmic Surg Lasers Imaging Retina 2022; 53:310-316. [PMID: 35724373 DOI: 10.3928/23258160-20220601-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND OBJECTIVE The purpose of this study was to implement a clinical decision support tool (CDS) and assess its impact on adherence to 2016 American Academy of Ophthalmology (AAO) hydroxychloroquine dosing recommendations. PATIENTS AND METHODS This retrospective, interventional study implemented an automated alert to calculate maximum daily hydroxychloroquine dose based on 2016 AAO recommendations and flag noncompliant orders. Prevalence of excessive dosing after CDS implementation was assessed. RESULTS A total of 7,417 patients met inclusion criteria. After intervention, prevalence of excessive dosing decreased from 27.4% to 21.1% (P < .001) among all prescriptions and from 26.8% to 16.2% (P < .001) among new prescriptions. Daily doses exceeding 400 mg decreased from 0.8% to 0.02% (P < .001). Risk factors for excessive dosing included low weight (odds ratio, 75.6 [95% CI, 54.0 to 105.8]) and nonrheumatologist prescriber (odds ratio, 1.60 to 3.63; all P < .005). CONCLUSIONS This study highlights the efficacy of a CDS in reducing excessive hydroxychloroquine dosing and improving adherence to AAO ophthalmic safety guidelines. [Ophthalmic Surg Lasers Imaging 2022;53:310-316.].
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Hong W, Park YK, Kim BO, Park SK, Shin J, Jang SP, Park HW, Yang W, Jang J, Jang SW, Hwang TH. Use of combined treatment of 3rd-generation cephalosporin, azithromycin and antiviral agents on moderate SARs-CoV-2 patients in South Korea: A retrospective cohort study. PLoS One 2022; 17:e0267645. [PMID: 35507600 PMCID: PMC9067652 DOI: 10.1371/journal.pone.0267645] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 04/12/2022] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES To assess efficacy and safety of the combined treatment of antibiotics (3rd-generation cephalosporin and azithromycin) and antiviral agents (lopinavir/ritonavir or hydroxychloroquine) on moderate COVID-19 patients in South Korea. METHODS A retrospective cohort study of the 358 laboratory-confirmed SARS-CoV-2 (COVID-19) patients was conducted. 299 patients met inclusion criteria for analysis. Propensity score matching (PSM) and Cox regression method were used to control and adjust for confounding factors. Mild to moderate COVID-19 patients were managed with either CA/LoP (cephalosporin, azithromycin, and lopinavir/ritonavir) (n = 57), CA/HQ (cephalosporin, azithromycin, and hydroxychloroquine) (n = 25) or standard supportive care (n = 217). We analyzed the association between treatment group and standard supportive group in terms of three endpoints: time to symptom resolution, time to viral clearance, and hospital stay duration. Using propensity-score matching analysis, three rounds of propensity-matching analysis were performed to balance baseline characteristics among three cohorts. RESULTS Kaplan-Meier curves fitted using propensity score-matched data revealed no significant differences on time to symptom resolution, time to viral clearance, hospital stay duration among the three treatment arms (CA/LoP vs Standard, log-rank p-value = 0.2, 0.58, and 0.74 respectively for the three endpoints) (CA/HQ vs Standard, log-rank p-value = 0.46, 0.99, and 0.75 respectively). Similarly, Cox regression analysis on matched cohorts of CA/LoP and standard supportive group showed that hazard ratios of time to symptom resolution (HR: 1.447 [95%-CI: 0.813-2.577]), time to viral clearance(HR: 0.861, [95%-CI: 0.485-1.527]), and hospital stay duration (HR: 0.902, [95%-CI: 0.510-1.595]) were not significant. For CA/HQ and standard supportive group, hazard ratios of the three endpoints all showed no statistical significance (HR: 1.331 [95%-CI:0.631-2.809], 1.005 [95%-CI:0.480-2.105], and 0.887, [95%-CI:0.422-1.862] respectively). No severe adverse event or death was observed in all groups. CONCLUSIONS Combined treatment of 3rd cephalosporin, azithromycin and either low-dose lopinavir/ritonavir or hydroxychloroquine was not associated with better clinical outcomes in terms of time to symptom resolution, time to viral clearance, and hospital stay duration compared to standard supportive treatment alone. Microbiological evidence should be closely monitored when treating SARS-CoV-2 patients with antibiotics to prevent indiscreet administration of empirical antimicrobial treatments.
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Affiliation(s)
- Wooyoung Hong
- Department of Chemistry and Chemical Biology, Harvard University, Cambridge, MA, United States of America
| | - Yu-Kyung Park
- Korea Workers’ Compensation & Welfare Services Daegu Hospital, Buk-gu, Daegu, Republic of Korea
| | - Bong-Ok Kim
- Korea Workers’ Compensation & Welfare Services Daegu Hospital, Buk-gu, Daegu, Republic of Korea
| | - Sung Kyu Park
- Korea Workers’ Compensation & Welfare Services Daegu Hospital, Buk-gu, Daegu, Republic of Korea
| | - Jiin Shin
- School of Medicine, Seoul National University, Seoul, Republic of Korea
| | - Soon-Pyo Jang
- Department of Oral and Maxillofacial Surgery, Division of Oral Pathobiological Science, Graduate School of Dental Medicine, Hokkaido University, Hokkaido, Japan
| | - Hea-Woon Park
- Korea Workers’ Compensation & Welfare Services Daegu Hospital, Buk-gu, Daegu, Republic of Korea
| | - Wonjong Yang
- Korea Workers’ Compensation & Welfare Services Daegu Hospital, Buk-gu, Daegu, Republic of Korea
| | - Joonyoung Jang
- Korea Workers’ Compensation & Welfare Services Daegu Hospital, Buk-gu, Daegu, Republic of Korea
| | - Soon-Woo Jang
- Director of Bukha Public Health Center, Jangseong, Republic of Korea
- Pusan University, School of Medicine, Yangsan, Republic of Korea
| | - Tae-Ho Hwang
- Department of Pharmacology, School of Medicine, Pusan National University, Yangsan, Republic of Korea
- Gene and Cell Therapy Research Center for Vessel-associated Diseases, School of Medicine, Pusan National University, Yangsan, Republic of Korea
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Abu-Zaid MH, Aly HM, Moshrif A, Abdeldaim DE, El-Ghobashy N. Hydroxychloroquine non-availability during COVID-19 pandemic and its relation to anxiety level and disease activity in rheumatoid arthritis and lupus patients: a cross-sectional study. EGYPTIAN RHEUMATOLOGY AND REHABILITATION 2022. [PMCID: PMC8907908 DOI: 10.1186/s43166-022-00117-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
During COVID-19 disease era, there is an accelerated demand for hydroxychloroquine since it was suggested by some centers as potential therapy for COVID-19 which has led to diminished supplies for patients with rheumatic disease and which carried unexpected risk for disease flare particularly in patients with systemic lupus erythematosus and rheumatoid arthritis. The purpose of the work is to detect the effect of HCQ shortage in patients with RA and SLE on anxiety and disease activity.
Results
A total of 320 patients were divided into two groups: group 1—216RA patients with mean age 45.5 ± 9.59 years, disease duration 43.4 ± 25.6 months with female predominance (62.5%). Group 2—104 SLE patients with mean33.4 ± 7.9 age years, disease duration 52.1 ± 34.6 months with female predominance (85.6%). HCQ shortage occurred in 174 RA patients (80.5%) and 76 lupus patients (73.1%). Despite HCQ shortage, there were no significant change in disease activity of RA (using CDAI) and SLE (using SELENA) p = 0.063 and 0.064 respectively before and after HCQ shortage. Anxiety level was higher in patients who were exposed to HCQ shortage in both groups (SLE p 0.0058 and RA p 0.0044) when we compared them to those without HCQ shortage.
Conclusion
In most patients with RA and SLE, the COVID-19 pandemic resulted in a HCQ scarcity, with no effect on disease activity. Anxiety was found to be associated with HCQ shortage in both diseases.
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Parthasarathy P, Shaikh H, Ryan PM, Mondal T. Does treatment with hydroxychloroquine or chloroquine lead to QTc prolongation in children? PROGRESS IN PEDIATRIC CARDIOLOGY 2022. [DOI: 10.1016/j.ppedcard.2021.101465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Effects of hydroxychloroquine and its metabolites in patients with connective tissue diseases. Inflammopharmacology 2021; 29:1795-1805. [PMID: 34743268 PMCID: PMC8572531 DOI: 10.1007/s10787-021-00887-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 10/24/2021] [Indexed: 11/24/2022]
Abstract
Hydroxychloroquine has attracted attention in the treatment of COVID-19. Many conflicting findings have been reported regarding the efficacy and safety of this drug, which has been used safely in the rheumatological diseases for years. However, these studies lacked measurement methods that allow accurate assessment of hydroxychloroquine and its metabolite levels. The aim of this study was to measure hydroxychloroquine and its metabolite levels in whole blood samples of patients with rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), Sjogren’s syndrome (SS) and scleroderma (Scl) by a robust, simple and accurate validated tandem mass spectrometric method, and to investigate the relationship between these levels with drug-related adverse effects and disease activity scores. The validated LC–MS/MS method was applied to measure blood hydroxychloroquine and its metabolite levels of patients with RA, SLE, SS, Scl. Various haematological and biochemical parameters were measured with Beckman-Coulter AU 5800 and Beckman Coulter LH 780 analyzers, respectively. QTc intervals were calculated with Bazett’s formula, and the patients were followed up by clinicians in terms of clinical findings and adverse effects. Hydroxychloroquine levels of patients were similar to previous studies. There was a negative correlation between disease activity scores and hydroxychloroquine levels, while the highest correlation was between QTc interval, creatinine and GFR levels with desethylchloroquine. Bidetylchloroquine had the highest correlation with RBC count and liver function tests. Our findings showed that hydroxychloroquine and its metabolite levels were associated with disease activity scores, renal, hepatic function, QTc prolongation, and hematological parameters.
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Tedesco Silva LM, Cortes A, Rossi B, Boll L, Waclawovsky G, Eibel B, Cadaval Gonçalves S, Irigoyen MC, Martinez D. Effects of Hydroxychloroquine on endOthelial function in eLDerly with sleep apnea (HOLD): study protocol for a randomized clinical trial. Trials 2021; 22:638. [PMID: 34535165 PMCID: PMC8447592 DOI: 10.1186/s13063-021-05610-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 09/07/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Sleep apnea and coronary artery disease are prevalent and relevant diseases. The mechanism by which sleep apnea leads to coronary artery disease remains unclear. Intermittent hypoxia, caused by sleep apnea, leads to inflammation and consequent endothelial dysfunction. Endothelial dysfunction precedes the development of atherosclerotic disease and the occurrence of cardiovascular events. Agents that potentially act to improve endothelial function can help prevent cardiovascular events. Patients using immunomodulators due to rheumatic diseases have a lower prevalence of cardiovascular diseases. However, the potential cardioprotective effect of these drugs in patients without autoimmune diseases is not clear. Hydroxychloroquine (HCQ) is an immunomodulator used to treat rheumatoid arthritis and systemic lupus erythematosus. In addition to its anti-inflammatory properties, HCQ reduces cholesterol and blood glucose levels and has antithrombotic effects. The drug is inexpensive and widely available. Adverse effects of HCQ are rare and occur more frequently with high doses. OBJECTIVE In this randomized clinical trial, the effect of HCQ treatment on endothelial function will be tested in seniors with sleep apnea. METHODS We will recruit participants over the age of 65 and with moderate-severe sleep apnea from an ongoing cohort. We chose to use this sample already evaluated for sleep apnea for reasons of convenience, but also because the elderly with sleep apnea are vulnerable to heart disease. Endothelial function will be assessed by examining flow-mediated dilation of the brachial artery, the gold standard method, considered an independent predictor of cardiovascular events in the general population and by peripheral arterial tonometry, the most recent and most easily obtained method. Hydroxychloroquine will be used at a dose of 400 mg/daily for 8 weeks. DISCUSSION Our study aims to obtain evidence, albeit preliminary, of the efficacy of hydroxychloroquine in improving endothelial function and reducing cardiovascular risk markers. If the improvement occurs, we plan to design a randomized multicenter clinical trial to confirm the findings. TRIAL REGISTRATION ClinicalTrials.gov NCT04161339 . Registered on November 2019.
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Affiliation(s)
| | - Antonio Cortes
- Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Beatriz Rossi
- Instituto de Cardiologia - Fundação Universitária de Cardiologia (IC-FUC), Porto Alegre, Brazil
| | - Liliana Boll
- Instituto de Cardiologia - Fundação Universitária de Cardiologia (IC-FUC), Porto Alegre, Brazil
| | - Gustavo Waclawovsky
- Instituto de Cardiologia - Fundação Universitária de Cardiologia (IC-FUC), Porto Alegre, Brazil
| | - Bruna Eibel
- Instituto de Cardiologia - Fundação Universitária de Cardiologia (IC-FUC), Porto Alegre, Brazil
| | | | - Maria Claudia Irigoyen
- Instituto de Cardiologia - Fundação Universitária de Cardiologia (IC-FUC), Porto Alegre, Brazil
- Universidade de São Paulo, São Paulo, Brazil
| | - Denis Martinez
- Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
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Amani B, Khanijahani A, Amani B. Hydroxychloroquine plus standard of care compared with standard of care alone in COVID-19: a meta-analysis of randomized controlled trials. Sci Rep 2021; 11:11974. [PMID: 34099745 PMCID: PMC8184930 DOI: 10.1038/s41598-021-91089-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 05/20/2021] [Indexed: 01/08/2023] Open
Abstract
The efficacy and safety of Hydroxychloroquine (HCQ) in treating coronavirus disease (COVID-19) is disputed. This systematic review and meta-analysis aimed to examine the efficacy and safety of HCQ in addition to standard of care (SOC) in COVID-19. PubMed, the Cochrane Library, Embase, Web of sciences, and medRxiv were searched up to March 15, 2021. Clinical studies registry databases were also searched for identifying potential clinical trials. The references list of the key studies was reviewed to identify additional relevant resources. The quality of the included studies was evaluated using the Cochrane Collaboration tool and Jadad checklist. Meta-analysis was performed using RevMan software (version 5.3). Eleven randomized controlled trials with a total number of 8161 patients were identified as eligible for meta-analysis. No significant differences were observed between the two treatment groups in terms of negative rate of polymerase chain reaction (PCR) (Risk ratio [RR]: 0.99, 95% confidence interval (CI) 0.90, 1.08; P = 0.76), PCR negative conversion time (Mean difference [MD]: - 1.06, 95% CI - 3.10, 0.97; P = 0.30), all-cause mortality (RR: 1.09, 95% CI 1.00, 1.20; P = 0.06), body temperature recovery time (MD: - 0.64, 95% CI - 1.37, 0.10; P = 0.09), length of hospital stay (MD: - 0.17, 95% CI - 0.80, 0.46; P = 0.59), use of mechanical ventilation (RR: 1.12, 95% CI 0.95, 1.32; P = 0.19), and disease progression (RR = 0.82, 95% CI 0.37, 1.85; P = 0.64). However, there was a significant difference between two groups regarding adverse events (RR: 1.81, 95% CI 1.36, 2.42; P < 0.05). The findings suggest that the addition of HCQ to SOC has no benefit in the treatment of hospitalized patients with COVID-19. Additionally, it is associated with more adverse events.
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Affiliation(s)
- Bahman Amani
- Health Management and Economics Research Center, Health Management Research Institute, Iran University of Medical Sciences, Tehran, Iran
| | - Ahmad Khanijahani
- John G. Rangos School of Health Sciences, Duquesne University, 600 Forbes Ave, Pittsburgh, PA, 15282, USA
| | - Behnam Amani
- Health Management and Economics Research Center, Health Management Research Institute, Iran University of Medical Sciences, Tehran, Iran.
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Ulander L, Tolppanen H, Hartman O, Rissanen TT, Paakkanen R, Kuusisto J, Anttonen O, Nieminen T, Yrjölä J, Ryysy R, Drews T, Utriainen S, Karjalainen P, Anttila I, Nurmi K, Silventoinen K, Koskinen M, Kovanen PT, Lehtonen J, Eklund KK, Sinisalo J. Hydroxychloroquine reduces interleukin-6 levels after myocardial infarction: The randomized, double-blind, placebo-controlled OXI pilot trial. Int J Cardiol 2021; 337:21-27. [PMID: 33961943 DOI: 10.1016/j.ijcard.2021.04.062] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 04/06/2021] [Accepted: 04/28/2021] [Indexed: 12/27/2022]
Abstract
OBJECTIVES To determine the anti-inflammatory effect and safety of hydroxychloroquine after acute myocardial infarction. METHOD In this multicenter, double-blind, placebo-controlled OXI trial, 125 myocardial infarction patients were randomized at a median of 43 h after hospitalization to receive hydroxychloroquine 300 mg (n = 64) or placebo (n = 61) once daily for 6 months and, followed for an average of 32 months. Laboratory values were measured at baseline, 1, 6, and 12 months. RESULTS The levels of interleukin-6 (IL-6) were comparable at baseline between study groups (p = 0.18). At six months, the IL-6 levels were lower in the hydroxychloroquine group (p = 0.042, between groups), and in the on-treatment analysis, the difference at this time point was even more pronounced (p = 0.019, respectively). The high-sensitivity C-reactive protein levels did not differ significantly between study groups at any time points. Eleven patients in the hydroxychloroquine group and four in the placebo group had adverse events leading to interruption or withdrawal of study medication, none of which was serious (p = 0.10, between groups). CONCLUSIONS In patients with myocardial infarction, hydroxychloroquine reduced IL-6 levels significantly more than did placebo without causing any clinically significant adverse events. A larger randomized clinical trial is warranted to prove the potential ability of hydroxychloroquine to reduce cardiovascular endpoints after myocardial infarction.
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Affiliation(s)
- Lotta Ulander
- Heart and Lung Center, Helsinki University Hospital, Helsinki University, Helsinki, Finland
| | - Heli Tolppanen
- Heart and Lung Center, Helsinki University Hospital, Helsinki University, Helsinki, Finland
| | - Otto Hartman
- Heart and Lung Center, Helsinki University Hospital, Helsinki University, Helsinki, Finland
| | - Tuomas T Rissanen
- Heart Center, North Karelia Central Hospital, Siunsote, Joensuu, Finland
| | - Riitta Paakkanen
- Heart and Lung Center, Helsinki University Hospital, Helsinki University, Helsinki, Finland
| | - Jouni Kuusisto
- Heart and Lung Center, Helsinki University Hospital, Helsinki University, Helsinki, Finland
| | - Olli Anttonen
- Department of Internal Medicine, Päijät-Häme Central Hospital, Lahti, Finland
| | - Tuomo Nieminen
- Department of Internal Medicine, Päijät-Häme Central Hospital, Lahti, Finland
| | - Jaana Yrjölä
- Department of Internal Medicine, Kymenlaakson Central Hospital, Kotka, Finland
| | - Ransu Ryysy
- Department of Internal Medicine, Kymenlaakson Central Hospital, Kotka, Finland
| | - Teemu Drews
- Department of Internal Medicine, South Karelia Central Hospital, Lappeenranta, Finland
| | - Seppo Utriainen
- Department of Internal Medicine, South Karelia Central Hospital, Lappeenranta, Finland
| | - Pasi Karjalainen
- Heart and Lung Center, Helsinki University Hospital, Helsinki University, Helsinki, Finland
| | - Ismo Anttila
- Department of Internal Medicine, Seinäjoki Central Hospital, Seinäjoki, Finland
| | - Katariina Nurmi
- Department of Rheumatology, Helsinki University Hospital, Helsinki University, ORTON Orthopaedic Hospital of the Orton Foundation, Helsinki, Finland
| | - Kristiina Silventoinen
- Department of Rheumatology, Helsinki University Hospital, Helsinki University, ORTON Orthopaedic Hospital of the Orton Foundation, Helsinki, Finland
| | - Miika Koskinen
- Helsinki Biobank, Helsinki University Hospital, Helsinki University, Helsinki, Finland
| | | | - Jukka Lehtonen
- Heart and Lung Center, Helsinki University Hospital, Helsinki University, Helsinki, Finland
| | - Kari K Eklund
- Department of Rheumatology, Helsinki University Hospital, Helsinki University, ORTON Orthopaedic Hospital of the Orton Foundation, Helsinki, Finland
| | - Juha Sinisalo
- Heart and Lung Center, Helsinki University Hospital, Helsinki University, Helsinki, Finland.
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Çelik HG, Keske Ş, Şener Ü, Tekbaş M, Kapmaz M, Şahin ŞT, Özyıldırım A, Aytekin S, Aytekin V, Ergönül Ö. Why we should be more careful using hydroxychloroquine in influenza season during COVID-19 pandemic? Int J Infect Dis 2021; 102:389-391. [PMID: 33130195 PMCID: PMC7834514 DOI: 10.1016/j.ijid.2020.10.080] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 10/22/2020] [Accepted: 10/23/2020] [Indexed: 01/08/2023] Open
Abstract
The aim of this study was to describe the QTc prolongation and related adverse cardiac events during the administration of hydroxychloroquine (HCQ) and its combinations for the treatment of coronavirus disease 2019 (COVID-19). Hospitalized patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) who received HCQ and had initial and follow-up electrocardiograms performed between March 10 and May 30, 2020 were included. Critical QTc prolongation was detected in 12% of the patients. On multivariate analysis, diabetes mellitus (odds ratio 5.8, 95% confidence interval 1.11-30.32, p = 0.037) and the use of oseltamivir (odds ratio 5.3, 95% confidence interval 1.02-28, p = 0.047) were found to be associated with critical QTc prolongation.
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Affiliation(s)
| | - Şiran Keske
- Department of Infectious Diseases, American Hospital, Istanbul, Turkey
| | - Ülker Şener
- Department of Pharmacy, American Hospital, Istanbul, Turkey
| | - Müge Tekbaş
- Department of Pharmacy, Koç University Hospital, Istanbul, Turkey
| | - Mahir Kapmaz
- Koç University İş Bank Research Center for Infectious Diseases, Istanbul, Turkey
| | | | | | - Saide Aytekin
- Department of Cardiology, Koç University School of Medicine, Istanbul, Turkey
| | - Vedat Aytekin
- Department of Cardiology, Koç University School of Medicine, Istanbul, Turkey
| | - Önder Ergönül
- Koç University İş Bank Research Center for Infectious Diseases, Istanbul, Turkey.
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14
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Haugaard JH, Dreyer L, Ottosen MB, Gislason G, Kofoed K, Egeberg A. Use of hydroxychloroquine and risk of major adverse cardiovascular events in patients with lupus erythematosus: A Danish nationwide cohort study. J Am Acad Dermatol 2020; 84:930-937. [PMID: 33321159 DOI: 10.1016/j.jaad.2020.12.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 11/08/2020] [Accepted: 12/01/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Limited data suggest that hydroxychloroquine may affect risk of cardiovascular disease in patients with lupus erythematosus (LE). OBJECTIVE To investigate whether hydroxychloroquine treatment is associated with major adverse cardiovascular events (MACE) (myocardial infarction, ischemic stroke, or cardiovascular-associated death) in patients with cutaneous LE (CLE) or systemic LE (SLE). METHODS Based on the Danish nationwide registers, an observational cohort study was conducted including patients with first-time diagnosis of CLE or SLE (between 1997 and 2017). Cox regression models calculating the hazard ratio (HR) analyzing the risk of MACE were performed comparing time on and off hydroxychloroquine (including never users). The models were adjusted for age, sex, socioeconomic status, concomitant treatment, and cardiovascular risk factors. RESULTS Among 4587 patients with LE, 51% (n = 2343) were treated with hydroxychloroquine during the study period. An inverse association between use of hydroxychloroquine and MACE risk was observed among patients with SLE (adjusted HR, 0.65; 95% confidence interval, 0.46-0.90) and patients with CLE (adjusted HR, 0.71; 95% confidence interval, 0.42-1.19). Consistent results were found in sensitivity analyses including a case-time control design. LIMITATIONS No information on disease activity/severity was available. CONCLUSION Our findings indicate an opportunity to reduce the risk of cardiovascular events in patients with LE through use of hydroxychloroquine.
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Affiliation(s)
- Jeanette Halskou Haugaard
- Department of Dermatology, Allergy and Venerology, Herlev and Gentofte University Hospital, Copenhagen, Denmark.
| | - Lene Dreyer
- Departments of Clinical Medicine and Rheumatology, Aalborg University and Aalborg University Hospital, Aalborg, Denmark
| | - Mathias Bo Ottosen
- Department of Dermatology, Allergy and Venerology, Herlev and Gentofte University Hospital, Copenhagen, Denmark
| | - Gunnar Gislason
- Department of Cardiology, Herlev and Gentofte University Hospital, Copenhagen, Denmark
| | - Kristian Kofoed
- Department of Dermatology, Allergy and Venerology, Herlev and Gentofte University Hospital, Copenhagen, Denmark
| | - Alexander Egeberg
- Department of Dermatology, Allergy and Venerology, Herlev and Gentofte University Hospital, Copenhagen, Denmark
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15
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Merone L, Finlay S. Pandemic and promise: progress towards finding an effective treatment for Novel Coronavirus 19. Aust N Z J Public Health 2020; 44:437-439. [PMID: 33044799 PMCID: PMC7675746 DOI: 10.1111/1753-6405.13044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Affiliation(s)
- Lea Merone
- Apunipima Cape York Health Council, Queensland,Division of Tropical Health and Medicine, James Cook University, Queensland
| | - Summer Finlay
- School of Health and Society, University of Wollongong, New South Wales,Health Research Institute, University of Canberra, Australian Capital Territory,Correspondence to: Summer Finlay, School of Health and Society, University of Wollongong, New South Wales
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16
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The effect of long-term hydroxychloroquine use on the corneal endothelium in patients with systemic lupus erythematosus. Int Ophthalmol 2020; 41:937-943. [PMID: 33196914 DOI: 10.1007/s10792-020-01649-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 10/29/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE To evaluate the effect of long-term effects of hydroxychloroquine (HCQ) use on the corneal endothelium in patients with systemic lupus erythematosus (SLE). METHODS The study included 30 eyes of 15 patients who used HCQ for at least five years and were followed up in the rheumatology clinic for SLE and 29 eyes of 15 patients newly diagnosed with SLE who had not taken any medication. All patients underwent complete ophthalmologic examinations, central corneal thickness measurements, endothelial cell counts and endothelial morphological examinations by specular microscopy. RESULTS The mean age was 41.25 ± 6.89 years in group 1 and 41.81 ± 5.78 years in group 2 (p = 0.737). The mean corneal endothelial cell density was 2662 ± 184 cells/mm2 in group 1 and 2649 ± 315 cells/mm2 in group 2 (p = 0.843). The percentage of cell hexagonality was 46.6 ± 11.8% in group 1 and 48.7 ± 13.8% in group 2 (p = 0.625). A difference was noted in endothelial cell variation in both groups, at 36.7 ± 6.9% in group 1 and 39.9 ± 6.2% in group 2 (p = 0.057) but not statistically significant. No difference was observed between the two groups in terms of central corneal thickness. The duration of HCQ use was negatively correlated with hexagonality (r = -0.564, p = 0.001) CONCLUSION: Long-term use of HCQ in SLE patients had no negative effect on endothelial cell density and cell variation, but a negative correlation existed between the duration of HCQ usage and hexagonality.
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17
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Elsawah HK, Elsokary MA, Elrazzaz MG, Elshafie AH. Hydroxychloroquine for treatment of nonsevere COVID-19 patients: Systematic review and meta-analysis of controlled clinical trials. J Med Virol 2020; 93:1265-1275. [PMID: 32808712 PMCID: PMC7461373 DOI: 10.1002/jmv.26442] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 08/13/2020] [Indexed: 12/19/2022]
Abstract
Being a pandemic and having a high global case fatality rate directed us to assess the evidence strength of hydroxychloroquine efficacy in treating coronavirus disease‐2019 (COVID‐19) arising from clinical trials and to update the practice with the most reliable clinical evidence. A comprehensive search was started in June up to 18 July, 2020 in many databases, including PubMed, Embase, and others. Of 432 studies found, only six studies fulfilled the inclusion criteria, which includes: clinical trials, age more than 12 years with nonsevere COVID‐19, polymerase chain reaction‐confirmed COVID‐19, hydroxychloroquine is the intervention beyond the usual care. Data extraction and bias risk assessment were done by two independent authors. Both fixed‐effect and random‐effect models were utilized for pooling data using risk difference as a summary measure. The primary outcomes are clinical and radiological COVID‐19 progression, severe acute respiratory syndrome coronavirus‐2 clearance in the pharyngeal swab, and mortality. The secondary outcomes are the adverse effects of hydroxychloroquine. Among 609 COVID‐19 confirmed patients obtained from pooling six studies, 294 patients received hydroxychloroquine and 315 patients served as a control. Hydroxychloroquine significantly prevents early radiological progression relative to control with risk difference and 95% confidence interval of −0.2 (−0.36 to −0.03). On the other hand, hydroxychloroquine did not prevent clinical COVID‐19 progression, reduce 5‐day mortality, or enhance viral clearance on days 5, 6, and 7. Moreover, many adverse effects were reported with hydroxychloroquine therapy. Failure of hydroxychloroquine to show viral clearance or clinical benefits with additional adverse effects outweigh its protective effect from radiological progression in nonsevere COVID‐19 patients. Benefit‐risk balance should determine the hydroxychloroquine use in COVID‐19. Hydroxychloroquine does not reduce mortality or save COVID‐19 patients live. Hydroxychloroquine does not promote a clinical improvement of SARS CoV‐2 infected patients. Hydroxychloroquine Fails to accelerate clearance of new coronavirus. Hydroxychloroquine increases adverse events specially diarrhea without proven clinical benefits. Meta‐analysis of clinical trials failed to show clear evidence, large randomized trial is required.
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Affiliation(s)
- Hozaifa Khalil Elsawah
- Department of Biostatistics, High Institute of Public Health, Alexandria University, Alexandria, Egypt
| | - Mohamed Ahmed Elsokary
- Department of Biostatistics, High Institute of Public Health, Alexandria University, Alexandria, Egypt
| | | | - Ahmed Hanei Elshafie
- Department of Neuropsychiatry, Shebin Elkom Teaching Hospital, Shebin Elkom, Egypt
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18
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Baghchechi M, Jaipaul N, Jacob SE. The rise and evolution of COVID-19. Int J Womens Dermatol 2020; 6:248-254. [PMID: 32838013 PMCID: PMC7318922 DOI: 10.1016/j.ijwd.2020.06.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 06/10/2020] [Accepted: 06/17/2020] [Indexed: 02/06/2023] Open
Abstract
Coronaviridae (CoV) is a large family of zoonotic viruses linked to a range of diseases from the common cold to severe acute and Middle East respiratory syndrome CoV epidemics. In 2019, a novel virus emerged from Wuhan, China, and resulted in a marked worldwide outbreak of respiratory illness. Prevention and containment became the prioritized intervention against COVID-19, coupled with a continued search for hallmarks of the disease that would allow early detection and provide insight into management and triage. Cutaneous findings associated with COVID-19 include diffuse maculopapular rashes, livedo reticularis, and acro-ischemic "COVID toes." These skin findings occurred anywhere from days before respiratory symptom onset to weeks after recovery, and predominantly in child and adolescent populations. The role of dermatologists can be expanded during this COVID-19 pandemic to help identify disease through cutaneous presentations.
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Affiliation(s)
| | - Navin Jaipaul
- Department of Nephrology, Loma Linda University, Loma Linda, CA, USA
- Veterans Affairs-Loma Linda, Loma Linda, CA, USA
- University of California, Riverside, CA, USA
| | - Sharon E. Jacob
- Veterans Affairs-Loma Linda, Loma Linda, CA, USA
- University of California, Riverside, CA, USA
- Department of Dermatology, Loma Linda University, Loma Linda, CA, USA
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19
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Gobbett A, Kotagiri A, Bracewell C, Smith J. Two years' experience of screening for hydroxychloroquine retinopathy. Eye (Lond) 2020; 35:1171-1177. [PMID: 32636495 DOI: 10.1038/s41433-020-1028-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 06/04/2020] [Accepted: 06/05/2020] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The Royal College of Ophthalmologists (RCOphth) recently produced new guidelines for the screening of hydroxychloroquine (HCQ) retinopathy. New imaging techniques have suggested an increased prevalence of retinopathy (7.5%) compared with previous studies (0.5%). METHODS We collected prospective data from all patients referred to Sunderland Eye Infirmary, Sunderland for HCQ screening. Patients were screened according to RCOphth guidelines. In addition to retinal images, the data recorded included visual acuity, visual fields and multifocal electroretinography as appropriate, the patient's age, diagnosis, weight, renal function and use of tamoxifen. RESULTS Of the 678 patients screened, 333 were categorised to be at risk (251 patients had been on HCQ >5 years, 117 had an estimated glomerular function rate <60 ml/min/1.73 m2, and 46 were on a dose >5 mg/kg/day). Eighty patients had multiple risk factors, 31 had been on doses of >5 mg/kg/day for >5 years. One hundred and sixty-eight of these patients have now been screened twice. The prevalence of HCQ retinopathy was 2/678 (0.3%) of all screened, 2/333 (0.6%) of patients at risk. CONCLUSIONS Our results show a far lower rate of retinopathy compared to the widely reported figure taken as standard by the RCOphth. This may be multifactorial: this prospective analysis has fewer patients taking higher doses of HCQ and shorter follow up, the comparison of serial images may highlight more cases and in addition, there are significant numbers of patients yet to be referred. Finally, the RCOphth's diagnostic criteria is more exacting than that of the recent literature.
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Affiliation(s)
- Anne Gobbett
- Sunderland Eye Infirmary, Queen Alexandra Rd, Sunderland, SR2 9HP, UK.
| | - Ajay Kotagiri
- Sunderland Eye Infirmary, Queen Alexandra Rd, Sunderland, SR2 9HP, UK
| | | | - Jonathan Smith
- Sunderland Eye Infirmary, Queen Alexandra Rd, Sunderland, SR2 9HP, UK
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20
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Lazaros G, Antonopoulos AS, Antonatou K, Skendros P, Ritis K, Hadziyannis E, Lazarou E, Leontsinis I, Simantiris S, Vlachopoulos C, Tousoulis D, Vassilopoulos D. Hydroxychloroquine for colchicine-resistant glucocorticoid-dependent idiopathic recurrent pericarditis: A pilot observational prospective study. Int J Cardiol 2020; 311:77-82. [DOI: 10.1016/j.ijcard.2020.03.069] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Revised: 03/14/2020] [Accepted: 03/27/2020] [Indexed: 12/29/2022]
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21
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Gendelman O, Amital H, Bragazzi NL, Watad A, Chodick G. Continuous hydroxychloroquine or colchicine therapy does not prevent infection with SARS-CoV-2: Insights from a large healthcare database analysis. Autoimmun Rev 2020; 19:102566. [PMID: 32380315 PMCID: PMC7198406 DOI: 10.1016/j.autrev.2020.102566] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 04/29/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Some disease-modifying agents commonly used to treat patients with rheumatic diseases/autoimmune disorders, such as hydroxychloroquine and colchicine, are under investigation as potential therapies for the "coronavirus disease 2019" (COVID-19). However, the role of such agents as prophylactic tools is still not clear. METHODS This is a retrospective study based on a large healthcare computerized database including all patients that were screened for the "Severe Acute Respiratory Syndrome Coronavirus type 2" (SARS-CoV-2) in the study period from February 23rd 2020 to March 31st 2020. A comparison was conducted between subjects tested positive for SARS-CoV-2 and those found negative in terms of rate of administration of hydroxychloroquine/colchicine therapy. RESULTS An overall sample of 14,520 subjects were screened for SARS-CoV-2 infection and 1317 resulted positive. No significant difference was found in terms of rates of usage of hydroxychloroquine or colchicine between those who were found positive for SARS-CoV-2 and those who were found negative (0.23% versus 0.25% for hydroxychloroquine, and 0.53% versus 0.48% for colchicine, respectively). CONCLUSION These findings raise doubts regarding the protective role of these medications in the battle against SARS-CoV-2 infection.
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Affiliation(s)
- Omer Gendelman
- Department of Medicine 'B', Sheba Medical Center, Tel-Hashomer, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Howard Amital
- Department of Medicine 'B', Sheba Medical Center, Tel-Hashomer, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Nicola Luigi Bragazzi
- Department of Mathematics and Statistics, Laboratory for Industrial and Applied Mathematics (LIAM), York University, Toronto, ON M3J 1P3, Canada
| | - Abdulla Watad
- Department of Medicine 'B', Sheba Medical Center, Tel-Hashomer, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gabriel Chodick
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Maccabitech, Maccabi Healthcare Services, Tel Aviv, Israel
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22
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Kulshrestha R, Dhanda H, Pandey A, Singh A, Kumar R. Immunopathogenesis and therapeutic potential of macrophage influx in diffuse parenchymal lung diseases. Expert Rev Respir Med 2020; 14:917-928. [PMID: 32600077 DOI: 10.1080/17476348.2020.1776117] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
INTRODUCTION The diffuse parenchymal lung diseases (DPLD)/interstitial lung diseases (ILD) are progressive lung disorders with usually unclear etiology, poor long-term survival and no effective treatment. Their pathogenesis is characterized by alveolar epithelial cell injury, inflammation, epithelial-mesenchymal transition, and parenchymal fibrosis. Macrophages play diverse roles in their development, both in the acute phase and in tissue repair. AREAS COVERED In this review, we summarize the current state of knowledge regarding the role of macrophages and their phenotypes in the immunopathogenesis of DPLDs; CVD-ILD, UIP, NSIP, DIP, RB-ILD, AIP, HP, Sarcoidosis, etc. Our goal is to update the understanding of the immune mechanisms underlying the initiation and progression of fibrosis in DPLDs. This will help in identification of biomarkers and in developing novel therapeutic strategies for DPLDs. A thorough literature search of the published studies in PubMed (from 1975 to 2020) was done. EXPERT OPINION The macrophage associated inflammatory markers needs to be explored for their potential as biomarkers of disease activity and progression. Pharmacological targeting of macrophage activation may reduce the risk of macrophage activation syndrome (MAS) and help improving the survival and prognosis of these patients.
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Affiliation(s)
| | - Himanshu Dhanda
- Department of Pathology, V.P.Chest Institute , New Delhi, India
| | - Apoorva Pandey
- Department of Pathology, V.P.Chest Institute , New Delhi, India
| | - Amit Singh
- Department of Pathology, V.P.Chest Institute , New Delhi, India
| | - Raj Kumar
- Department of Pulmonary Medicine, V.P.Chest Institute , New Delhi, India
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23
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Marshall E, Robertson M, Kam S, Penwarden A, Riga P, Davies N. Prevalence of hydroxychloroquine retinopathy using 2018 Royal College of Ophthalmologists diagnostic criteria. Eye (Lond) 2020; 35:343-348. [PMID: 32587388 PMCID: PMC7316164 DOI: 10.1038/s41433-020-1038-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 06/01/2020] [Accepted: 06/09/2020] [Indexed: 12/14/2022] Open
Abstract
Introduction To measure the prevalence of hydroxychloroquine retinopathy in patients attending a hydroxychloroquine monitoring service using 2018 Royal College of Ophthalmologists diagnostic criteria. Methods A service evaluation audit of a hydroxychloroquine retinopathy monitoring service was undertaken. Results of Humphrey 10–2 field tests, spectral-domain optical coherence tomography and fundus autofluorescence were collected with data on dose, weight, duration of treatment, estimated glomerular filtration rate, and concurrent tamoxifen therapy. Visual field tests were assessed as reliable or unreliable, and classified as normal, hydroxychloroquine-like, poor test or related to other pathology. Cases of definite and possible retinopathy were identified using the 2018 RCOphth criteria. Results There were 1976 attendances over two years of 1597 patients. Seven hundred and twenty-eight patients had taken hydroxychloroquine for less than 5 years and 869 had taken hydroxychloroquine for 5 years or more. Fourteen patients were identified with definite hydroxychloroquine retinopathy (1.6%), and 41 patients with possible retinopathy (4.7%). Sixty-seven per cent of 861 visual fields were performed reliably, with 66.9% classified as normal, 24.9% as poor test, 5.2% hydroxychloroquine-like and 3.0% abnormal due to other pathology. Conclusions The 1.6% prevalence of hydroxychloroquine retinopathy is lower than the previously reported prevalence of 7.5% as reported by Melles and Marmor JAMA Ophthalmol 132: 1453–60 (2014). This is because of a difference in the diagnostic criteria. Both definite and possible retinopathy would meet the diagnostic criteria of the Melles and Marmor study; 6.3% in our data, compared with 7.5%, a much smaller difference and likely to be explained by differences in the risk characteristics of the two groups.
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Affiliation(s)
- Elena Marshall
- Department of Ophthalmology, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK
| | - Matt Robertson
- Department of Ophthalmology, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK
| | - Satu Kam
- Department of Ophthalmology, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK
| | - Alison Penwarden
- Department of Ophthalmology, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK
| | - Paraskevi Riga
- Department of Ophthalmology, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK
| | - Nigel Davies
- Department of Ophthalmology, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK.
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Ramireddy A, Chugh H, Reinier K, Ebinger J, Park E, Thompson M, Cingolani E, Cheng S, Marban E, Albert CM, Chugh SS. Experience With Hydroxychloroquine and Azithromycin in the Coronavirus Disease 2019 Pandemic: Implications for QT Interval Monitoring. J Am Heart Assoc 2020; 9:e017144. [PMID: 32463348 PMCID: PMC7429030 DOI: 10.1161/jaha.120.017144] [Citation(s) in RCA: 86] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background Despite a lack of clinical evidence, hydroxychloroquine and azithromycin are being administered widely to patients with verified or suspected coronavirus disease 2019 (COVID-19). Both drugs may increase risk of lethal arrhythmias associated with QT interval prolongation. Methods and Results We analyzed a case series of COVID-19-positive/suspected patients admitted between February 1, 2020, and April 4, 2020, who were treated with azithromycin, hydroxychloroquine, or a combination of both drugs. We evaluated baseline and postmedication QT interval (corrected QT interval [QTc]; Bazett) using 12-lead ECGs. Critical QTc prolongation was defined as follows: (1) maximum QTc ≥500 ms (if QRS <120 ms) or QTc ≥550 ms (if QRS ≥120 ms) and (2) QTc increase of ≥60 ms. Tisdale score and Elixhauser comorbidity index were calculated. Of 490 COVID-19-positive/suspected patients, 314 (64%) received either/both drugs and 98 (73 COVID-19 positive and 25 suspected) met study criteria (age, 62±17 years; 61% men). Azithromycin was prescribed in 28%, hydroxychloroquine in 10%, and both in 62%. Baseline mean QTc was 448±29 ms and increased to 459±36 ms (P=0.005) with medications. Significant prolongation was observed only in men (18±43 ms versus -0.2±28 ms in women; P=0.02). A total of 12% of patients reached critical QTc prolongation. Changes in QTc were highest with the combination compared with either drug, with much greater prolongation with combination versus azithromycin (17±39 ms versus 0.5±40 ms; P=0.07). No patients manifested torsades de pointes. Conclusions Overall, 12% of patients manifested critical QTc prolongation, and the combination caused greater prolongation than either drug alone. The balance between uncertain benefit and potential risk when treating COVID-19 patients should be carefully assessed.
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Affiliation(s)
- Archana Ramireddy
- The Smidt Heart Institute, Cedars-Sinai Health System Los Angeles CA
| | - Harpriya Chugh
- The Smidt Heart Institute, Cedars-Sinai Health System Los Angeles CA
| | - Kyndaron Reinier
- The Smidt Heart Institute, Cedars-Sinai Health System Los Angeles CA
| | - Joseph Ebinger
- The Smidt Heart Institute, Cedars-Sinai Health System Los Angeles CA
| | - Eunice Park
- Enterprise Information Systems Data Intelligence Team Cedars-Sinai Health System Los Angeles CA
| | - Michael Thompson
- Enterprise Information Systems Data Intelligence Team Cedars-Sinai Health System Los Angeles CA
| | - Eugenio Cingolani
- The Smidt Heart Institute, Cedars-Sinai Health System Los Angeles CA
| | - Susan Cheng
- The Smidt Heart Institute, Cedars-Sinai Health System Los Angeles CA
| | - Eduardo Marban
- The Smidt Heart Institute, Cedars-Sinai Health System Los Angeles CA
| | | | - Sumeet S Chugh
- The Smidt Heart Institute, Cedars-Sinai Health System Los Angeles CA
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25
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Petrić M, Božić J, Radić M, Perković D, Petrić M, Martinović Kaliterna D. Dietary Habits in Patients with Systemic Lupus Erythematosus. J Med Food 2020; 23:1176-1182. [PMID: 32150485 DOI: 10.1089/jmf.2019.0227] [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: 11/13/2022] Open
Abstract
Patients with systemic lupus erythematosus (SLE) are often interested in which diets to follow. Our aim was to investigate which dietary habits were common among our patients, and which of them were in correlation with laboratory parameters of disease activity, such as complement values and 24-h proteinuria. This study included 76 patients with SLE in clinical remission with a 6-month flare free period. They completed a specialized, self-administered, 23-item food frequency questionnaire about their weekly dietary habits. Basic anthropometric data, levels of C3 and C4, and 24-h proteinuria were recorded and analyzed with respect to their dietary habits. The majority of patients had a normal body mass index of 18.5-25 kg/m2, and worked out regularly. The most frequently consumed foods reported by the patients were fruits, milk, vegetables, meat, pasta, rice, and bread. Decreased values of C3 were found in 34 (44.7%) patients, and decreased values of C4 in 28 (36.8%) patients. Decreased values of C3 were found in patients who often consumed meat (P = .015), and decreased values of C4 in patients who often consumed fast food (P = .043). Patients who often consumed fast food demonstrated a decreasing trend of C3 (P = .060), and patients who often consumed fried food had a decreasing trend of C4 (P = .051). Significant correlation between daily proteinuria and dietary habits was not found. Dietary habits can influence the disease course of SLE. Our study confirms that decreased levels of complement compounds C3 and C4, which are possible predictors of disease activation, are associated with frequent consumption of low quality proteins and food rich in calories.
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Affiliation(s)
- Marin Petrić
- Division of Clinical Immunology and Rheumatology, Department of Internal Medicine, University Hospital of Split, Split, Croatia
| | - Joško Božić
- Department of Pathophysiology, School of Medicine, University of Split, Split, Croatia
| | - Mislav Radić
- Division of Clinical Immunology and Rheumatology, Department of Internal Medicine, University Hospital of Split, Split, Croatia.,Department of Internal Medicine, School of Medicine, University of Split, Split, Croatia
| | - Dijana Perković
- Division of Clinical Immunology and Rheumatology, Department of Internal Medicine, University Hospital of Split, Split, Croatia.,Department of Internal Medicine, School of Medicine, University of Split, Split, Croatia
| | - Marija Petrić
- Division of Clinical Immunology and Rheumatology, Department of Internal Medicine, University Hospital of Split, Split, Croatia
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Lee HJ, Kim SJ. Sudden visual loss in a patient with systemic lupus erythematosus caused by a combination of the disease itself and drug toxicity. Lupus 2020; 29:431-433. [PMID: 32090680 DOI: 10.1177/0961203320909150] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- H-J Lee
- Department of Ophthalmology, Seoul National University College of Medicine, South Korea
| | - S-J Kim
- Department of Ophthalmology, Seoul National University College of Medicine, South Korea
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27
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Feldman CH, Costenbader KH, Solomon DH, Subramanian SV, Kawachi I. Area-Level Predictors of Medication Nonadherence Among US Medicaid Beneficiaries With Lupus: A Multilevel Study. Arthritis Care Res (Hoboken) 2020; 71:903-913. [PMID: 30055088 DOI: 10.1002/acr.23721] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 07/24/2018] [Indexed: 01/05/2023]
Abstract
OBJECTIVE Adherence to hydroxychloroquine (HCQ) treatment in patients with systemic lupus erythematous (SLE) is suboptimal. Although individual-level factors, including younger age and non-white race/ethnicity, have been implicated, contextual factors have not been explored. The aim of this study was to investigate the effect of contextual factors, including racial composition, socioeconomic status, and the concentration of health care resources, on adherence to HCQ among SLE patients enrolled in Medicaid. METHODS We identified SLE patients from 28 states in the US who enrolled in Medicaid (2000-2010) and in whom HCQ treatment was newly initiated (no use for ≥6 months). We required 12 months of continuous enrollment with complete drug dispensing data and measured adherence using the proportion of days covered (PDC). We identified individual-level variables from Medicaid, zip code-level, county-level and state-level sociodemographic variables from the American Community Survey, and health resources from Area Health Resources Files. We used 4-level hierarchical multivariable logistic regression models to examine the odds ratios (ORs) and 95% credible intervals (95% CrIs) of adherence (PDC ≥80%) versus nonadherence. RESULTS Among 10,268 patients with SLE in whom HCQ treatment was initiated, 15% were adherent to treatment. After we adjusted for individual-level characteristics, we observed lower odds of adherence among patients living in zip code areas with a higher percentage of black individuals (highest tertile OR 0.81 [95% CrI 0.69-0.96] versus lowest tertile). This association persisted after controlling for area-level educational attainment, percent below federal poverty level (FPL), urbanicity, and health care resources. We did not observe statistically significant associations with zip code-level percent Hispanic, percent white, education, or percent below FPL. The odds of adherence were higher in counties with more hospitals (OR 1.30 [95% CrI 1.07-1.58]). CONCLUSION Among Medicaid beneficiaries with SLE, we observed significant effects of racial composition and hospital concentration on HCQ adherence. Interventions that acknowledge and address contextual factors should be considered in order to reduce high rates of nonadherence in vulnerable populations.
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Affiliation(s)
| | | | | | - 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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Dias-Santos A, Tavares Ferreira J, Pinheiro S, Cunha JP, Alves M, Papoila AL, Moraes-Fontes MF, Proença R. Ocular involvement in systemic lupus erythematosus patients: a paradigm shift based on the experience of a tertiary referral center. Lupus 2020; 29:283-289. [DOI: 10.1177/0961203320903080] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective To evaluate ocular involvement in a cohort of systemic lupus erythematosus (SLE) patients of a tertiary referral center and to compare the results with the existing literature. Methods Patients underwent a complete ophthalmological evaluation, including visual acuity, slit-lamp examination, fluorescein staining, Schirmer-I test, Goldmann applanation tonometry, fundoscopy, 10-2 automated threshold visual fields, fundus autofluorescence and spectral-domain optical coherence tomography to screen for hydroxychloroquine (HCQ) macular toxicity. Results A total of 161 patients (16 men and 145 women) were enrolled in this study. The mean age was 47.6 years and the mean disease duration was 11.5 years. Fifty patients (31.1%) had at least one ocular manifestation of SLE. The most frequent manifestation was dry eye syndrome (12.4%), immediately followed by cataracts (11.2%) and HCQ macular toxicity (11.2%). Among patients with HCQ maculopathy, two presented with an atypical spectral-domain optical coherence tomography pattern. Five patients (3.1%) presented with glaucoma, two patients (1.2%) presented with SLE retinopathy while only one presented with lupus choroidopathy (0.6%). Conclusions Compared with previous studies, we conclude there has been a significant reduction in disease-related ocular complications, particularly those associated with poor systemic disease control. On the other hand, drug and age-related complications are assuming a prominent role in the ophthalmic care of these patients.
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Affiliation(s)
- A Dias-Santos
- Department of Ophthalmology, Centro Hospitalar e Universitário de Lisboa Central, Lisbon, Portugal
- Department of Ophthalmology, Hospital CUF Descobertas, Lisbon, Portugal
- NOVA Medical School, Universidade NOVA de Lisboa, Lisbon, Portugal
| | - J Tavares Ferreira
- Department of Ophthalmology, Centro Hospitalar e Universitário de Lisboa Central, Lisbon, Portugal
- Department of Ophthalmology, Hospital CUF Descobertas, Lisbon, Portugal
- NOVA Medical School, Universidade NOVA de Lisboa, Lisbon, Portugal
| | - S Pinheiro
- Autoimmune Disease Unit, Unidade de Doenças Auto-imunes/Serviço Medicina 3, Hospital de Santo António dos Capuchos, Centro Hospitalar e Universitário de Lisboa Central, Lisbon, Portugal
| | - J P Cunha
- Department of Ophthalmology, Centro Hospitalar e Universitário de Lisboa Central, Lisbon, Portugal
- NOVA Medical School, Universidade NOVA de Lisboa, Lisbon, Portugal
| | - M Alves
- Epidemiology and Statistics Unit, Research Center, Centro Hospitalar e Universitário de Lisboa Central, Lisbon, Portugal
| | - A L Papoila
- NOVA Medical School, Universidade NOVA de Lisboa, Lisbon, Portugal
- Epidemiology and Statistics Unit, Research Center, Centro Hospitalar e Universitário de Lisboa Central, Lisbon, Portugal
- CEAUL (Center of Statistics and Applications), Lisbon University, Lisbon, Portugal
| | - M Francisca Moraes-Fontes
- NOVA Medical School, Universidade NOVA de Lisboa, Lisbon, Portugal
- Autoimmune Disease Unit, Unidade de Doenças Auto-imunes/Serviço de Medicina 7.2, Hospital Curry Cabral, Centro Hospitalar e Universitário de Lisboa Central, Lisbon, Portugal
- Instituto Gulbenkian de Ciência, Oeiras, Portugal
| | - R Proença
- Department of Ophthalmology, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal
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Chew CY, Mar A, Nikpour M, Saracino AM. Hydroxychloroquine in dermatology: New perspectives on an old drug. Australas J Dermatol 2019; 61:e150-e157. [PMID: 31612996 DOI: 10.1111/ajd.13168] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 09/04/2019] [Indexed: 12/18/2022]
Abstract
Hydroxychloroquine is an age-old drug whose use as an immunomodulatory agent with a low side-effect profile continues to expand. We present a review of this drug including recently updated prescribing recommendations and a summary of its clinical application in dermatology. A maximum daily dose of 5.0 mg/kg based on actual body weight and no greater than 400 mg is advised in order to reduce the risk of retinopathy, which is potentially permanent and has an estimated prevalence of 7.5% at 5 years on standard dosing. Baseline ophthalmologic assessment followed by annual screening after 5 years is recommended; however, closer monitoring should be considered in the setting of existing retinopathy, a cumulative dose > 1000 g or renal dysfunction. Hydroxychloroquine is now considered to be safe in pregnancy, and routine glucose-6-phosphate dehydrogenase (G6PD) deficiency testing is not required. Smoking can significantly decrease its efficacy although the reason is still uncertain. Hydroxychloroquine appears to also demonstrate antineoplastic and cardioprotective benefits.
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Affiliation(s)
| | - Adrian Mar
- Department of Dermatology, Monash Health, Clayton, Victoria, Australia
| | - Mandana Nikpour
- The University of Melbourne at St. Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Amanda M Saracino
- Division of Medicine, Centre for Rheumatology and Connective Tissue Diseases, University College London at Royal Free Hospital London, London, UK
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Cunha C, Alexander S, Ashby D, Lee J, Chusney G, Cairns TD, Lightstone L. Hydroxycloroquine blood concentration in lupus nephritis: a determinant of disease outcome? Nephrol Dial Transplant 2019; 33:1604-1610. [PMID: 29186572 DOI: 10.1093/ndt/gfx318] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 09/25/2017] [Indexed: 12/13/2022] Open
Abstract
Background Hydroxychloroquine (HCQ) is a recommended drug in systemic lupus erythematosus (SLE). It has a long terminal half-life, making it an attractive target for therapeutic drug monitoring. The aim of this study was to establish a relationship between blood HCQ concentration and lupus nephritis activity. Methods We conducted a retrospective observational study with data collected from clinical and laboratory records. Inclusion criteria were patients followed in the lupus clinic with biopsy-proven International Society of Nephrology/Renal Pathology Society Classes III, IV or V lupus nephritis on HCQ for at least 3 months (200-400 mg daily) and with HCQ levels measured during treatment. Exclusion criteria were patients on renal replacement therapy at baseline or patients lost to follow-up. Results In 171 patients, the HCQ level was measured in 1282 samples. The mean HCQ blood level was 0.75±0.54mg/L and it was bimodally distributed. An HCQ level <0.20 mg/L [232 samples (18.1%)] appeared to define a distinct group of abnormally low HCQ levels. For patients in complete or partial remission at baseline compared with those remaining in remission, patients with renal flare during follow-up had a significantly lower average HCQ level (0.59 versus 0.81 mg/L; P= 0.005). Our data suggest an HCQ target level to reduce the likelihood of renal flares >0.6 mg/L (600 ng/mL) in those patients with lupus nephritis. Conclusion HCQ level monitoring may offer a new approach to identify non-adherent patients and support them appropriately. We propose an HCQ minimum target level of at least 0.6 mg/L to reduce the renal flare rate, but this will require a prospective study for validation.
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Affiliation(s)
- Cátia Cunha
- Nephrology Department, Centro Hospitalar de VilaNova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Suceena Alexander
- Nephrology Department, Christian Medical College Vellore, Vellore, Tamilnadu, India
| | - Damien Ashby
- Imperial College Lupus Centre, Imperial College Healthcare NHS Trust, London, UK
| | - Janet Lee
- Leslie Brent Laboratory, Imperial College Healthcare NHS Trust, London, UK
| | - Gary Chusney
- Leslie Brent Laboratory, Imperial College Healthcare NHS Trust, London, UK
| | - Tom D Cairns
- Imperial College Lupus Centre, Imperial College Healthcare NHS Trust, London, UK
| | - Liz Lightstone
- Imperial College Lupus Centre, Imperial College Healthcare NHS Trust, London, UK.,Section of Renal Medicine, Department of Medicine, Imperial College London, UK
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31
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Peng W, Liu R, Zhang L, Fu Q, Mei D, Du X. Breast milk concentration of hydroxychloroquine in Chinese lactating women with connective tissue diseases. Eur J Clin Pharmacol 2019; 75:1547-1553. [DOI: 10.1007/s00228-019-02723-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 07/17/2019] [Indexed: 12/21/2022]
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Abstract
Lupus erythematosus (LE) represents a spectrum of inflammatory autoimmune disease comprising varying clinical entities ranging from primary cutaneous to systemic disease. There is a clear relationship between ultraviolet irradiation (UVR) and the clinical manifestations of LE in both adult and pediatric populations. Although it has been established that UVR exacerbates pre-existing LE, it remains unclear whether UVR induces the development of the disease. This review serves to discuss effective photoprotective measures in LE and describe the pathogenic relationship of UVR and LE.
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Affiliation(s)
- Jusleen Ahluwalia
- Department of Dermatology, University of California, San Diego School of Medicine, La Jolla, USA
| | - Amanda Marsch
- Department of Dermatology, University of California, San Diego School of Medicine, La Jolla, USA
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Mok CC. Is Treat-to-target in Lupus Nephritis Realistic in Clinical Practice? Curr Rheumatol Rev 2018; 15:2-6. [PMID: 29623845 DOI: 10.2174/1573397114666180406100857] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 02/19/2018] [Accepted: 04/01/2018] [Indexed: 11/22/2022]
Abstract
The Treat-to-Target (T2T) principle has been advocated in a number of inflammatory
and non-inflammatory medical illnesses. Tight control of disease activity has been shown to improve
the outcome of rheumatoid arthritis and psoriatic arthritis as compared to the conventional
approach. However, whether T2T can be applied to patients with lupus nephritis is still under
emerging discussion. Treatment of lupus nephritis should target at inducing and maintaining remission
of the kidney inflammation so as to preserve renal function and improve survival in the longterm.
However, there is no universal agreement on the definition of remission or low disease activity
state of nephritis, as well as the time points for switching of therapies. Moreover, despite the
availability of objective parameters for monitoring such as proteinuria and urinary sediments, differentiation
between ongoing activity and damage in some patients with persistent urinary abnormalities
remains difficult without a renal biopsy. A large number of serum and urinary biomarkers
have been tested in lupus nephritis but none of them have been validated for routine clinical use. In
real life practice, therapeutic options for lupus nephritis are limited. As patients with lupus nephritis
are more prone to infective complications, tight disease control with aggressive immunosuppressive
therapies may have safety concern. Not until the feasibility, efficacy, safety and cost-effectiveness
of T2T in lupus nephritis is confirmed by comparative trials, this approach should not be routinely
recommended with the current treatment armamentarium and monitoring regimes.
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Affiliation(s)
- Chi Chiu Mok
- Department of Medicine, Tuen Mun Hospital, Hong Kong, SAR, China
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Khosa S, Khanlou N, Khosa GS, Mishra SK. Hydroxychloroquine-induced autophagic vacuolar myopathy with mitochondrial abnormalities. Neuropathology 2018; 38:646-652. [PMID: 30411412 DOI: 10.1111/neup.12520] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 09/25/2018] [Indexed: 12/13/2022]
Abstract
Hydroxychloroquine (HCQ) and chloroquine are used worldwide for malaria as well as connective and rheumatological disorders. They have been reported to be linked to myopathy in patients. We report four patients who were receiving HCQ as part of treatment for connective tissue disorder and who presented with myopathy. The muscle biopsy in these patients was consistent with findings of HCQ toxicity. HCQ muscle toxicity is usually self-limiting after discontinuation of the drug. It also usually tends to be under-reported due to presence of various confounding factors. This warrants close monitoring and consideration of muscle biopsy as part of initial work up of patients who present with myopathy while receiving HCQ.
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Affiliation(s)
- Shaweta Khosa
- Department of Neurology, Olive-View UCLA Medical Center, Los Angeles, California, USA
| | - Negar Khanlou
- Department of Pathology and Laboratory Medicine - Neuropathology and Electron Microscopy, UCLA David Geffen School of Medicine, Los Angeles, California, USA
| | | | - Shri K Mishra
- Department of Neurology, University of Southern California, Keck School of Medicine, Los Angeles, California, USA
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Hartman O, Kovanen PT, Lehtonen J, Eklund KK, Sinisalo J. Hydroxychloroquine for the prevention of recurrent cardiovascular events in myocardial infarction patients: rationale and design of the OXI trial. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2018; 3:92-97. [PMID: 28025216 DOI: 10.1093/ehjcvp/pvw035] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 11/28/2016] [Indexed: 01/11/2023]
Abstract
Background Inflammation of the arterial wall plays a central role in the pathogenesis of atherosclerosis. Among patients with rheumatic diseases, anti-rheumatic medication reduces the incidence of cardiovascular (CV) diseases, but only few studies have addressed their cardioprotective effects on patients with no rheumatic diseases. Hydroxychloroquine (HCQ) is an anti-rheumatic drug commonly used in the treatment of rheumatoid arthritis and systemic lupus erythematosus. In addition to its anti-inflammatory properties, HCQ reduces cholesterol levels and the risk of type II diabetes, and has also anti-platelet effects. Design The OXI trial is an event-driven trial that will randomize 2500 patients hospitalized for myocardial infarction (MI). Participants will receive active HCQ or placebo for at least 12 months, and until 350 CV events are confirmed. The primary trial endpoint is the composite of death, MI, hospitalization for unstable angina, urgent percutaneous coronary intervention, and urgent coronary artery bypass grafting. Secondary trial endpoints are the primary end point plus stroke, the effect of HCQ treatment on lipids, on the incidence of Type 2 diabetes, on the level of haemoglobin A1c, and on inflammatory parameters. A 6 months placebo-controlled safety pilot trial with 200 patients is currently ongoing to assess the safety of HCQ in the setting of MI. Summary The OXI trial will determine whether treatment with HCQ, as compared with placebo, will reduce recurrent CV events among MI patients. If positive, then the OXI trial would provide an entirely novel multitarget approach for the secondary prevention of atherosclerotic cardiovascular diseases (ACVD).
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Affiliation(s)
- Otto Hartman
- Heart and Lung Center, University of Helsinki and Helsinki University Hospital, PL 340, 00029 HUS, Finland
| | - Petri T Kovanen
- Wihuri Research Institute, Biomedicum Helsinki, Haartmaninkatu 8, Helsinki 00290, Finland
| | - Jukka Lehtonen
- Heart and Lung Center, University of Helsinki and Helsinki University Hospital, PL 340, 00029 HUS, Finland
| | - Kari K Eklund
- Department of Rheumatology, University of Helsinki and Helsinki University Hospital, PL 340, 00029 HUS, Helsinki, Finland
| | - Juha Sinisalo
- Heart and Lung Center, University of Helsinki and Helsinki University Hospital, PL 340, 00029 HUS, Finland
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Chloroquine attenuates TLR3-mediated plasminogen activator inhibitor-1 expression in cultured human glomerular endothelial cells. Clin Exp Nephrol 2018; 23:448-454. [PMID: 30341573 DOI: 10.1007/s10157-018-1659-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 10/07/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Chloroquine, an antimalarial agent, has been reported to prevent the risk of thrombosis and decrease renal damage in patients with systemic lupus erythematosus (SLE); however, its detailed mechanisms remain unclear. Plasminogen activator inhibitor-1 (PAI-1) is an inhibitor of fibrinolysis and is involved in fibrin deposition in glomeruli. Since upregulation of glomerular Toll-like receptor 3 (TLR3) signaling reportedly plays a pivotal role in the pathogenesis of lupus nephritis (LN), we examined whether chloroquine affects TLR3-mediated expression of PAI-1 in cultured human glomerular endothelial cells (GECs). METHODS We examined the effect of polyinosinic-polycytidylic acid (poly IC), an authentic double-stranded RNA, on PAI-1 and tissue plasminogen activator (t-PA) expression in GECs. Then, we analyzed whether pretreatment of chloroquine or dexamethasone inhibits poly IC-induced expression of these proteins using reverse-transcriptase polymerase chain reaction and enzyme-linked immunosorbent assay. RESULTS Poly IC increased PAI-1 expression in a time- and concentration-dependent manner, but did not affect t-PA expression in GECs. RNA interference against TLR3 inhibited poly IC-induced PAI-1 expression. Interestingly, pretreating cells with chloroquine, and also hydroxychloroquine, but not dexamethasone, attenuated poly IC-induced PAI-1 expression in GECs. CONCLUSION Considering that TLR3 signaling is implicated in LN pathogenesis, our results suggest that chloroquine exert postulated renoprotective effects by inhibiting PAI-1 expression.
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Tselios K, Deeb M, Gladman DD, Harvey P, Akhtari S, Mak S, Butany J, Urowitz MB. Antimalarial-induced Cardiomyopathy in Systemic Lupus Erythematosus: As Rare as Considered? J Rheumatol 2018; 46:391-396. [PMID: 30323009 DOI: 10.3899/jrheum.180124] [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: 07/24/2018] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Antimalarials (AM) are recommended for all systemic lupus erythematosus (SLE) patients without specific contraindications. Their main adverse effect is retinal damage; however, heart disease has been described in isolated cases. The aim of our study is to describe 8 patients with AM-induced cardiomyopathy (AMIC) in a defined SLE cohort. METHODS Patients attending the Toronto Lupus Clinic and diagnosed with definite (based on endomyocardial biopsy; EMB) and possible AMIC were included [based on cardiac magnetic resonance imaging (cMRI) and other investigations]. RESULTS Eight female patients (median age 62.5 yrs, disease duration 35 yrs, AM use duration 22 yrs) were diagnosed with AMIC in the past 2 years. Diagnosis was based on EMB in 3 (extensive cardiomyocyte vacuolation, intracytoplasmic myelinoid, and curvilinear bodies). In 4 patients, cMRI was highly suggestive of AMIC (ventricular hypertrophy and/or atrial enlargement and late gadolinium enhancement in a nonvascular pattern). Another patient was diagnosed with complete atrioventricular block, left ventricular and septal hypertrophy, along with concomitant ocular toxicity. All patients had abnormal cardiac troponin I (cTnI) and brain natriuretic peptide (BNP), whereas 7/8 also had chronically elevated creatine phosphokinase. During followup, 1 patient died from refractory heart failure. In the remaining patients, hypertrophy regression and a steady decrease of heart biomarkers were observed after AM cessation. CONCLUSION Once considered extremely rare, AMIC seems to be underrecognized, probably because of the false attribution of heart failure or hypertrophy to other causes. Certain biomarkers (cTnI, BNP) and imaging findings may lead to early diagnosis and enhance survival.
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Affiliation(s)
- Konstantinos Tselios
- From the University of Toronto Lupus Clinic, Toronto Western Hospital, Centre for Prognosis Studies in the Rheumatic Diseases, University Health Network; University of Toronto, Krembil Research Institute; Department of Cardiology, University of Toronto, Women's College Hospital; Mecklinger Family and Posluns Family Cardiac Catheterization Research Laboratory, Department of Medicine, Division of Cardiology, Mount Sinai Hospital, University of Toronto; Department of Laboratory Medicine and Pathobiology, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada.,K. Tselios, MD, PhD, Clinical Research Fellow, University of Toronto Lupus Clinic, Toronto Western Hospital, Centre for Prognosis Studies in the Rheumatic Diseases; M. Deeb, MSc, Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Lupus Clinic, University Health Network; D.D. Gladman, MD, FRCPC, Professor of Medicine, University of Toronto, Senior Scientist, Krembil Research Institute, Co-Director, University of Toronto Lupus Clinic, Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital; P. Harvey, BMBS, PhD, FRACP, Department of Cardiology, University of Toronto, Women's College Hospital; S. Akhtari, MD, FRCPC, Department of Cardiology, University of Toronto, Women's College Hospital; S. Mak, MD, PhD, Mecklinger Family and Posluns Family Cardiac Catheterization Research Laboratory, Department of Medicine, Division of Cardiology, Mount Sinai Hospital, University of Toronto; J. Butany, MBBS, MS, FRCPC, Department of Laboratory Medicine and Pathobiology, University Health Network, Toronto General Hospital; M.B. Urowitz, MD, FRCPC, Professor of Medicine, University of Toronto, Senior Scientist, Krembil Research Institute, Director, University of Toronto Lupus Clinic, Centre for Prognosis Studies in the Rheumatic Diseases
| | - Mery Deeb
- From the University of Toronto Lupus Clinic, Toronto Western Hospital, Centre for Prognosis Studies in the Rheumatic Diseases, University Health Network; University of Toronto, Krembil Research Institute; Department of Cardiology, University of Toronto, Women's College Hospital; Mecklinger Family and Posluns Family Cardiac Catheterization Research Laboratory, Department of Medicine, Division of Cardiology, Mount Sinai Hospital, University of Toronto; Department of Laboratory Medicine and Pathobiology, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada.,K. Tselios, MD, PhD, Clinical Research Fellow, University of Toronto Lupus Clinic, Toronto Western Hospital, Centre for Prognosis Studies in the Rheumatic Diseases; M. Deeb, MSc, Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Lupus Clinic, University Health Network; D.D. Gladman, MD, FRCPC, Professor of Medicine, University of Toronto, Senior Scientist, Krembil Research Institute, Co-Director, University of Toronto Lupus Clinic, Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital; P. Harvey, BMBS, PhD, FRACP, Department of Cardiology, University of Toronto, Women's College Hospital; S. Akhtari, MD, FRCPC, Department of Cardiology, University of Toronto, Women's College Hospital; S. Mak, MD, PhD, Mecklinger Family and Posluns Family Cardiac Catheterization Research Laboratory, Department of Medicine, Division of Cardiology, Mount Sinai Hospital, University of Toronto; J. Butany, MBBS, MS, FRCPC, Department of Laboratory Medicine and Pathobiology, University Health Network, Toronto General Hospital; M.B. Urowitz, MD, FRCPC, Professor of Medicine, University of Toronto, Senior Scientist, Krembil Research Institute, Director, University of Toronto Lupus Clinic, Centre for Prognosis Studies in the Rheumatic Diseases
| | - Dafna D Gladman
- From the University of Toronto Lupus Clinic, Toronto Western Hospital, Centre for Prognosis Studies in the Rheumatic Diseases, University Health Network; University of Toronto, Krembil Research Institute; Department of Cardiology, University of Toronto, Women's College Hospital; Mecklinger Family and Posluns Family Cardiac Catheterization Research Laboratory, Department of Medicine, Division of Cardiology, Mount Sinai Hospital, University of Toronto; Department of Laboratory Medicine and Pathobiology, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada.,K. Tselios, MD, PhD, Clinical Research Fellow, University of Toronto Lupus Clinic, Toronto Western Hospital, Centre for Prognosis Studies in the Rheumatic Diseases; M. Deeb, MSc, Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Lupus Clinic, University Health Network; D.D. Gladman, MD, FRCPC, Professor of Medicine, University of Toronto, Senior Scientist, Krembil Research Institute, Co-Director, University of Toronto Lupus Clinic, Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital; P. Harvey, BMBS, PhD, FRACP, Department of Cardiology, University of Toronto, Women's College Hospital; S. Akhtari, MD, FRCPC, Department of Cardiology, University of Toronto, Women's College Hospital; S. Mak, MD, PhD, Mecklinger Family and Posluns Family Cardiac Catheterization Research Laboratory, Department of Medicine, Division of Cardiology, Mount Sinai Hospital, University of Toronto; J. Butany, MBBS, MS, FRCPC, Department of Laboratory Medicine and Pathobiology, University Health Network, Toronto General Hospital; M.B. Urowitz, MD, FRCPC, Professor of Medicine, University of Toronto, Senior Scientist, Krembil Research Institute, Director, University of Toronto Lupus Clinic, Centre for Prognosis Studies in the Rheumatic Diseases
| | - Paula Harvey
- From the University of Toronto Lupus Clinic, Toronto Western Hospital, Centre for Prognosis Studies in the Rheumatic Diseases, University Health Network; University of Toronto, Krembil Research Institute; Department of Cardiology, University of Toronto, Women's College Hospital; Mecklinger Family and Posluns Family Cardiac Catheterization Research Laboratory, Department of Medicine, Division of Cardiology, Mount Sinai Hospital, University of Toronto; Department of Laboratory Medicine and Pathobiology, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada.,K. Tselios, MD, PhD, Clinical Research Fellow, University of Toronto Lupus Clinic, Toronto Western Hospital, Centre for Prognosis Studies in the Rheumatic Diseases; M. Deeb, MSc, Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Lupus Clinic, University Health Network; D.D. Gladman, MD, FRCPC, Professor of Medicine, University of Toronto, Senior Scientist, Krembil Research Institute, Co-Director, University of Toronto Lupus Clinic, Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital; P. Harvey, BMBS, PhD, FRACP, Department of Cardiology, University of Toronto, Women's College Hospital; S. Akhtari, MD, FRCPC, Department of Cardiology, University of Toronto, Women's College Hospital; S. Mak, MD, PhD, Mecklinger Family and Posluns Family Cardiac Catheterization Research Laboratory, Department of Medicine, Division of Cardiology, Mount Sinai Hospital, University of Toronto; J. Butany, MBBS, MS, FRCPC, Department of Laboratory Medicine and Pathobiology, University Health Network, Toronto General Hospital; M.B. Urowitz, MD, FRCPC, Professor of Medicine, University of Toronto, Senior Scientist, Krembil Research Institute, Director, University of Toronto Lupus Clinic, Centre for Prognosis Studies in the Rheumatic Diseases
| | - Shadi Akhtari
- From the University of Toronto Lupus Clinic, Toronto Western Hospital, Centre for Prognosis Studies in the Rheumatic Diseases, University Health Network; University of Toronto, Krembil Research Institute; Department of Cardiology, University of Toronto, Women's College Hospital; Mecklinger Family and Posluns Family Cardiac Catheterization Research Laboratory, Department of Medicine, Division of Cardiology, Mount Sinai Hospital, University of Toronto; Department of Laboratory Medicine and Pathobiology, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada.,K. Tselios, MD, PhD, Clinical Research Fellow, University of Toronto Lupus Clinic, Toronto Western Hospital, Centre for Prognosis Studies in the Rheumatic Diseases; M. Deeb, MSc, Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Lupus Clinic, University Health Network; D.D. Gladman, MD, FRCPC, Professor of Medicine, University of Toronto, Senior Scientist, Krembil Research Institute, Co-Director, University of Toronto Lupus Clinic, Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital; P. Harvey, BMBS, PhD, FRACP, Department of Cardiology, University of Toronto, Women's College Hospital; S. Akhtari, MD, FRCPC, Department of Cardiology, University of Toronto, Women's College Hospital; S. Mak, MD, PhD, Mecklinger Family and Posluns Family Cardiac Catheterization Research Laboratory, Department of Medicine, Division of Cardiology, Mount Sinai Hospital, University of Toronto; J. Butany, MBBS, MS, FRCPC, Department of Laboratory Medicine and Pathobiology, University Health Network, Toronto General Hospital; M.B. Urowitz, MD, FRCPC, Professor of Medicine, University of Toronto, Senior Scientist, Krembil Research Institute, Director, University of Toronto Lupus Clinic, Centre for Prognosis Studies in the Rheumatic Diseases
| | - Susanna Mak
- From the University of Toronto Lupus Clinic, Toronto Western Hospital, Centre for Prognosis Studies in the Rheumatic Diseases, University Health Network; University of Toronto, Krembil Research Institute; Department of Cardiology, University of Toronto, Women's College Hospital; Mecklinger Family and Posluns Family Cardiac Catheterization Research Laboratory, Department of Medicine, Division of Cardiology, Mount Sinai Hospital, University of Toronto; Department of Laboratory Medicine and Pathobiology, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada.,K. Tselios, MD, PhD, Clinical Research Fellow, University of Toronto Lupus Clinic, Toronto Western Hospital, Centre for Prognosis Studies in the Rheumatic Diseases; M. Deeb, MSc, Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Lupus Clinic, University Health Network; D.D. Gladman, MD, FRCPC, Professor of Medicine, University of Toronto, Senior Scientist, Krembil Research Institute, Co-Director, University of Toronto Lupus Clinic, Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital; P. Harvey, BMBS, PhD, FRACP, Department of Cardiology, University of Toronto, Women's College Hospital; S. Akhtari, MD, FRCPC, Department of Cardiology, University of Toronto, Women's College Hospital; S. Mak, MD, PhD, Mecklinger Family and Posluns Family Cardiac Catheterization Research Laboratory, Department of Medicine, Division of Cardiology, Mount Sinai Hospital, University of Toronto; J. Butany, MBBS, MS, FRCPC, Department of Laboratory Medicine and Pathobiology, University Health Network, Toronto General Hospital; M.B. Urowitz, MD, FRCPC, Professor of Medicine, University of Toronto, Senior Scientist, Krembil Research Institute, Director, University of Toronto Lupus Clinic, Centre for Prognosis Studies in the Rheumatic Diseases
| | - Jagdish Butany
- From the University of Toronto Lupus Clinic, Toronto Western Hospital, Centre for Prognosis Studies in the Rheumatic Diseases, University Health Network; University of Toronto, Krembil Research Institute; Department of Cardiology, University of Toronto, Women's College Hospital; Mecklinger Family and Posluns Family Cardiac Catheterization Research Laboratory, Department of Medicine, Division of Cardiology, Mount Sinai Hospital, University of Toronto; Department of Laboratory Medicine and Pathobiology, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada.,K. Tselios, MD, PhD, Clinical Research Fellow, University of Toronto Lupus Clinic, Toronto Western Hospital, Centre for Prognosis Studies in the Rheumatic Diseases; M. Deeb, MSc, Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Lupus Clinic, University Health Network; D.D. Gladman, MD, FRCPC, Professor of Medicine, University of Toronto, Senior Scientist, Krembil Research Institute, Co-Director, University of Toronto Lupus Clinic, Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital; P. Harvey, BMBS, PhD, FRACP, Department of Cardiology, University of Toronto, Women's College Hospital; S. Akhtari, MD, FRCPC, Department of Cardiology, University of Toronto, Women's College Hospital; S. Mak, MD, PhD, Mecklinger Family and Posluns Family Cardiac Catheterization Research Laboratory, Department of Medicine, Division of Cardiology, Mount Sinai Hospital, University of Toronto; J. Butany, MBBS, MS, FRCPC, Department of Laboratory Medicine and Pathobiology, University Health Network, Toronto General Hospital; M.B. Urowitz, MD, FRCPC, Professor of Medicine, University of Toronto, Senior Scientist, Krembil Research Institute, Director, University of Toronto Lupus Clinic, Centre for Prognosis Studies in the Rheumatic Diseases
| | - Murray B Urowitz
- From the University of Toronto Lupus Clinic, Toronto Western Hospital, Centre for Prognosis Studies in the Rheumatic Diseases, University Health Network; University of Toronto, Krembil Research Institute; Department of Cardiology, University of Toronto, Women's College Hospital; Mecklinger Family and Posluns Family Cardiac Catheterization Research Laboratory, Department of Medicine, Division of Cardiology, Mount Sinai Hospital, University of Toronto; Department of Laboratory Medicine and Pathobiology, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada. .,K. Tselios, MD, PhD, Clinical Research Fellow, University of Toronto Lupus Clinic, Toronto Western Hospital, Centre for Prognosis Studies in the Rheumatic Diseases; M. Deeb, MSc, Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Lupus Clinic, University Health Network; D.D. Gladman, MD, FRCPC, Professor of Medicine, University of Toronto, Senior Scientist, Krembil Research Institute, Co-Director, University of Toronto Lupus Clinic, Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital; P. Harvey, BMBS, PhD, FRACP, Department of Cardiology, University of Toronto, Women's College Hospital; S. Akhtari, MD, FRCPC, Department of Cardiology, University of Toronto, Women's College Hospital; S. Mak, MD, PhD, Mecklinger Family and Posluns Family Cardiac Catheterization Research Laboratory, Department of Medicine, Division of Cardiology, Mount Sinai Hospital, University of Toronto; J. Butany, MBBS, MS, FRCPC, Department of Laboratory Medicine and Pathobiology, University Health Network, Toronto General Hospital; M.B. Urowitz, MD, FRCPC, Professor of Medicine, University of Toronto, Senior Scientist, Krembil Research Institute, Director, University of Toronto Lupus Clinic, Centre for Prognosis Studies in the Rheumatic Diseases.
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Monção CSA, Martins LN, Penteado MPS, Reis RCP, Santos FMM, Lanna CCD, Ribeiro AL, Telles RW. Incidence of cardiovascular risk factors in female patients with systemic lupus erythematosus: a 3-year follow-up cohort. Lupus 2018; 27:1790-1798. [DOI: 10.1177/0961203318790676] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Objectives To evaluate the incidence and variability of traditional coronary artery disease (CAD) risk factors in a cohort of lupus patients and to investigate if prednisone use predicts an increase in the number of risk factors. Methods A total of 151 women, 37.8 ± 11.1 (mean ± SD) years old at baseline, were reevaluated after a median period of 39 (interquartile range 36.5–42.0) months. The cumulative incidence of traditional risk factors, the incidence rate (with 95% confidence interval) of hypertension, diabetes, dyslipidemia and hypertriglyceridemia, and the frequency of the risk factors’ disappearance were calculated. Metabolic syndrome (MetS) and Framingham risk score (FRS) were computed. Logistic regression was used to investigate if maximum or cumulative prednisone dose used during follow-up predicted an increase in the cardiometabolic risk factors’ number. Results The cumulative incidence of risk factors varied from 39.1% (abdominal obesity) to zero (smoking), and the incidence rate varied from 133.2 (87.8–178.6) per 1000 person-years (dyslipidemia) to 10.4 (1.3–19.5) per 1000 person-years (diabetes). The cumulative incidence for MetS was 18.8%, and 11.7% of 143 patients with low FRS at baseline (T1) were classified in the high-risk category at the end of the study (T2). Dyslipidemia was the most variable risk factor, with 43.5% disappearance at T2. The maximum prednisone dose used during follow-up was borderline ( p = 0.050) for prediction of an increase in the number of cardiometabolic risk factors in an adjusted model for antimalarial use, modified Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K) and age. Conclusion The authors described high incidence and variability of CAD risk factors in female lupus patients, with higher prednisone dose being borderline for an increase in the number of cardiometabolic risk factors.
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Affiliation(s)
- C S A Monção
- Universidade Federal de Minas Gerais, Faculdade de Medicina Belo Horizonte, Minas Gerais, Brazil
| | - L N Martins
- Universidade Federal de Minas Gerais, Faculdade de Medicina Belo Horizonte, Minas Gerais, Brazil
| | - M P S Penteado
- Universidade Federal de Minas Gerais, Faculdade de Medicina Belo Horizonte, Minas Gerais, Brazil
| | - R C P Reis
- Universidade Federal de Minas Gerais, Faculdade de Medicina Belo Horizonte, Minas Gerais, Brazil
| | - F M M Santos
- Universidade Federal de Minas Gerais, Faculdade de Medicina Belo Horizonte, Minas Gerais, Brazil
| | - C C D Lanna
- Universidade Federal de Minas Gerais, Faculdade de Medicina Belo Horizonte, Minas Gerais, Brazil
| | - A L Ribeiro
- Universidade Federal de Minas Gerais, Faculdade de Medicina Belo Horizonte, Minas Gerais, Brazil
| | - R W Telles
- Universidade Federal de Minas Gerais, Faculdade de Medicina Belo Horizonte, Minas Gerais, Brazil
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Martínez-García EA, Zavala-Cerna MG, Lujano-Benítez AV, Sánchez-Hernández PE, Martín-Márquez BT, Sandoval-García F, Vázquez-Del Mercado M. Potential Chronotherapeutic Optimization of Antimalarials in Systemic Lupus Erythematosus: Is Toll-Like Receptor 9 Expression Dependent on the Circadian Cycle in Humans? Front Immunol 2018; 9:1497. [PMID: 30034390 PMCID: PMC6043638 DOI: 10.3389/fimmu.2018.01497] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 06/15/2018] [Indexed: 12/13/2022] Open
Abstract
Toll-like receptor 9 (TLR9) belongs to the group of endosomal receptors of the innate immune system with the ability to recognize hypomethylated CpG sequences from DNA. There is scarce information about TLR9 expression and its association with the circadian cycle (CC). Different patterns of TLR9 expression are regulated by the CC in mice, with an elevated expression at Zeitgeber time 19 (1:00 a.m.); nevertheless, we still need to corroborate this in humans. In systemic lupus erythematosus (SLE), the inhibitory effect of chloroquine (CQ) on TLR9 is limited. TLR9 activation has been associated with the presence of some autoantibodies: anti-Sm/RNP, anti-histone, anti-Ro, anti-La, and anti-double-stranded DNA. Treatment with CQ for SLE has been proven to be useful, in part by interfering with HLA-antigen coupling and with TLR9 ligand recognition. Studies have shown that TLR9 inhibitors such as antimalarial drugs are able to mask TLR9-binding sites on nucleic acids. The data presented here provide the basic information that could be useful for other clinical researchers to design studies that will have an impact in achieving a chronotherapeutic effect by defining the ideal time for CQ administration in SLE patients, consequently reducing the pathological effects that follow the activation of TLR9.
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Affiliation(s)
- Erika Aurora Martínez-García
- Instituto de Investigación en Reumatología y del Sistema Músculo Esquelético, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Mexico
- Departamento de Fisiología, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Mexico
- UDG-CA-703, Inmunología y Reumatología, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Mexico
| | - Maria Guadalupe Zavala-Cerna
- Immunology Research Laboratory, Programa Internacional de Medicina, Universidad Autonoma de Guadalajara, Guadalajara, Mexico
| | - Andrea Verónica Lujano-Benítez
- Instituto de Investigación en Reumatología y del Sistema Músculo Esquelético, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Mexico
| | - Pedro Ernesto Sánchez-Hernández
- Departamento de Fisiología, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Mexico
- Laboratorio de Inmunología, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Mexico
| | - Beatriz Teresita Martín-Márquez
- Instituto de Investigación en Reumatología y del Sistema Músculo Esquelético, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Mexico
- UDG-CA-703, Inmunología y Reumatología, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Mexico
| | - Flavio Sandoval-García
- Instituto de Investigación en Reumatología y del Sistema Músculo Esquelético, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Mexico
- Departamento de Clínicas Médicas, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Mexico
- UDG CA-701, Inmunometabolismo en Enfermedades Emergentes (GIIEE), Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Mexico
| | - Mónica Vázquez-Del Mercado
- Instituto de Investigación en Reumatología y del Sistema Músculo Esquelético, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Mexico
- UDG-CA-703, Inmunología y Reumatología, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Mexico
- Hospital Civil de Guadalajara “Juan I. Menchaca”, Servicio de Reumatología, Programa Nacional de Posgrados de Calidad (PNPC), Consejo Nacional de Ciencia y Tecnología (CONACYT), Guadalajara, Mexico
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Antimalarials - are they effective and safe in rheumatic diseases? Reumatologia 2018; 56:164-173. [PMID: 30042604 PMCID: PMC6052376 DOI: 10.5114/reum.2018.76904] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Accepted: 05/09/2018] [Indexed: 12/24/2022] Open
Abstract
Antimalarial drugs (AD) are a group of widespread therapeutic agents in multiple rheumatic indications. Although the effect of AD is mild and extended in time, low toxicity is their appreciated value. This paper describes the current state of knowledge on the mechanism of action, use, toxicity and pleiotropic effects of AD in the pharmacotherapy of autoimmune diseases.
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Affiliation(s)
- K Schreiber
- Thrombosis & Haemophilia Centre, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - N Davies
- Ophthalmology Department, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - B J Hunt
- Thrombosis & Haemophilia Centre, Guy's & St Thomas' NHS Foundation Trust, London, UK
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Worth C, Yusuf IH, Turner B, Gourier H, Brooks EE, Mort DO, Sharma S, Downes SM, Luqmani RA. An audit of the use of hydroxychloroquine in rheumatology clinics. Rheumatol Adv Pract 2018; 2:rky013. [PMID: 31431961 PMCID: PMC6649984 DOI: 10.1093/rap/rky013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 03/25/2018] [Indexed: 12/23/2022] Open
Abstract
Objective The aim was to audit the use, indications, complications and patient information regarding HCQ treatment in rheumatology clinics in a tertiary referral centre. Methods During a 9-month period, we identified all patients prescribed HCQ and attending rheumatology clinics in one hospital. We established: (i) the indication for HCQ; (ii) the prevalence of HCQ overdosing based on absolute body weight (ABW); (iii) documentation of warning of risk of retinal toxicity; (iv) systemic and ocular co-morbidities; (v) ocular symptoms during treatment; and (vi) reasons for stopping HCQ. Results We identified 427 patients (104 male and 323 female). The cumulative dose of HCQ was lower in RA (median 365 g; range 6–1752 g) compared with SLE (450 g; 66–1788 g) (P = 0.105). The median duration of HCQ therapy was 4 years (range 0.1–13 years); 28% of patients with RA and 29% with SLE continued HCQ beyond 5 years. After adjusting for ABW and renal function, 10% (31/312) had been prescribed doses exceeding recommendations. Formal documentation of counselling on ocular complications was found in only one-third of patients. Three cases of HCQ retinopathy were identified (all of whom had RA). Conclusion HCQ therapy is being used for >5 years in 29% of patients with rheumatic diseases, with higher than recommended doses in ∼10% of patients. We recommend more rigorous scrutiny of the use of HCQ to reduce the risk of retinopathy.
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Affiliation(s)
- Claudia Worth
- Department of Rheumatology, Oxford University Hospitals, Oxford
| | - Imran H Yusuf
- Oxford Eye Hospital, Oxford University Hospitals, Oxford
| | - Bethany Turner
- Department of Rheumatology, Oxford University Hospitals, Oxford
| | - Hanae Gourier
- Department of Emergency Medicine, Stoke Mandeville Hospital, Aylesbury
| | - Emma E Brooks
- School of Medicine, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK
| | - Daniel O Mort
- School of Medicine, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK
| | | | - Susan M Downes
- Oxford Eye Hospital, Oxford University Hospitals, Oxford
| | - Raashid A Luqmani
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK
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Margiotta DPE, Basta F, Dolcini G, Batani V, Lo Vullo M, Vernuccio A, Navarini L, Afeltra A. Physical activity and sedentary behavior in patients with Systemic Lupus Erythematosus. PLoS One 2018; 13:e0193728. [PMID: 29505598 PMCID: PMC5837187 DOI: 10.1371/journal.pone.0193728] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 02/16/2018] [Indexed: 12/21/2022] Open
Abstract
Introduction The aim of this study was to evaluate the proportion of patients with Systemic Lupus Erythematosus (SLE) who did not met the WHO recommendations for physical activity and to evaluate the amount of time spent in sedentary behavior. Methods SLE patients were consecutively enrolled in a cross sectional study. The type and the time spent in physical activity and sedentary behavior were evaluated using the IPAQ short form questionnaire. The adequate physical activity was defined according to the 2010 WHO recommendations for health and the sedentary behavior according to the 2017 SBRN consensus. We also assessed quality of life using SF-36, mood disorders using BDI and HAM-H, fatigue using Facit-Fatigue and sleep disorders using PSQI scores. Results Physical activity was not sufficient to meet WHO recommendations in 56 of 93 SLE patients (60%). SLE patients spent a median (95% range) of 180 (0–600) minutes everyday in sedentary activities. The length of daily sedentary time was more than 6 hours in 25% of SLE patients. In multivariable analysis, the factors associated to the probability of not meeting WHO criteria was only the time of exposure to antimalarials (OR 0.88, p 0.03) and the factors related to the probability of being in the upper tertile of sedentary time (more than 270 minutes) were age (OR 1.04, p 0.02), disease activity expressed by SELENA-SLEDAI score (OR 1.2, p 0.01) and Facit-fatigue score (OR 0.94, p 0.04). Conclusion A relevant proportion of SLE patients were inadequately physically active. It is essential to improve the awareness of the importance of increase physical activity and reduce sedentary time. A better control of disease activity and fatigue and a prolonged use of antimalarials could help to reach this notable goal.
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Affiliation(s)
| | - Fabio Basta
- Unit of Allergology, Clinical Immunology and Rheumatology, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Giulio Dolcini
- Unit of Allergology, Clinical Immunology and Rheumatology, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Veronica Batani
- Unit of Allergology, Clinical Immunology and Rheumatology, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Marina Lo Vullo
- Unit of Allergology, Clinical Immunology and Rheumatology, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Alessia Vernuccio
- Unit of Allergology, Clinical Immunology and Rheumatology, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Luca Navarini
- Unit of Allergology, Clinical Immunology and Rheumatology, Università Campus Bio-Medico di Roma, Rome, Italy
- * E-mail:
| | - Antonella Afeltra
- Unit of Allergology, Clinical Immunology and Rheumatology, Università Campus Bio-Medico di Roma, Rome, Italy
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Cohen EM, D'Silva K, Kreps D, Son MB, Costenbader KH. Arthritis and use of hydroxychloroquine associated with a decreased risk of macrophage activation syndrome among adult patients hospitalized with systemic lupus erythematosus. Lupus 2018; 27:1065-1071. [PMID: 29451069 DOI: 10.1177/0961203318759428] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Background Macrophage activation syndrome (MAS) is an uncommon but serious complication of systemic lupus erythematosus (SLE). We aimed to identify factors associated with MAS among adult hospitalized SLE patients. Methods Within the Brigham and Women's Hospital (BWH) Lupus Center Registry, we identified adult SLE patients > age 17 who had been hospitalized from 1970 to 2016, with either ferritin > 5000 ng/ml during admission or "macrophage activation syndrome" or "MAS" in discharge summary. We confirmed MAS by physician diagnosis in medical record review. We matched each hospitalized SLE patient with MAS to four SLE patients hospitalized without MAS (by SLE diagnosis date ±1 year). We employed conditional logistic regression models to identify clinical factors associated with MAS among hospitalized SLE patients. Results Among 2094 patients with confirmed SLE, we identified 23 who had a hospitalization with MAS and compared them to 92 hospitalized without MAS. Cases and controls had similar age at SLE diagnosis (29.0 vs. 30.5, p = 0.60), and hospital admission (43.0 vs. 38.3, p = 0.80), proportion female (78% vs. 84%, p = 0.55), and time between SLE diagnosis and hospitalization (1971 vs. 1732 days, p = 0.84). Arthritis (OR 0.04 (95% CI 0.004-0.35)) and hydroxychloroquine use (OR 0.18 (95% CI 0.04-0.72)) on admission were associated with decreased MAS risk. Admission Systemic Lupus Erythematosus Disease Activity Index scores (30 vs. 19, p = 0.002) and lengths of stay (16 days vs. 3 days, p < 0.0001) were much higher among cases. Death during hospitalization was 19% among cases and 3% among controls ( p = 0.03). Conclusions In this case-control study of hospitalized adult SLE patients, arthritis and hydroxychloroquine use at hospital admission were associated with decreased MAS risk. Further studies are needed to validate these factors associated with lowered MAS risk.
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Affiliation(s)
- E M Cohen
- 1 Division of Immunology, 1862 Boston Children's Hospital , Boston, MA, USA
| | - K D'Silva
- 2 Department of Rheumatology, 1861 Brigham and Women's Hospital , Boston, MA, USA
| | - D Kreps
- 2 Department of Rheumatology, 1861 Brigham and Women's Hospital , Boston, MA, USA
| | - M B Son
- 1 Division of Immunology, 1862 Boston Children's Hospital , Boston, MA, USA
| | - K H Costenbader
- 2 Department of Rheumatology, 1861 Brigham and Women's Hospital , Boston, MA, USA
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Dammacco R. Systemic lupus erythematosus and ocular involvement: an overview. Clin Exp Med 2017; 18:135-149. [PMID: 29243035 DOI: 10.1007/s10238-017-0479-9] [Citation(s) in RCA: 90] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 11/02/2017] [Indexed: 12/23/2022]
Abstract
Systemic lupus erythematosus (SLE) is a multisystem autoimmune disease of undefined etiology and with remarkably heterogeneous clinical features. Virtually any organ system can be affected, including the eye. SLE-related eye involvement can be diagnosed in approximately one-third of the patients and is usually indicative of disease activity. An early diagnosis and the adoption of suitable therapeutic measures are necessary to prevent sight-threatening consequences, especially in patients with juvenile SLE. Periocular lesions, such as eyelid involvement and orbital inflammation, are relatively rare and, in case of orbital masses, may require a biopsy control. Keratoconjunctivitis sicca or secondary Sjögren's syndrome is the most frequent ophthalmic manifestation of SLE. According to its variable severity, lubricating tear drops may be sufficient in mild cases, whereas cyclosporine-A ophthalmic solution, glucocorticoids (GCs), methotrexate, and/or other immunosuppressive drugs may be required in the more severe cases. Partial occlusion of the lacrimal punctum by thermal cautery is rarely applied. Although uncommon, episcleritis and scleritis can sometimes be detected as an initial finding of SLE and reveal themselves as moderate to intense ocular pain, redness, blurred vision, and lacrimation. Unilateral or more often bilateral retinopathy is responsible for visual loss of variable severity and is ascribed to vasculitis of the retinal capillaries and arterioles. In addition to the combined treatment suitable for all patients with active SLE, intravitreal bevacizumab should be considered in cases of severe vaso-occlusive retinopathy and laser photocoagulation in cases of neovascularization. Purtscher-like retinopathy is likely ascribable to the formation of microemboli that results in retinal vascular occlusion and microvascular infarcts. Choroidal disease is characterized by monolateral or bilateral blurred vision. Because of the choroidal effusion, retinal detachment and secondary angle-closure glaucoma may occur. Ischemic optic neuropathy is characterized by acute-onset and progressive binocular visual impairment as a consequence of occlusion of the small vessels of the optic nerves due to immune complex vasculitis. Intravenous GC boluses followed by oral GCs and/or, in case of recurrence, intravenous cyclophosphamide and/or rituximab are commonly employed. Neovascularization can be treated by intravitreal bevacizumab and progression of retinal ischemic areas by retinal laser photocoagulation. Ocular adverse events (AE) have been described following the long-term administration of one or more of the drugs presently used for the treatment of SLE patients. Posterior subcapsular cataracts and secondary open-angle glaucoma are common AE of the prolonged GC administration. The long-term administration of hydroxychloroquine (HCQ) sulfate is well known to be associated with AE, such as vortex keratopathy and in particular the often irreversible and sight-threatening maculopathy. Length of administration > 5 years, > 1000 g total HCQ consumption, > 6.5 mg/kg daily dosing, coexistence of renal disease, and preexisting maculopathy are all considered risk factors for HCQ-induced retinopathy. Ocular AE of additional immunosuppressive and biological agents are still poorly known, given the worldwide more limited experience with their long-term use. A thorough ophthalmological control is strongly recommended at closer intervals for all SLE patients, in step with the total length of exposure to the drugs and the cumulative dose administered.
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Affiliation(s)
- Rosanna Dammacco
- Department of Basic Medical Sciences, Neurosciences and Sensory Organ, University of Bari Medical School, Clinica Oculistica, Policlinico, Piazza Giulio Cesare, 70124, Bari, Italy.
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Compliance and persistence with hydroxychloroquine in South Korean patients with systemic lupus erythematosus. Lupus 2017; 27:753-761. [DOI: 10.1177/0961203317742712] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Margiotta DPE, Basta F, Dolcini G, Batani V, Navarini L, Afeltra A. The relation between, metabolic syndrome and quality of life in patients with Systemic Lupus Erythematosus. PLoS One 2017; 12:e0187645. [PMID: 29112985 PMCID: PMC5675433 DOI: 10.1371/journal.pone.0187645] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2017] [Accepted: 10/23/2017] [Indexed: 11/20/2022] Open
Abstract
Introduction Systemic Lupus Erythematosus (SLE) is associated to an increased prevalence of Metabolic Syndrome (MeS) and to a reduction of Quality of Life (QoL). The aim of this study is to evaluate the association between MeS and QoL in SLE. Methods SLE patients were consecutively enrolled in a cross sectional study. MeS was defined according to IFD definition. Therapy with glucocorticoids (GC) and antimalarial was analyzed as cumulative years of exposure. We used a cut off of 7.5 mg of prednisone to define high daily dose of GC. QoL was quantified using SF-36. We used BDI and HAM-H to assess symptoms of mood disorders. Fatigue was evaluated using Facit-Fatigue, physical activity using IPAQ, sleep quality using PSQI and alexithymia using TAS-20. Results We enrolled 100 SLE patients. MeS prevalence was 34%. Patients with MeS presented reduced scores in SF-36 MCS and PCS compared to patients without MeS (p 0.03 and p 0.004). BDI and HAM-H score were significantly higher in patients meeting MeS criteria compared to subjects without MeS (p 0.004, p 0.02). These results were confirmed after adjustment for confounders. Compared to patients without MeS, those with MeS presented higher age, lower education level, higher recent SELENA-SLEDAI, higher number of flares, increased SDI, longer cumulative exposure to high dose GC and shorter duration of antimalarial therapy. In the multiple logistic regression model, the variable associated to the Odds Ratio of having MeS were: the average of recent SELENA-SLEDAI (OR 1.15 p 0.04), the years of exposure to high dose of GC (OR 1.18 p 0.004), the years of exposure to antimalarials (OR 0.82 p 0.03) and the BDI score (OR 1.1 p 0.005). Conclusion A modern management of SLE should not miss to take all the possible measures to ensure an adequate QoL to SLE patients, with particular attention to those affected by MeS.
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Affiliation(s)
| | - Fabio Basta
- Unit of Allergology, Clinical Immunology and Rheumatology, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Giulio Dolcini
- Unit of Allergology, Clinical Immunology and Rheumatology, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Veronica Batani
- Unit of Allergology, Clinical Immunology and Rheumatology, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Luca Navarini
- Unit of Allergology, Clinical Immunology and Rheumatology, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Antonella Afeltra
- Unit of Allergology, Clinical Immunology and Rheumatology, Università Campus Bio-Medico di Roma, Rome, Italy
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Mok CC, Tse SM, Chan KL, Ho LY. Effect of immunosuppressive therapies on survival of systemic lupus erythematosus: a propensity score analysis of a longitudinal cohort. Lupus 2017; 27:722-727. [PMID: 29087260 DOI: 10.1177/0961203317739129] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Objectives The aim of this study was to study the relationship between immunosuppressive drug treatment and survival in patients with systemic lupus erythematosus (SLE). Methods Patients who fulfilled four or more American College of Rheumatology criteria for SLE were followed longitudinally. Clinical characteristics, use of immunosuppressive agents and mortality were reviewed. Cox regression was used to study the relationship between immunosuppressive treatment and survival, adjusted for age, sex, vascular risk factors, organ damage, the anti-phospholipid antibodies and a propensity score for the indication of individual immunosuppressive agent derived from separate regression models. Results A total of 803 SLE patients were studied (92% women; age of SLE onset 33.2±14 years; follow-up time 10.8±7.7 years). The frequencies of ever use of immunosuppressive agents were: high-dose prednisolone (≥0.6 mg/kg/day for ≥4 weeks) (85%), azathioprine (63%), cyclophosphamide (25%), mycophenolate mofetil (27%), the calcineurin inhibitors (23%) and hydroxychloroquine (69%). Ninety-seven patients (12%) died and 56 (7%) patients were lost to follow-up. The causes of death were infection (44%), cerebrovascular events (12%), cardiovascular events (10%) and malignancy (8.2%). Cox regression revealed that the ever use of high-dose prednisolone, mycophenolate mofetil, calcineurin inhibitors or cyclophosphamide was not significantly associated with improved survival. However, the ever use of hydroxychloroquine (hazard ratio 0.59 (0.37-0.93); P=0.02) and azathioprine (hazard ratio 0.46 (0.28-0.75); P=0.002) was significantly associated with reduced mortality (41% and 54%, respectively) after adjustment for the propensity score and other confounding factors. A similar beneficial effect of hydroxychloroquine and azathioprine on survival was also observed in patients with lupus nephritis. Conclusions In this longitudinal cohort of Chinese SLE patients, the ever use of hydroxychloroquine and azathioprine was significantly associated with a probability of better survival. Treatment with high-dose prednisolone, cyclophosphamide, mycophenolate mofetil or the calcineurin inhibitors was not associated with long-term survival benefit.
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Affiliation(s)
- C C Mok
- Department of Medicine, 36658 Tuen Mun Hospital , Hong Kong, SAR China
| | - S M Tse
- Department of Medicine, 36658 Tuen Mun Hospital , Hong Kong, SAR China
| | - K L Chan
- Department of Medicine, 36658 Tuen Mun Hospital , Hong Kong, SAR China
| | - L Y Ho
- Department of Medicine, 36658 Tuen Mun Hospital , Hong Kong, SAR China
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Yusuf IH, Sharma S, Luqmani R, Downes SM. Hydroxychloroquine retinopathy. Eye (Lond) 2017; 31:828-845. [PMID: 28282061 DOI: 10.1038/eye.2016.298] [Citation(s) in RCA: 149] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Accepted: 08/24/2016] [Indexed: 12/16/2022] Open
Abstract
Hydroxychloroquine (HCQ; Plaquenil) is used increasingly in the management of a variety of autoimmune disorders, with well established roles in dermatology and rheumatology and emerging roles in oncology. Hydroxychloroquine has demonstrated a survival benefit in patients with systemic lupus erythematosus; some clinicians advocate its use in all such patients. However, Hydroxychloroquine and chloroquine (CQ) have been associated with irreversible visual loss due to retinal toxicity. Hydroxychloroquine retinal toxicity is far more common than previously considered; an overall prevalence of 7.5% was identified in patients taking HCQ for greater than 5 years, rising to almost 20% after 20 years of treatment. This review aims to provide an update on HCQ/CQ retinopathy. We summarise emerging treatment indications and evidence of efficacy in systemic disease, risk factors for retinopathy, prevalence among HCQ users, diagnostic tests, and management of HCQ retinopathy. We highlight emerging risk factors such as tamoxifen use, and new guidance on safe dosing, reversing the previous recommendation to use ideal body weight, rather than actual body weight. We summarise uncertainties and the recommendations made by existing HCQ screening programmes. Asian patients with HCQ retinopathy may demonstrate an extramacular or pericentral pattern of disease; visual field testing and retinal imaging should include a wider field for screening in this group. HCQ is generally safe and effective for the treatment of systemic disease but because of the risk of HCQ retinal toxicity, modern screening methods and ideal dosing should be implemented. Guidelines regarding optimal dosing and screening regarding HCQ need to be more widely disseminated.
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Affiliation(s)
- I H Yusuf
- The Oxford Eye Hospital, West Wing, John Radcliffe Hospital, Oxford, UK
| | - S Sharma
- The Oxford Eye Hospital, West Wing, John Radcliffe Hospital, Oxford, UK
| | - R Luqmani
- Department of Rheumatology, Nuffield Orthopaedic Centre, Oxford, UK
| | - S M Downes
- The Oxford Eye Hospital, West Wing, John Radcliffe Hospital, Oxford, UK
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