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Paredes-Ruiz D, Martin-Iglesias D, Amo L, Ruiz-Irastorza G. Elucidating the mechanisms and efficacy of antimalarial drugs in systemic lupus erythematosus. Expert Opin Pharmacother 2024:1-14. [PMID: 39354741 DOI: 10.1080/14656566.2024.2412252] [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: 06/29/2024] [Revised: 09/30/2024] [Accepted: 09/30/2024] [Indexed: 10/03/2024]
Abstract
INTRODUCTION Antimalarials (AMs) are old drugs with a wide range of beneficial effects in systemic lupus erythematosus (SLE) beyond the control of activity. The most recent debate is focused on defining the optimal doses to assure the best benefit/risk ratio. AREAS COVERED We have reviewed the pharmacological basis underlying the various therapeutic effects of AMs and the beneficial and toxic effects of HCQ, also discussing the role of mepacrine not only as a substitute in cases of maculopathy, but also as a very effective therapy combined with HCQ. We searched PubMed and Embase for articles published in English at any time. We used the terms "hydroxychloroquine" or "mepacrine" or "chloroquine" or "antimalarials", "pharmacokinetics", "efficacy", "remission", "toxicity", "adherence". We reviewed original research articles, large observational studies, systematic reviews, and expert consensus statements. Additionally, studies were identified through the assessment of the reference lists of the evaluated manuscripts. EXPERT OPINION We advocate for the widespread use of HCQ at stable doses of 200 mg/d (≤4 mg/kg/d for most patients) and also for the early combination therapy with mepacrine to assure a good control of SLE activity, and also a durable and safe use of these essential drugs for the management of SLE.
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Affiliation(s)
- Diana Paredes-Ruiz
- Biobizkaia Health Research Institute, Hospital Universitario Cruces, Bizkaia, The Basque Country, Spain
| | - Daniel Martin-Iglesias
- Biobizkaia Health Research Institute, Hospital Universitario Cruces, Bizkaia, The Basque Country, Spain
- Internal Medicine Department, Hospital Universitario de Leon, Leon, Spain
| | - Laura Amo
- Immunopathology Group, Biocruces Bizkaia Health Research Institute, Barakaldo, Spain
- Ikerbasque, Basque Foundation for Science, Bilbao, Spain
| | - Guillermo Ruiz-Irastorza
- Biobizkaia Health Research Institute, Hospital Universitario Cruces, Bizkaia, The Basque Country, Spain
- Department of Medicine, University of The Basque Country, UPV/EHU, Bizkaia, The Basque Country, Spain
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Simard JF, Liu EF, Rector A, Cantu M, Chakravarty E, Druzin M, Kuo DZ, Shaw GM, Weisman M, Hedderson M. Hydroxychloroquine and Pre-eclampsia in a Diverse Cohort of Women With Systemic Lupus Erythematosus. Arthritis Care Res (Hoboken) 2024; 76:1390-1395. [PMID: 38926748 PMCID: PMC11424256 DOI: 10.1002/acr.25386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 05/09/2024] [Accepted: 05/29/2024] [Indexed: 06/28/2024]
Abstract
OBJECTIVE Patients with systemic lupus erythematosus (SLE) are at risk for pregnancy complications such as pre-eclampsia and eclampsia. These clinically important complications are associated with maternal morbidity, mortality, and postpartum cardiovascular disease. Some studies suggest that hydroxychloroquine (HCQ) may reduce pre-eclampsia risk in lupus pregnancy. Using a cohort of pregnant patients with prevalent SLE at Kaiser Permanente Northern California (KPNC), we investigated whether HCQ treatment in early pregnancy reduced the risk of pre-eclampsia or eclampsia. METHODS Among pregnant patients with SLE from 2011 to 2020, we assessed HCQ treatment from three months before pregnancy through the first trimester. HCQ exposure was defined multiple ways to account for adherence and duration of treatment. Propensity scores accounted for multiple confounders and modified Poisson models estimated risk ratios (RRs) and 95% confidence intervals of the association between HCQ treatment and pre-eclampsia or eclampsia. Effect modification by pregestational hypertension, history of nephritis, and antiphospholipid antibody (aPL) status was investigated through stratified analysis. RESULTS There were 399 pregnancies among 324 patients with SLE at KPNC between 2011 and 2020. Considering multiple exposure definitions, we consistently found a null association between HCQ and pre-eclampsia or eclampsia. The RRs were consistently lower among nullipara patients, and RRs were consistently protective but not statistically significant among the high-risk subgroup of patients with a history of nephritis, aPL positivity, or pregestational hypertension (for both nullipara and multipara patients). CONCLUSION Although this study found no reduced risk of HCQ on pre-eclampsia or eclampsia, residual confounding may be attenuating the effect despite an integrated health care delivery system setting with detailed clinical data.
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Affiliation(s)
- Julia F Simard
- Stanford University School of Medicine, Stanford, California
| | - Emily F Liu
- Kaiser Permanente Northern California Division of Research, Oakland
| | - Amadeia Rector
- Stanford University School of Medicine, Stanford, California
| | | | | | - Maurice Druzin
- Stanford University School of Medicine, Stanford, California
| | - Daniel Z Kuo
- Kaiser Permanente, Redwood City Medical Center, Redwood City, California
| | - Gary M Shaw
- Stanford University School of Medicine, Stanford, California
| | - Michael Weisman
- Stanford University School of Medicine, Stanford, California
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Wind M, Fierro JJ, Bloemenkamp KWM, de Leeuw K, Lely AT, Limper M, Sueters M, Teng YKO, Walter IJ, Kooiman J. Pregnancy outcome predictors in systemic lupus erythematosus: a systematic review and meta-analysis. THE LANCET. RHEUMATOLOGY 2024; 6:e667-e683. [PMID: 39153486 DOI: 10.1016/s2665-9913(24)00160-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Revised: 06/04/2024] [Accepted: 06/04/2024] [Indexed: 08/19/2024]
Abstract
BACKGROUND To enhance patient-tailored preconception risk assessment for women with systemic lupus erythematosus (SLE), knowledge on risk factors associated with adverse pregnancy outcomes is required. Therefore, we did a systematic review and meta-analysis to identify and provide unambiguous effect sizes of preconception predictors of pregnancy outcomes in women with SLE. METHODS In this systematic review and meta-analysis, we searched PubMed and Embase for studies reporting preconception predictors of pregnancy outcomes in women with SLE, from database inception to Aug 22, 2023. Studies were included if they presented original, quantitative data on pregnant women with SLE and reported on preconception risk factors on at least one of the outcomes as defined in the protocol. Studies were excluded if they had a sample size of less than 20 patients, were restricted to multiple pregnancies, had unclear timing of prognostication, or exclusively reported a composite outcome. Literature screening, data extraction, and risk-of-bias assessment (quality in prognostic studies tool) were done by two reviewers independently, in a blinded, standardised manner. The reported outcomes included livebirth, pre-eclampsia, small for gestational age, preterm birth, pregnancy loss before and after 20 weeks of gestation, and SLE flares. We computed pooled univariate odds ratios (ORs) and 95% CIs using a random effects model. We assessed heterogeneity using the I2 statistic and prediction intervals. This study is registered with PROSPERO, CRD42022344732. FINDINGS Of the 6705 unique articles identified, 72 (1·1%) were included in the meta-analysis, comprising 10 355 pregnancies in 8065 women with SLE. One potentially eligible study was retracted and therefore removed from our analysis. Previous lupus nephritis was associated with decreased livebirth probability (OR 0·62 [95% CI 0·47-0·81]; I2=0%), increased risk of preterm birth (2·00 [1·55-2·57]; I2=17%), and increased risk of pre-eclampsia (3·11 [2·35-4·12]; I2=0%). Chronic hypertension was associated with increased risk of disease flare (2·50 [1·74-3·58]; I2=0%), preterm birth (2·65 [1·87-3·77]; I2=0%), and pre-eclampsia (5·86 [3·41-10·06]; I2=33%). SLE disease activity at conception or preconception was associated with increased risk of preterm birth (2·91 [1·96-4·33]; I2=21%) and pre-eclampsia (2·32 [1·40-3·83]; I2=0%). Secondary antiphospholipid syndrome was associated with decreased livebirth probability (0·40 [0·27-0·58]; I2=0%), increased risk of pregnancy loss after 20 weeks of gestation (2·77 [1·44-5·31]; I2=0%), and increased risk of preterm birth (1·65 [1·29-2·11]; I2=0%). Across studies, risk-of-bias assessment suggested considerable bias in study attrition and confounding. INTERPRETATION We identified previous lupus nephritis, chronic hypertension, SLE disease activity before and at conception, and secondary antiphospholipid syndrome as predictors of adverse pregnancy outcomes in women with SLE. These findings contribute to an optimal patient-tailored risk assessment in preconception counselling. FUNDING None.
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Affiliation(s)
- Merlijn Wind
- Department of Obstetrics, Leiden, Netherlands; Leiden University Medical Centre, Leiden, Netherlands; Department of Obstetrics, Haaglanden Medical Centre, The Hague, Netherlands.
| | - Juan J Fierro
- Department of Rheumatology and Clinical Immunology, University Medical Centre Groningen, Groningen, Netherlands; Grupo Reproducción, Departamento de Microbiología y Parasitología, Universidad de Antioquia UdeA, Medellín, Colombia
| | | | - Karina de Leeuw
- Department of Rheumatology and Clinical Immunology, University Medical Centre Groningen, Groningen, Netherlands
| | - A Titia Lely
- Department of Obstetrics, Utrecht, the Netherlands
| | - Maarten Limper
- Department of Rheumatology and Clinical Immunology, Utrecht, the Netherlands
| | | | | | | | - Judith Kooiman
- Department of Obstetrics, Utrecht, the Netherlands; University Medical Centre Utrecht, Utrecht, the Netherlands; Department of Obstetrics, Erasmus Medical Center, Rotterdam, Netherlands
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Zheng Y, Zha X, Zhang B, Elsabagh M, Wang H, Wang M, Zhang H. The interaction of ER stress and autophagy in trophoblasts: navigating pregnancy outcome†. Biol Reprod 2024; 111:292-311. [PMID: 38678504 DOI: 10.1093/biolre/ioae066] [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: 11/27/2023] [Revised: 04/12/2024] [Accepted: 04/22/2024] [Indexed: 05/01/2024] Open
Abstract
The endoplasmic reticulum is a complex and dynamic organelle that initiates unfolded protein response and endoplasmic reticulum stress in response to the accumulation of unfolded or misfolded proteins within its lumen. Autophagy is a paramount intracellular degradation system that facilitates the transportation of proteins, cytoplasmic components, and organelles to lysosomes for degradation and recycling. Preeclampsia and intrauterine growth retardation are two common complications of pregnancy associated with abnormal trophoblast differentiation and placental dysfunctions and have a major impact on fetal development and maternal health. The intricate interplay between endoplasmic reticulum stress, and autophagy and their impact on pregnancy outcomes, through mediating trophoblast differentiation and placental development, has been highlighted in various reports. Autophagy controls trophoblast regulation through a variety of gene expressions and signaling pathways while excessive endoplasmic reticulum stress triggers downstream apoptotic signaling, culminating in trophoblast apoptosis. This comprehensive review delves into the intricacies of placental development and explores the underlying mechanisms of preeclampsia and intrauterine growth retardation. In addition, this review will elucidate the molecular mechanisms of endoplasmic reticulum stress and autophagy, both individually and in their interplay, in mediating placental development and trophoblast differentiation, particularly highlighting their roles in preeclampsia and intrauterine growth retardation development. This research seeks to the interplay between endoplasmic reticulum stress and impaired autophagy in the placental trophoderm, offering novel insights into their contribution to pregnancy complications.
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Affiliation(s)
- Yi Zheng
- Laboratory of Metabolic Manipulation of Herbivorous Animal Nutrition, College of Animal Science and Technology, Yangzhou University, Yangzhou, People's Repubic of China
- Joint International Research Laboratory of Agriculture and Agri-Product Safety, the Ministry of Education of China, Yangzhou University, Yangzhou, People's Republic of China
| | - Xia Zha
- Laboratory of Metabolic Manipulation of Herbivorous Animal Nutrition, College of Animal Science and Technology, Yangzhou University, Yangzhou, People's Repubic of China
- Joint International Research Laboratory of Agriculture and Agri-Product Safety, the Ministry of Education of China, Yangzhou University, Yangzhou, People's Republic of China
| | - Bei Zhang
- Laboratory of Metabolic Manipulation of Herbivorous Animal Nutrition, College of Animal Science and Technology, Yangzhou University, Yangzhou, People's Repubic of China
- Joint International Research Laboratory of Agriculture and Agri-Product Safety, the Ministry of Education of China, Yangzhou University, Yangzhou, People's Republic of China
| | - Mabrouk Elsabagh
- Department of Animal Production and Technology, Faculty of Agricultural Sciences and Technologies, Niğde Ömer Halisdemir University, Nigde, Turkey
- Department of Nutrition and Clinical Nutrition, Faculty of Veterinary Medicine, Kafrelsheikh University, KafrelSheikh, Egypt
| | - Hongrong Wang
- Laboratory of Metabolic Manipulation of Herbivorous Animal Nutrition, College of Animal Science and Technology, Yangzhou University, Yangzhou, People's Repubic of China
- Joint International Research Laboratory of Agriculture and Agri-Product Safety, the Ministry of Education of China, Yangzhou University, Yangzhou, People's Republic of China
| | - Mengzhi Wang
- Laboratory of Metabolic Manipulation of Herbivorous Animal Nutrition, College of Animal Science and Technology, Yangzhou University, Yangzhou, People's Repubic of China
- Joint International Research Laboratory of Agriculture and Agri-Product Safety, the Ministry of Education of China, Yangzhou University, Yangzhou, People's Republic of China
- State Key Laboratory of Sheep Genetic Improvement and Healthy Production, Xinjiang Academy of Agricultural Reclamation Science, Shihezi, P. R. China
| | - Hao Zhang
- Laboratory of Metabolic Manipulation of Herbivorous Animal Nutrition, College of Animal Science and Technology, Yangzhou University, Yangzhou, People's Repubic of China
- Joint International Research Laboratory of Agriculture and Agri-Product Safety, the Ministry of Education of China, Yangzhou University, Yangzhou, People's Republic of China
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Soto-Peleteiro A, Gonzalez-Echavarri C, Ruiz-Irastorza G. Obstetric antiphospholipid syndrome. Med Clin (Barc) 2024; 163 Suppl 1:S14-S21. [PMID: 39174149 DOI: 10.1016/j.medcli.2024.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 05/06/2024] [Accepted: 05/08/2024] [Indexed: 08/24/2024]
Abstract
Antiphospholipid syndrome (APS) is the most frequent acquired thrombophilia of autoimmune basis. Pregnancy complications of APS may include recurrent miscarriage, and placental dysfunction presenting as fetal death, prematurity, intrauterine growth restriction and preeclampsia. For the management of obstetric APS, a coordinated medical-obstetric management is essential, and this should start for a preconceptional visit in order to estimate the individual risk for complications, adjust therapies and establish the indications for preconceptional and first-trimester therapy. The basis of APS therapy during pregnancy is low-dose aspirin, combined in certain clinical scenarios with low-molecular weight heparin. Induction of delivery should not be routinely indicated in the absence of maternal and/or fetal complications. Postpartum management should be warranted.
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Affiliation(s)
- Adriana Soto-Peleteiro
- Autoimmune Diseases Research Unit, Department of Internal Medicine, Biobizkaia Health Research Institute, Hospital Universitario Cruces, Spain
| | - Cristina Gonzalez-Echavarri
- Autoimmune Diseases Research Unit, Department of Internal Medicine, Biobizkaia Health Research Institute, Hospital Universitario Cruces, Spain
| | - Guillermo Ruiz-Irastorza
- Autoimmune Diseases Research Unit, Department of Internal Medicine, Biobizkaia Health Research Institute, Hospital Universitario Cruces, Spain; University of The Basque Country, Bizkaia, The Basque Country, Spain.
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Bezemer RE, Faas MM, van Goor H, Gordijn SJ, Prins JR. Decidual macrophages and Hofbauer cells in fetal growth restriction. Front Immunol 2024; 15:1379537. [PMID: 39007150 PMCID: PMC11239338 DOI: 10.3389/fimmu.2024.1379537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 06/14/2024] [Indexed: 07/16/2024] Open
Abstract
Placental macrophages, which include maternal decidual macrophages and fetal Hofbauer cells, display a high degree of phenotypical and functional plasticity. This provides these macrophages with a key role in immunologically driven events in pregnancy like host defense, establishing and maintaining maternal-fetal tolerance. Moreover, placental macrophages have an important role in placental development, including implantation of the conceptus and remodeling of the intrauterine vasculature. To facilitate these processes, it is crucial that placental macrophages adapt accordingly to the needs of each phase of pregnancy. Dysregulated functionalities of placental macrophages are related to placental malfunctioning and have been associated with several adverse pregnancy outcomes. Although fetal growth restriction is specifically associated with placental insufficiency, knowledge on the role of macrophages in fetal growth restriction remains limited. This review provides an overview of the distinct functionalities of decidual macrophages and Hofbauer cells in each trimester of a healthy pregnancy and aims to elucidate the mechanisms by which placental macrophages could be involved in the pathogenesis of fetal growth restriction. Additionally, potential immune targeted therapies for fetal growth restriction are discussed.
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Affiliation(s)
- Romy Elisa Bezemer
- Department of Obstetrics and Gynecology, University Medical Center Groningen, Groningen, Netherlands
- Department of Pathology and Medical Biology, University Medical Center Groningen, Groningen, Netherlands
| | - Marijke M Faas
- Department of Obstetrics and Gynecology, University Medical Center Groningen, Groningen, Netherlands
- Department of Pathology and Medical Biology, University Medical Center Groningen, Groningen, Netherlands
| | - Harry van Goor
- Department of Pathology and Medical Biology, University Medical Center Groningen, Groningen, Netherlands
| | - Sanne Jehanne Gordijn
- Department of Obstetrics and Gynecology, University Medical Center Groningen, Groningen, Netherlands
| | - Jelmer R Prins
- Department of Obstetrics and Gynecology, University Medical Center Groningen, Groningen, Netherlands
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Rector A, Marić I, Chaichian Y, Chakravarty E, Cantu M, Weisman MH, Shaw GM, Druzin M, Simard JF. Hydroxychloroquine in Lupus Pregnancy and Risk of Preeclampsia. Arthritis Rheumatol 2024; 76:919-927. [PMID: 38272838 PMCID: PMC11136600 DOI: 10.1002/art.42793] [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: 01/17/2023] [Revised: 11/28/2023] [Accepted: 12/26/2023] [Indexed: 01/27/2024]
Abstract
OBJECTIVE Systemic lupus erythematosus (SLE) disproportionately affects women during childbearing years, and hydroxychloroquine (HCQ) is the standard first-line treatment. Preeclampsia complicates up to one-third of pregnancies in lupus patients, although reports vary by parity and multifetal gestation. We investigated whether taking HCQ early in pregnancy may reduce the risk of preeclampsia. METHODS We studied 1,068 live birth singleton pregnancies among 1,020 privately insured patients with SLE (2007-2016). HCQ treatment was defined as three months preconception through the first trimester, and prescription fills were a proxy for taking HCQ. Modified Poisson regression estimated risk ratios (RRs) and 95% confidence intervals (CIs), stratified by parity. Propensity scores accounted for confounders, and stratified analyses examined effect modification. RESULTS Approximately 15% of pregnant patients were diagnosed with preeclampsia. In 52% of pregnancies, patients had one or more HCQ fills. Pregnant patients exposed to HCQ had more comorbidities, SLE activity, and azathioprine treatment. We found no evidence of a statistical association between HCQ and preeclampsia among nulliparous (RR 1.26 [95% CI 0.82-1.93]) and multiparous pregnancies (RR 1.20 [95% CI 0.80-1.70]). Additional controls for confounding decreased the RRs toward the null (nulliparous pregnancy, propensity score-adjusted [PS-adj] RR 1.09 [95% CI 0.68-1.76]; multiparous pregnancy, PS-adj RR 1.01 [95% CI 0.66-1.53]). CONCLUSION Using a large insurance-based database, we did not observe a decreased risk of preeclampsia associated with HCQ treatment in pregnancy, although we cannot rule out residual and unmeasured confounding and misclassification. Further studies leveraging large population-based data and prospective collection could characterize how HCQ influences preeclampsia risk in pregnant patients with SLE and among persons at greater risk of hypertensive disorders of pregnancy.
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Affiliation(s)
- Amadeia Rector
- Department of Epidemiology and Population Health, Stanford University School of Medicine
| | - Ivana Marić
- Department of Pediatrics, Stanford University School of Medicine
| | - Yashaar Chaichian
- Division of Immunology and Rheumatology, Department of Medicine, Stanford University School of Medicine
| | - Eliza Chakravarty
- Arthritis and Clinical Immunology. Oklahoma Medical Research Foundation, Oklahoma City, OK 73104
| | | | - Michael H Weisman
- Division of Immunology and Rheumatology, Department of Medicine, Stanford University School of Medicine
| | - Gary M Shaw
- Department of Pediatrics, Stanford University School of Medicine
| | - Maurice Druzin
- Department of Obstetrics and Gynecology, Stanford University School of Medicine
| | - Julia F Simard
- Department of Epidemiology and Population Health, Stanford University School of Medicine
- Division of Immunology and Rheumatology, Department of Medicine, Stanford University School of Medicine
- Department of Obstetrics and Gynecology, Stanford University School of Medicine
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Paredes-Ruiz D, Martin-Iglesias D, Ruiz-Irastorza G. Balancing risks and benefits in the use of hydroxychloroquine and glucocorticoids in systemic lupus erythematosus. Expert Rev Clin Immunol 2024; 20:359-373. [PMID: 38112074 DOI: 10.1080/1744666x.2023.2294938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 12/08/2023] [Indexed: 12/20/2023]
Abstract
INTRODUCTION Hydroxychloroquine (HCQ) and glucocorticoids (GCs) constitute the oldest and more used drugs in the treatment of systemic lupus erythematosus (SLE). Despite this long experience, both are still subject to a number of uncertainties, mainly regarding the dose. AREAS COVERED We review the main mechanisms of action, the clinical and toxic effects of HCQ and GCs and analyze the recommendations for the use of both in guidelines published since 2018. We offer a set of recommendations based on the pharmacology, mechanisms of action and clinical evidence. EXPERT OPINION HCQ is the backbone therapy for SLE, and a judicious use must be accomplished, using doses that allow a good control of lupus without compromising the safety of treatments very much prolonged over the time. Stable doses of 200 mg/day seem to accomplish both conditions. GCs should be used more judiciously, with methyl-prednisolone pulses as the main therapy for inducing rapid remission and doses ≤5-2.5 mg/day be never exceeded in long-term maintenance treatments.
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Affiliation(s)
- Diana Paredes-Ruiz
- Autoimmune Diseases Research Unit, Department of Internal Medicine, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, The Basque Country, Spain
| | - Daniel Martin-Iglesias
- Autoimmune Diseases Research Unit, Department of Internal Medicine, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, The Basque Country, Spain
| | - Guillermo Ruiz-Irastorza
- Autoimmune Diseases Research Unit, Department of Internal Medicine, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, The Basque Country, Spain
- Department of Medicine, University of the Basque Country, The Basque Country, Spain
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Tarter L, Bermas BL. Expert Perspective on a Clinical Challenge: Lupus and Pregnancy. Arthritis Rheumatol 2024; 76:321-331. [PMID: 37975160 DOI: 10.1002/art.42756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 10/10/2023] [Accepted: 11/13/2023] [Indexed: 11/19/2023]
Abstract
Systemic lupus erythematosus (SLE), a multiorgan systemic inflammatory disorder, predominantly affects women during their reproductive years. In this review, we summarize the state of knowledge about preconception planning and management of SLE during pregnancy. Achieving remission or low disease activity for several months on medications compatible with pregnancy prior to conception is essential to decreasing the risk of disease flare and improving pregnancy outcomes, including pre-eclampsia, preterm birth, and intrauterine growth restriction. With close management and well-controlled disease before and during pregnancy, <10% of patients flare. All patients with SLE should remain on hydroxychloroquine unless contraindicated. Expectant mothers with a history of antiphospholipid syndrome should be treated with anticoagulant therapy during pregnancy. Women with anti-Ro/SSA or anti-La/SSB antibodies require additional monitoring because their offspring are at increased risk for congenital heart block. Patients with SLE should be offered low-dose aspirin starting at the end of the first trimester to reduce the risk of pre-eclampsia. Flares of SLE during pregnancy require escalation of therapy. The immunosuppressives azathioprine, tacrolimus, and cyclosporine are compatible with pregnancy, and biologic agents can also be considered. Glucocorticoid use in pregnancy should be limited to the lowest effective dose. Mycophenolate mofetil/mycophenolic acid, methotrexate, leflunomide, and cyclophosphamide are known to be teratogenic and are contraindicated in pregnancy. Distinguishing a flare of lupus nephritis during pregnancy from pre-eclampsia can be particularly challenging. Overall, outcomes in pregnancy for women with lupus are improving, but gaps in knowledge about optimal management strategies persist.
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Affiliation(s)
- Laura Tarter
- Brigham and Women's Hospital, Boston, Massachusetts
| | - Bonnie L Bermas
- University of Texas Southwestern Medical Center, Dallas, Texas
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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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Al-Husban N, Abu-Hassan DW, Saleem RAA, Al-Abdallat L, Alhusban AE, Adwan MH. Therapeutic changes of systemic lupus erythematosus (SLE) patients in pregnancy and feto-maternal outcomes: a retrospective cohort study. J Int Med Res 2024; 52:3000605231225349. [PMID: 38263912 PMCID: PMC10807327 DOI: 10.1177/03000605231225349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 12/20/2023] [Indexed: 01/25/2024] Open
Abstract
OBJECTIVES Patients with systemic lupus erythematosus (SLE) frequently show non-compliance with their medication. We evaluated the compliance of patients with SLE in Jordan with their medication and the relationships with fetal and maternal outcomes. METHODS We performed a retrospective cohort study of patients with SLE who had no co-morbidities or antiphospholipid syndrome; and were taking only prednisolone, hydroxychloroquine, and/or antiplatelet and anticoagulant medication. RESULTS We studied 173 pregnancies. Prednisolone was administered around pregnancy in 50 (28.9%) of these. The compliance with hydroxychloroquine, prednisolone, and anticoagulant and antiplatelet medication was 87.5%, 91.4%, and 97.3%, respectively. Non-compliance with anticoagulant/antiplatelet therapy was significantly associated with pregnancy-related complications. No complications developed in participants who were non-compliant with prednisolone therapy. The mean pre-pregnancy Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) for the pregnancies was 3.7, indicating low disease activity. Pregnancies with high pre-pregnancy SLEDAI scores tended to be more likely to have preterm deliveries, intrauterine growth restriction, and stillbirth. Postpartum relapse tended to be associated with higher pre-pregnancy SLEDAI. CONCLUSIONS In patients with pre-conceptional low SLE activity, changes in therapeutic compliance during pregnancy are not associated with adverse outcomes. In addition, post-partum relapse is not associated with pre-pregnancy SLEDAI score in therapeutically compliant patients.
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Affiliation(s)
- Naser Al-Husban
- Department of Obstetrics and Gynecology, School of Medicine, The University of Jordan, Amman, Jordan
| | - Diala Walid Abu-Hassan
- Department of Physiology and Biochemistry, School of Medicine, The University of Jordan Amman, Jordan
| | | | | | | | - Marwan H Adwan
- Department of Medicine, Division of Rheumatology, The University of Jordan, Amman, Jordan
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Jung YS, Song YJ, Keum J, Lee JW, Jang EJ, Cho SK, Sung YK, Jung SY. Identifying pregnancy episodes and estimating the last menstrual period using an administrative database in Korea: an application to patients with systemic lupus erythematosus. Epidemiol Health 2023; 46:e2024012. [PMID: 38476014 PMCID: PMC11040213 DOI: 10.4178/epih.e2024012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 10/19/2023] [Indexed: 03/14/2024] Open
Abstract
OBJECTIVES This study developed an algorithm for identifying pregnancy episodes and estimating the last menstrual period (LMP) in an administrative claims database and applied it to investigate the use of pregnancy-incompatible immunosuppressants among pregnant women with systemic lupus erythematosus (SLE). METHODS An algorithm was developed and applied to a nationwide claims database in Korea. Pregnancy episodes were identified using a hierarchy of pregnancy outcomes and clinically plausible periods for subsequent episodes. The LMP was estimated using preterm delivery, sonography, and abortion procedure codes. Otherwise, outcome-specific estimates were applied, assigning a fixed gestational age to the corresponding pregnancy outcome. The algorithm was used to examine the prevalence of pregnancies and utilization of pregnancy-incompatible immunosuppressants (cyclophosphamide [CYC]/mycophenolate mofetil [MMF]/methotrexate [MTX]) and non-steroidal anti-inflammatory drugs (NSAIDs) during pregnancy in SLE patients. RESULTS The pregnancy outcomes identified in SLE patients included live births (67%), stillbirths (2%), and abortions (31%). The LMP was mostly estimated with outcome-specific estimates for full-term births (92.3%) and using sonography procedure codes (54.7%) and preterm delivery diagnosis codes (37.9%) for preterm births. The use of CYC/MMF/MTX decreased from 7.6% during preconception to 0.2% at the end of pregnancy. CYC/MMF/MTX use was observed in 3.6% of women within 3 months preconception and 2.5% during 0-7 weeks of pregnancy. CONCLUSIONS This study presents the first pregnancy algorithm using a Korean administrative claims database. Although further validation is necessary, this study provides a foundation for evaluating the safety of medications during pregnancy using secondary databases in Korea, especially for rare diseases.
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Affiliation(s)
- Yu-Seon Jung
- Chung-Ang University College of Pharmacy, Seoul, Korea
| | - Yeo-Jin Song
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea
- Hanyang University Institute for Rheumatology Research, Seoul, Korea
| | - Jihyun Keum
- Department of Obstetrics and Gynecology, Hanyang University College of Medicine, Seoul, Korea
| | - Ju Won Lee
- Chung-Ang University College of Pharmacy, Seoul, Korea
- Department of Global Innovative Drugs, Graduate School of Chung-Ang University, Seoul, Korea
| | - Eun Jin Jang
- Department of Information Statistics, Andong National University, Andong, Korea
| | - Soo-Kyung Cho
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea
- Hanyang University Institute for Rheumatology Research, Seoul, Korea
| | - Yoon-Kyoung Sung
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea
- Hanyang University Institute for Rheumatology Research, Seoul, Korea
| | - Sun-Young Jung
- Chung-Ang University College of Pharmacy, Seoul, Korea
- Department of Global Innovative Drugs, Graduate School of Chung-Ang University, Seoul, Korea
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Kawano Y, Kolstad KD, Li S, Simard JF, Chung L. Trends in adverse pregnancy outcomes among women with systemic sclerosis in the United States. Semin Arthritis Rheum 2023; 63:152252. [PMID: 37666113 PMCID: PMC11178391 DOI: 10.1016/j.semarthrit.2023.152252] [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: 04/29/2023] [Revised: 07/31/2023] [Accepted: 08/03/2023] [Indexed: 09/06/2023]
Abstract
OBJECTIVES We sought to examine temporal trends in adverse pregnancy outcomes among SSc pregnancies in a large nationwide sample. METHODS We used the National Inpatient Sample (NIS) database from 2000 - 2017 to derive national estimates of delivery-associated hospitalizations in the United States among patients with SSc. Each SSc delivery was matched to 100 non-SSc deliveries by age, delivery year, and race. We evaluated adverse pregnancy outcomes (APOs) including maternal and fetal death, cesarean delivery, hospital length of stay, preterm delivery, intrauterine growth restriction, and hypertensive disorders of pregnancy. We used multivariable regression models with an interaction term between SSc and year and adjusting for race, advanced maternal age, diabetes mellitus, and pre-existing hypertension to evaluate temporal trends in APOs among SSc and non-SSc deliveries. RESULTS From 2000 to 2017, there were 3740 delivery-associated hospitalizations for women with SSc. SSc was associated with an increased risk of all APOs compared to non-SSc deliveries. Fetal death declined in SSc deliveries from 49.0 per 1000 delivery-related admissions in 2000 - 2005 to 16.2 per 1000 in 2012 - 2017. There was a significant difference in trends for fetal death between SSc and non-SSc deliveries (p = 0.043), but the trends for other APOs did not differ between the two groups. CONCLUSIONS In this large nationwide sample, the risk of fetal death among women with SSc markedly improved over the past 18 years. The risk for other APOs remained high in SSc deliveries compared to non-SSc deliveries, and further studies are needed to determine what strategies can improve these outcomes.
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Affiliation(s)
- Yumeko Kawano
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, MA, USA
| | - Kathleen D Kolstad
- Division of Rheumatology, University of California Los Angeles, Los Angeles, CA, USA
| | - Shufeng Li
- Department of Dermatology, Stanford University School of Medicine, Palo Alto, CA, USA; Department of Urology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Julia F Simard
- Division of Immunology and Rheumatology, Stanford University School of Medicine, Palo Alto, CA, USA; Department of Epidemiology and Population Health, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Lorinda Chung
- Division of Immunology and Rheumatology, Stanford University School of Medicine, Palo Alto, CA, USA; Division of Rheumatology, Palo Alto VA Health Care System, Palo Alto, CA, USA.
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Sangah AB, Jabeen S, Hunde MZ, Devi S, Mumtaz H, Shaikh SS. Maternal and fetal outcomes of SLE in pregnancy: a literature review. J OBSTET GYNAECOL 2023; 43:2205513. [PMID: 37154805 DOI: 10.1080/01443615.2023.2205513] [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: 05/10/2023]
Abstract
Systemic Lupus Erythematosus (SLE) is an auto-immune disease in which the immune system assaults its tissues. We aimed to analyse the maternal and foetal outcomes during pregnancy in SLE mothers. A literature search was conducted by two investigators to assess SLE's outcomes on maternal and foetal during pregnancies. We searched PubMed/Medline, Embase, and Google scholar to collect evidence from different research studies, draw the conclusion, and report it. In our investigation, we found out that SLE could cause a spectrum of complications during pregnancy, not only for the mother but also for the foetus. It could affect fertility and cause difficult pregnancies for the couple as well which includes certain complications such as: preterm labour and delivery, high blood pressure (preeclampsia), placental insufficiency, miscarriage or stillbirth, whereas in the foetus SLE can cause mortality, preterm birth, and neonatal lupus (a temporary condition in the baby caused by SLE-related antibodies) and structural abnormalities. The literature suggests that SLE could prove fatal for the foetus and induce many complications in the mother. However, this could be avoided if pregnancy is planned right from the start and proper management is provided to the mother during pregnancy and delivery.p.
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Affiliation(s)
- Abdul Basit Sangah
- Liaquat National Hospital and Medical College Karachi, Karachi, Pakistan
| | - Sidra Jabeen
- Liaquat National Hospital and Medical College Karachi, Karachi, Pakistan
| | | | - Sunita Devi
- Liaquat National Hospital and Medical College Karachi, Karachi, Pakistan
| | - Hassan Mumtaz
- Senior Clinical Research Associate, Maroof International Hospital, Public Health Scholar, Health Services Academy, Islamabad, Pakistan
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15
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Gibson S, Johnson N, Simpson Brown S, Hartley S, Maloney K, Gossell-Williams M, Hunter T. Pregnancy outcomes in systemic lupus erythematosus: experience from a Caribbean center. J Matern Fetal Neonatal Med 2023; 36:2204392. [PMID: 37127567 DOI: 10.1080/14767058.2023.2204392] [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: 05/03/2023]
Abstract
BACKGROUND Systemic Lupus Erythematosus (SLE) is a chronic autoimmune multi-system disorder frequently affecting black women of childbearing age. No published data exist on the obstetric outcomes in a Caribbean population. OBJECTIVE We analyzed pregnancy outcomes in an Afro-Caribbean cohort of women with SLE at a tertiary university hospital. METHODS A retrospective cohort study was performed of all pregnant women with SLE prior to pregnancy from January 1990 to December 2021 at the University Hospital of the West Indies (UHWI), Jamaica. Maternal rheumatologic, obstetric, fetal/neonatal data were analyzed. Descriptive statistical analyses were performed. To determine if outcomes were associated with various factors, Spearman's rho was followed by logistic regression analysis to estimate unadjusted odds ratios with statistical significance at p < 0.05. RESULTS A total of 56 pregnancies in 47 women were identified with SLE. Live births were 87.5%, with 10.7% spontaneous miscarriages and no neonatal deaths. Prednisone was the most used drug in 67.9% of patients. 85% of women had an adverse outcome with an adverse fetal outcome occurring in 55% of cases. Prednisone was associated with an adverse fetal/neonatal outcome (Spearman's rho = 0.38; p = .004). CONCLUSION In this first Caribbean series on SLE in pregnancy, reasonably successful pregnancy outcomes are achievable in Afro-Caribbean women managed in multidisciplinary centers.
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Affiliation(s)
- Shanea Gibson
- Department of Obstetrics and Gynaecology, University of the West Indies, Mona, Kingston
| | - Nadine Johnson
- Department of Obstetrics and Gynaecology, University of the West Indies, Mona, Kingston
| | - Simone Simpson Brown
- Department of Obstetrics and Gynaecology, University of the West Indies, Mona, Kingston
| | - Shwantay Hartley
- Department of Basic Medical Sciences, University of the West Indies, Mona, Kingston
| | - Keisha Maloney
- Department of Medicine, University of the West Indies, Mona, Kingston
| | | | - Tiffany Hunter
- Department of Obstetrics and Gynaecology, University of the West Indies, Mona, Kingston
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Rao IR, Kolakemar A, Shenoy SV, Prabhu RA, Nagaraju SP, Rangaswamy D, Bhojaraja MV. Hydroxychloroquine in nephrology: current status and future directions. J Nephrol 2023; 36:2191-2208. [PMID: 37530940 PMCID: PMC10638202 DOI: 10.1007/s40620-023-01733-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 07/03/2023] [Indexed: 08/03/2023]
Abstract
Hydroxychloroquine is one of the oldest disease-modifying anti-rheumatic drugs in clinical use. The drug interferes with lysosomal activity and antigen presentation, inhibits autophagy, and decreases transcription of pro-inflammatory cytokines. Owing to its immunomodulatory, anti-inflammatory, anti-thrombotic effect, hydroxychloroquine has been an integral part of therapy for systemic lupus erythematosus and lupus nephritis for several decades. The therapeutic versatility of hydroxychloroquine has led to repurposing it for other clinical conditions, with recent studies showing reduction in proteinuria in IgA nephropathy. Research is also underway to investigate the efficacy of hydroxychloroquine in primary membranous nephropathy, Alport's syndrome, systemic vasculitis, anti-GBM disease, acute kidney injury and for cardiovascular risk reduction in chronic kidney disease. Hydroxychloroquine is well-tolerated, inexpensive, and widely available and therefore, should its indications expand in the future, it would certainly be welcomed. However, clinicians should be aware of the risk of irreversible and progressive retinal toxicity and rarely, cardiomyopathy. Monitoring hydroxychloroquine levels in blood appears to be a promising tool to evaluate compliance, individualize the dose and reduce the risk of retinal toxicity, although this is not yet standard clinical practice. In this review, we discuss the existing knowledge regarding the mechanism of action of hydroxychloroquine, its utility in lupus nephritis and other kidney diseases, the main adverse effects and the evidence gaps that need to be addressed in future research. Created with Biorender.com. HCQ, hydroxychloroquine; GBM, glomerular basement membrane; mDC, myeloid dendritic cell; MHC, major histocompatibility complex; TLR, toll-like receptor.
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Affiliation(s)
- Indu Ramachandra Rao
- Department of Nephrology, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India, 576104.
| | - Ashwija Kolakemar
- Department of Nephrology, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India, 576104
| | - Srinivas Vinayak Shenoy
- Department of Nephrology, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India, 576104
| | - Ravindra Attur Prabhu
- Department of Nephrology, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India, 576104
| | - Shankar Prasad Nagaraju
- Department of Nephrology, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India, 576104
| | - Dharshan Rangaswamy
- Department of Nephrology, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India, 576104
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Suzuki K, Uno S, Wakasugi N. Tacrolimus use and renal function in pregnancy with lupus nephritis: Analysis of post-marketing surveillance data in Japan. Mod Rheumatol 2023; 33:944-952. [PMID: 35982545 DOI: 10.1093/mr/roac094] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 07/18/2022] [Accepted: 08/09/2022] [Indexed: 11/14/2022]
Abstract
OBJECTIVES Tacrolimus may be administered to pregnant women with lupus nephritis in Japan if considered therapeutically beneficial, but supporting data are limited. We assessed the safety and effectiveness of tacrolimus before, during, and after pregnancy in women with lupus nephritis receiving tacrolimus. METHODS This was an ad hoc analysis of data from a post-marketing surveillance study of tacrolimus in patients with lupus nephritis in Japan. Pregnancy outcomes, nephritis status, and adverse events were assessed for up to 2 years postpartum. RESULTS Data were available for 23 births in 21 patients (two patients had two births each). Tacrolimus for lupus nephritis was continued during 11 births in nine patients (during and after pregnancy) and discontinued in 12 patients (when pregnancy was known or when approaching delivery). Renal function was generally maintained in patients who gave birth while receiving tacrolimus; however, there were cases of increased urine protein and decreased renal function over 2 years. There were no unexpected adverse events/safety concerns. CONCLUSIONS These data from clinical practice suggest that tacrolimus is a valid treatment option for lupus nephritis in fertile women in Japan and, with careful monitoring, pregnant women with lupus nephritis may continue their tacrolimus treatment.
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Liu Y, Wei Y, Zhang Y, Yang H. Hydroxychloroquine significantly decreases the risk of preeclampsia in pregnant women with autoimmune disorders: a systematic review and meta-analysis. Clin Rheumatol 2023; 42:1223-1235. [PMID: 36729357 DOI: 10.1007/s10067-022-06496-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 12/16/2022] [Accepted: 12/19/2022] [Indexed: 02/03/2023]
Abstract
This meta-analysis aimed to investigate whether hydroxychloroquine (HCQ) intervention could decrease the incidence of preeclampsia and other maternal and fetal outcomes among pregnant women with autoimmune disorders. PubMed, EMBASE, Web of Science, and the Cochrane databases were searched from inception until January 2022. Data on maternal or fetal outcomes of the control and hydroxychloroquine treatment groups were gathered and analyzed. Pooled odds ratio (OR) with 95% confidence intervals (CIs) were determined. Cochran's Q test, I2 statistics, leave-one-out analysis, Baujat plot analysis, GOSH plot analysis, and multivariable meta-regression were applied to assess between-study heterogeneity. The meta-analysis was performed using the Stata V.16.1 software. Baujat plot analysis and GOSH plot analysis were performed using the R V.4.0.0 software. Our study included 21 cohort studies and one case-control study with a total of 3948 pregnancies with immune disorders. HCQ treatment significantly reduced the incidence of preeclampsia (OR 0.45, 95% CI 0.33-0.63, p = 0.000, I2 3.68%). After outlier omission, HCQ treatment significantly reduced the incidence of premature delivery (OR 0.84, 95% CI 0.73-0.96, p = 0.01, I2 44.81%) in pregnant women with autoimmune disorders. In sub-group analysis, HCQ also significantly reduced the incidence of gestational hypertension (OR 0.42, 95% CI 0.26-0.68, p = 0.001, I2 49.33%) and preterm birth (OR 0.63, 95% CI 0.48-0.82, p = 0.001, I2 27.63%) in pregnant women with lupus. The heterogeneity of the findings mentioned above was low to moderate. There were no significant differences in the risk of other outcomes, including gestational diabetes, HELLP syndrome, thrombosis, spontaneous abortion, fetal loss, small for gestational age infant (SGA), low birth weight, stillbirth, APGAR score < 7, and congenital malformation. This meta-analysis indicated that HCQ treatment could significantly decrease the incidence of preeclampsia and premature delivery in pregnant women with autoimmune disorders. In addition, HCQ could reduce the risk of gestational hypertension in pregnant lupus patients.
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Affiliation(s)
- Yingnan Liu
- Department of Obstetrics and Gynecology, Peking University First Hospital, Peking University, Beijing, China
| | - Yumei Wei
- Department of Obstetrics and Gynecology, Peking University First Hospital, Peking University, Beijing, China
- Beijing Key Laboratory of Maternal-Fetal Medicine of Gestational Diabetes Mellitus, Beijing, China
| | - Yueyi Zhang
- Department of Internal Medicine, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Huixia Yang
- Department of Obstetrics and Gynecology, Peking University First Hospital, Peking University, Beijing, China.
- Beijing Key Laboratory of Maternal-Fetal Medicine of Gestational Diabetes Mellitus, Beijing, China.
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Leon-Martinez D, Lynn T, Abrahams VM. Cell-free fetal DNA impairs trophoblast migration in a TLR9-dependent manner and can be reversed by hydroxychloroquine. J Reprod Immunol 2023; 157:103945. [PMID: 37062109 DOI: 10.1016/j.jri.2023.103945] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 02/13/2023] [Accepted: 04/03/2023] [Indexed: 04/08/2023]
Abstract
Growing evidence suggests a relationship between elevated circulating placental-derived cell-free fetal DNA (cffDNA) and preeclampsia. Hypomethylation of CpG motifs, a hallmark of cffDNA, allows it to activate Toll-like receptor 9 (TLR9). Using an in vitro human first trimester extravillous trophoblast cell model, we sought to determine if trophoblast-derived cffDNA and ODN 2216, a synthetic unmethylated CpG oligodeoxynucleotide, directly impacted spontaneous trophoblast migration. The role of the DNA sensors TLR9, AIM2, and cGAS was assessed using the inhibitor A151. To test whether any effects could be reversed by therapeutic agents, trophoblasts were treated with or without cffDNA or ODN 2216 with or without aspirin (ASA; a known cGAS inhibitor), aspirin-triggered lipoxin (ATL), or hydroxychloroquine (HCQ; a known TLR9 inhibitor). Trophoblast-derived cffDNA and ODN 2216 reduced trophoblast migration without affecting cell viability. Reduced trophoblast migration in response to cffDNA or ODN 2216 was reversed by A151. cffDNA inhibition of trophoblast migration was reversed by HCQ, while ASA or ATL had no effect. In contrast ODN 2216 inhibition of trophoblast migration was reversed by ASA, ATL and HCQ. Our findings suggest that cffDNA can exert a local effect on placental function by impairing trophoblast migration through activation of innate immune DNA sensors. HCQ, a known TLR9 inhibitor, reversed the effects of cffDNA on trophoblast migration. Greater insights into the molecular underpinnings of how cffDNA impacts placentation can aid in our understanding of the pathogenesis of preeclampsia, and in the development of novel therapeutic approaches for preeclampsia therapy.
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Preeclampsia in women with lupus - Influence of aspirin and hydroxychloroquine on pregnancy outcome. Pregnancy Hypertens 2023; 31:14-16. [PMID: 36436478 DOI: 10.1016/j.preghy.2022.11.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 10/30/2022] [Accepted: 11/17/2022] [Indexed: 11/21/2022]
Abstract
Systemic lupus erythematosus is associated with increased rates of preeclampsia. Both aspirin and hydroxychloroquine are recommended for preeclampsia prophylaxis in women with lupus but there are no studies examining related outcomes in an Australian cohort. This was a single centre retrospective study of lupus affected pregnancies. The association between hydroxychloroquine, aspirin and preeclampsia was examined using adjusted logistic regression models. In 95 pregnancies, hydroxychloroquine was associated with a significantly lower risk of preeclampsia (adjusted OR 0.16, 95 % CI 0.04-0.64) but there was no association between aspirin and preeclampsia (adjusted OR 1.34, 95 % CI 0.33-5.40).
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Chen Y, Xiao L, Xu J, Wang J, Yu Z, Zhao K, Zhang H, Cheng S, Sharma S, Liao A, Liu C. Recent insight into autophagy and immunity at the maternal-fetal interface. J Reprod Immunol 2023; 155:103781. [PMID: 36463798 DOI: 10.1016/j.jri.2022.103781] [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: 08/20/2022] [Revised: 11/01/2022] [Accepted: 11/27/2022] [Indexed: 11/30/2022]
Abstract
Autophagy is a lysosomal degradation pathway that supports metabolic adaptation and energy cycling. It is essential for cell homeostasis, differentiation, development, and survival. Recent studies have shown that autophagy could influence immune responses by regulating immune cell functions. Reciprocally, immune cells strongly influence autophagy. Immune cells at the maternal-fetal interface are thought to play essential roles in pregnancy. Here, we review the induction of autophagy at the maternal-fetal interface and its role in decidualization and placental development. Additionally, we emphasize the role of autophagy in the immune microenvironment at the maternal-fetal interface, including innate immunity, adaptive immunity, and immune tolerance molecules. It also suggests new research directions and prospects.
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Affiliation(s)
- Yuanyao Chen
- Institute of Reproductive Health, Tongji Medical College, Huazhong University of Science and Technology, Hubei 430030, PR China
| | - Lin Xiao
- Institute of Reproductive Health, Tongji Medical College, Huazhong University of Science and Technology, Hubei 430030, PR China
| | - Jia Xu
- Institute of Reproductive Health, Tongji Medical College, Huazhong University of Science and Technology, Hubei 430030, PR China
| | - Jingming Wang
- Tongji Medical College, Huazhong University of Science and Technology, Hubei 430030, PR China
| | - Zhiquan Yu
- Tongji Medical College, Huazhong University of Science and Technology, Hubei 430030, PR China
| | - Kai Zhao
- Institute of Reproductive Health, Tongji Medical College, Huazhong University of Science and Technology, Hubei 430030, PR China
| | - Huiping Zhang
- Institute of Reproductive Health, Tongji Medical College, Huazhong University of Science and Technology, Hubei 430030, PR China
| | - Shibin Cheng
- Department of Pediatrics, Obstetrics and Gynecology and Pathology, Women and Infants Hospital of Rhode Island, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Surendra Sharma
- Department of Pediatrics, Obstetrics and Gynecology and Pathology, Women and Infants Hospital of Rhode Island, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Aihua Liao
- Institute of Reproductive Health, Tongji Medical College, Huazhong University of Science and Technology, Hubei 430030, PR China.
| | - Chunyan Liu
- Institute of Reproductive Health, Tongji Medical College, Huazhong University of Science and Technology, Hubei 430030, PR China.
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Hu Z, Gao R, Huang W, Wang H, Qin L. Effect of Hydroxychloroquine on Lupus Activity, Preeclampsia and Intrauterine Growth Restriction in Pregnant Women with Systemic Lupus Erythematosus and/or Antiphospholipid Syndrome: A Systematic Review and Meta-Analysis. J Clin Med 2023; 12:jcm12020485. [PMID: 36675415 PMCID: PMC9866542 DOI: 10.3390/jcm12020485] [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] [Received: 11/19/2022] [Revised: 12/31/2022] [Accepted: 01/05/2023] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Hydroxychloroquine (HCQ) has been used in the treatment of systematic lupus erythematosus (SLE) and antiphospholipid syndrome (APS), but its effect on lupus activity during pregnancy, preeclampsia and intrauterine growth restriction (IUGR) remains unclear. METHODS PubMed, Embase and Cochrane databases were searched before 11 September 2022 for randomized clinical trials (RCT) or observational studies involving additional HCQ treatment and pregnant women diagnosed as having SLE and/or APS/positive antiphospholipid antibodies (aPLs). Risks of high lupus activity, preeclampsia and IUGR were explored. RESULTS One RCT and 13 cohort studies were included. A total of 1764 pregnancies were included in the pooled meta-analysis (709 in the HCQ group vs. 1055 in the control group). After the additional use of HCQ, the risk of high lupus activity decreased (RR: 0.74, 95% CI: 0.57-0.97, p = 0.03). For preeclampsia, the total incidence decreased (RR: 0.54, 95% CI: 0.37-0.78, p = 0.001). The subgroup analysis showed statistical significance in the SLE subgroup (RR: 0.51, 95% CI: 0.34-0.78, p = 0.002) but not in the APS/aPLs subgroup (RR: 0.66, 95% CI: 0.29-1.54, p = 0.34). For IUGR, the decrease in incidence was not statistically significant (RR: 0.80, 95% CI: 0.47-1.35, p = 0.46), neither in the SLE subgroup (RR: 0.74, 95% CI: 0.40-1.36, p = 0.33) nor in the APS/aPLs subgroup (RR: 1.26, 95% CI: 0.34-4.61, p = 0.73). CONCLUSION The additional use of HCQ may decrease the risk of high lupus activity during pregnancy and the incidence of preeclampsia for SLE patients, but the results do not support that using HCQ decreases the incidence of preeclampsia for APS/aPLs patients or reduces IUGR risk for SLE and/or APS/aPLs patients.
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Affiliation(s)
- Zhengyan Hu
- The Reproductive Medical Center, Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu 610041, China
- Key Laboratory of Birth Defects and Related of Women and Children of Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu 610041, China
- West China School of Medicine, Sichuan University, Chengdu 610041, China
| | - Rui Gao
- The Reproductive Medical Center, Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu 610041, China
- Key Laboratory of Birth Defects and Related of Women and Children of Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu 610041, China
- West China School of Medicine, Sichuan University, Chengdu 610041, China
| | - Wanrong Huang
- Department of Dermatology, The First Hospital of China Medical University, Shenyang 110001, China
| | - Huiqing Wang
- Key Laboratory of Birth Defects and Related of Women and Children of Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu 610041, China
- Medical Simulation Centre, West China Second University Hospital, Sichuan University, Chengdu 610041, China
- Correspondence: (H.W.); (L.Q.)
| | - Lang Qin
- The Reproductive Medical Center, Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu 610041, China
- Key Laboratory of Birth Defects and Related of Women and Children of Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu 610041, China
- Correspondence: (H.W.); (L.Q.)
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Téllez Arévalo AM, Quaye A, Rojas-Rodríguez LC, Poole BD, Baracaldo-Santamaría D, Tellez Freitas CM. Synthetic Pharmacotherapy for Systemic Lupus Erythematosus: Potential Mechanisms of Action, Efficacy, and Safety. MEDICINA (KAUNAS, LITHUANIA) 2022; 59:56. [PMID: 36676680 PMCID: PMC9866503 DOI: 10.3390/medicina59010056] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 12/14/2022] [Accepted: 12/21/2022] [Indexed: 12/29/2022]
Abstract
The pharmacological treatment of systemic lupus erythematosus (SLE) aims to decrease disease activity, progression, systemic compromise, and mortality. Among the pharmacological alternatives, there are chemically synthesized drugs whose efficacy has been evaluated, but which have the potential to generate adverse events that may compromise adherence and response to treatment. Therapy selection and monitoring will depend on patient characteristics and the safety profile of each drug. The aim of this review is to provide a comprehensive understanding of the most important synthetic drugs used in the treatment of SLE, including the current treatment options (mycophenolate mofetil, azathioprine, and cyclophosphamide), review their mechanism of action, efficacy, safety, and, most importantly, provide monitoring parameters that should be considered while the patient is receiving the pharmacotherapy.
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Affiliation(s)
- Angélica María Téllez Arévalo
- Department of Physiological Sciences, School of Medicine, Pontificia Universidad Javeriana, Carrera 7 No. 40–62, Bogotá 110231, Colombia
| | - Abraham Quaye
- Department of Microbiology and Molecular Biology, Brigham Young University, Provo, UT 84602, USA
| | - Luis Carlos Rojas-Rodríguez
- Pharmacology Unit, Department of Biomedical Sciences, School of Medicine and Health Sciences, Universidad del Rosario, Bogotá 111221, Colombia
| | - Brian D. Poole
- Department of Microbiology and Molecular Biology, Brigham Young University, Provo, UT 84602, USA
| | - Daniela Baracaldo-Santamaría
- Pharmacology Unit, Department of Biomedical Sciences, School of Medicine and Health Sciences, Universidad del Rosario, Bogotá 111221, Colombia
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Mohammed RHA, Mumtaz H, Sangah AB, Shaikh SS, Nasir N, Jabeen S. Pregnancy in lupus: an updated consensus to guide best practice strategies. EGYPTIAN RHEUMATOLOGY AND REHABILITATION 2022. [DOI: 10.1186/s43166-022-00167-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Abstract
Background
Systemic lupus erythematosus is a multifaceted chronic relapsing autoimmune disease of unknown etiology. The disease has always been a serious diagnosis in women being a multisystem pathology that is classically encountered during the childbearing age posing serious systemic comorbidities with a potential impact on the functional performance, psychosocial status, and survival. In this article, we review critical issues related to the decision to conceive in female with lupus highlighting the impact of the diagnosis and disease activity status on the mother and the fetus, attempting to suggest a consensus to guide safe decision making for pregnancy with SLE.
Main body
The pleomorphic dysregulated immune nature of lupus in the presence of uncontrolled disease carries a higher risk of complicated pregnancy. Therefore, SLE pregnancies should be well planned and are usually encouraged if the disease is inactive (at least 6 months prior to conception) to ensure immune quiescence towards a safer outcome.
Conclusion
With the proper implementation of preconception counseling strategy, choice of the correct timing of conception, close monitoring of SLE flares with tight control, and the appreciation of the value of multidisciplinary management to best practice most young women with SLE can carry on successful pregnancies with favorable outcome.
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Choi M, Hwang JR, Sung JH, Byun N, Seok YS, Cho GJ, Choi SJ, Kim JS, Oh SY, Roh CR. Hydroxychloroquine reduces hypertension and soluble fms-like kinase-1 in a Nω-nitro-l-arginine methyl ester-induced preeclampsia rat model. J Hypertens 2022; 40:2459-2468. [PMID: 36321404 DOI: 10.1097/hjh.0000000000003279] [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: 06/16/2023]
Abstract
OBJECTIVE Hydroxychloroquine, a drug used for malaria and autoimmune diseases reportedly has beneficial effects against preeclampsia in pregnant women with lupus. However, its mechanism against preeclampsia remains unclear. We investigated the effect of hydroxychloroquine on an Nω-nitro-l-arginine methyl ester-induced preeclampsia rat model. METHODS Pregnant Sprague-Dawley rats were divided into four groups based on treatment (administered on gestational days 7-18): control, Nω-nitro-l-arginine methyl ester, hydroxychloroquine, and Nω-nitro-l-arginine methyl ester plus hydroxychloroquine. All animals were sacrificed on gestational day 19. We assayed tube formation and determined reactive oxygen species levels using human umbilical vein endothelial cells. RESULTS Results showed that hydroxychloroquine significantly lowered mean systolic blood pressure (P < 0.05) in Nω-nitro-l-arginine methyl ester-treated rats. Hydroxychloroquine did not affect their fetal and placental weights. Hydroxychloroquine mitigated Nω-nitro-l-arginine methyl ester-associated changes in proteinuria (P < 0.05). It normalized plasma soluble fms-like kinase-1 (P < 0.05) and endothelin-1 (P < 0.01) levels. In the tube formation assay, hydroxychloroquine increased the total meshes area (P < 0.05) and mitigated Nω-nitro-l-arginine methyl ester-induced reactive oxygen species formation (P < 0.05) in human umbilical vein endothelial cells. CONCLUSION We conclude that hydroxychloroquine alleviated hypertension, proteinuria, and normalized soluble fms-like kinase-1 and endothelin-1 levels in our preeclampsia model and that these changes may involve the restoration of endothelial dysfunction; thus, hydroxychloroquine could potentially be used for preventing preeclampsia, even in the absence of lupus.
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Affiliation(s)
- Minji Choi
- Department of Health Sciences and Technology, SAIHST, Sungkyunkwan University
- Samsung Biomedical Research Institute, Samsung Medical Center
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Jae Ryoung Hwang
- Sungkyunkwan University School of Medicine, Samsung Biomedical Research Institute, Samsung Medical Center
| | - Ji-Hee Sung
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Nagyeong Byun
- Samsung Biomedical Research Institute, Samsung Medical Center
| | - Ye Seon Seok
- Department of Obstetrics and Gynecology, Korea University College of Medicine
| | - Geum Joon Cho
- Department of Obstetrics and Gynecology, Korea University College of Medicine
| | - Suk-Joo Choi
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Jung-Sun Kim
- Department of Pathology and Translational Genomics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Soo-Young Oh
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Cheong-Rae Roh
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine
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Russell MD, Dey M, Flint J, Davie P, Allen A, Crossley A, Frishman M, Gayed M, Hodson K, Khamashta M, Moore L, Panchal S, Piper M, Reid C, Saxby K, Schreiber K, Senvar N, Tosounidou S, van de Venne M, Warburton L, Williams D, Yee CS, Gordon C, Giles I, Roddy E, Armon K, Astell L, Cotton C, Davidson A, Fordham S, Jones C, Joyce C, Kuttikat A, McLaren Z, Merrison K, Mewar D, Mootoo A, Williams E. British Society for Rheumatology guideline on prescribing drugs in pregnancy and breastfeeding: immunomodulatory anti-rheumatic drugs and corticosteroids. Rheumatology (Oxford) 2022; 62:e48-e88. [PMID: 36318966 PMCID: PMC10070073 DOI: 10.1093/rheumatology/keac551] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 09/15/2022] [Indexed: 11/07/2022] Open
Affiliation(s)
- Mark D Russell
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Mrinalini Dey
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Julia Flint
- Department of Rheumatology, Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Shropshire, UK
| | - Philippa Davie
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Alexander Allen
- Clinical Affairs, British Society for Rheumatology, London, UK
| | | | - Margreta Frishman
- Rheumatology, North Middlesex University Hospital NHS Trust, London, UK
| | - Mary Gayed
- Rheumatology, Sandwell and West Birmingham Hospitals, Birmingham, UK
| | | | - Munther Khamashta
- Lupus Research Unit, Division of Women's Health, King's College London, London, UK
| | - Louise Moore
- Rheumatic and Musculoskeletal Disease Unit, Our Lady's Hospice and Care Service, Dublin, Ireland
| | - Sonia Panchal
- Department of Rheumatology, South Warwickshire NHS Foundation Trust, Warwickshire, UK
| | - Madeleine Piper
- Royal National Hospital for Rheumatic Diseases, Royal United Hospital, Bath, UK
| | | | - Katherine Saxby
- Pharmacy, University College London Hospitals NHS Foundation Trust, London, UK
| | - Karen Schreiber
- Thrombosis and Haemostasis, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Department of Rheumatology, Danish Hospital for Rheumatic Diseases, Sonderborg, Denmark.,Department of Regional Health Research (IRS), University of Southern Denmark, Odense, Denmark
| | - Naz Senvar
- Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Sofia Tosounidou
- Lupus UK Centre of Excellence, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | | | | | - David Williams
- Obstetrics, University College London Hospitals NHS Foundation Trust, London, UK
| | - Chee-Seng Yee
- Department of Rheumatology, Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, Doncaster, UK
| | - Caroline Gordon
- Rheumatology Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Ian Giles
- Centre for Rheumatology, Division of Medicine, University College London, London, UK
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Campbell NE, Deer EM, Herrock OT, LaMarca BB. The Role of Different Lymphoid Cell Populations in Preeclampsia Pathophysiology. KIDNEY360 2022; 3:1785-1794. [PMID: 36514732 PMCID: PMC9717666 DOI: 10.34067/kid.0001282022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 08/11/2022] [Indexed: 01/12/2023]
Abstract
Preeclampsia (PE), new-onset hypertension during pregnancy, affects up to 10% of pregnancies worldwide. Despite being the leading cause of maternal and fetal morbidity and mortality, PE has no cure beyond the delivery of the fetal-placental unit. Although the exact pathogenesis of PE is unclear, there is a strong correlation between chronic immune activation; intrauterine growth restriction; uterine artery resistance; dysregulation of the renin-angiotensin system. Which contributes to renal dysfunction; and the resulting hypertension during pregnancy. The genesis of PE is thought to begin with insufficient trophoblast invasion leading to reduced spiral artery remodeling, resulting in decreased placental perfusion and thereby causing placental ischemia. The ischemic placenta releases factors that shower the endothelium and contribute to peripheral vasoconstriction and chronic immune activation and oxidative stress. Studies have shown imbalances in proinflammatory and anti-inflammatory cell types in women with PE and in animal models used to examine mediators of a PE phenotype during pregnancy. T cells, B cells, and natural killer cells have all emerged as potential mediators contributing to the production of vasoactive factors, renal and endothelial dysfunction, mitochondrial dysfunction, and hypertension during pregnancy. The chronic immune activation seen in PE leads to a higher risk for other diseases, such as cardiovascular disease, CKD, dementia during the postpartum period, and PE during a subsequent pregnancy. The purpose of this review is to highlight studies demonstrating the role that different lymphoid cell populations play in the pathophysiology of PE. Moreover, we will discuss treatments focused on restoring immune balance or targeting specific immune mediators that may be potential strategies to improve maternal and fetal outcomes associated with PE.
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Affiliation(s)
- Nathan E Campbell
- Department of Pharmacology and Toxicology, University of Mississippi Medical Center, Jackson, Mississippi
| | - Evangeline M Deer
- Department of Pharmacology and Toxicology, University of Mississippi Medical Center, Jackson, Mississippi
| | - Owen T Herrock
- Department of Pharmacology and Toxicology, University of Mississippi Medical Center, Jackson, Mississippi
| | - Babbette B LaMarca
- Department of Pharmacology and Toxicology, University of Mississippi Medical Center, Jackson, Mississippi
- Department of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson, Mississippi
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28
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Lucas A, Eudy AM, Gladman D, Petri M, Urowitz M, Wyatt CM, Clowse ME. The association of lupus nephritis with adverse pregnancy outcomes among women with lupus in North America. Lupus 2022; 31:1401-1407. [PMID: 36017607 PMCID: PMC9880879 DOI: 10.1177/09612033221123251] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVES We evaluated the association of lupus nephritis (LN) and adverse pregnancy outcomes in prospective cohorts of pregnant women with SLE (systemic lupus erythematosus). METHODS We conducted a patient-level pooled analysis of data from three cohorts of pregnant women with SLE. Pooled logistic regression models were used to evaluate the association of LN and adverse pregnancy outcomes. Odds ratios and 95% confidence intervals were calculated using a fixed effect model by enrolling cohort. RESULTS The pooled cohort included 393 women who received care at clinics in the United States and Canada from 1995 to 2015. There were 144 (37%) women with a history of LN. Compared to women without LN, those with LN had higher odds of fetal loss (OR: 1.90; 95% CI: 1.01, 3.56) and preeclampsia (OR: 2.04; 95% CI: 1.01, 4.13). Among the 31 women with active nephritis (defined as urine protein ≥ 0.5 g/24 h) there was a higher odds of poor pregnancy outcome (OR: 3.08; 95% CI: 1.31, 7.23) and fetal loss (OR: 6.29; 95% CI: 2.52, 15.70) compared to women without LN. CONCLUSIONS In this pooled cohort of women with SLE, a history of LN was associated with fetal loss and preeclampsia. Active nephritis was associated with poor pregnancy outcome and fetal loss.
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Affiliation(s)
- Anika Lucas
- 12277Duke University School of Medicine, Durham, NC, USA
| | - Amanda M Eudy
- 12277Duke University School of Medicine, Durham, NC, USA
| | | | - Michelle Petri
- School of Medicine, 1466Johns Hopkins University, Baltimore, MD, USA
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Reynolds JA, Gayed M, Khamashta MA, Leone F, Toescu V, Bruce IN, Giles I, Teh LS, McHugh N, Akil M, Edwards CJ, Gordon C. Outcomes of children born to mothers with systemic lupus erythematosus exposed to hydroxychloroquine or azathioprine. Rheumatology (Oxford) 2022; 62:1124-1135. [PMID: 35766806 PMCID: PMC9977116 DOI: 10.1093/rheumatology/keac372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 06/21/2022] [Accepted: 06/21/2022] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES HCQ and AZA are used to control disease activity and reduce risk of flare during pregnancy in patients with SLE. The aim of this study was to determine the outcomes of children born to mothers with SLE exposed to HCQ or AZA during pregnancy and breast-feeding. METHODS Women attending UK specialist lupus clinics with children ≤17 years old, born after SLE diagnosis, were recruited to this retrospective study. Data were collected using questionnaires and from clinical record review. Factors associated with the outcomes of low birth weight and childhood infection were determined using multivariable mixed-effects logistic regression models. RESULTS We analysed 284 live births of 199 mothers from 10 UK centres. The first pregnancies of 73.9% of mothers (147/199) were captured in the study; (60.4%) (150/248) and 31.1% (87/280) children were exposed to HCQ and AZA, respectively. There were no significant differences in the frequency of congenital malformations or intrauterine growth restriction between children exposed or not to HCQ or AZA. AZA use was increased in women with a history of hypertension or renal disease. Although AZA was associated with low birth weight in univariate models, there was no significant association in multivariable models. In adjusted models, exposure to AZA was associated with increased reports of childhood infection requiring hospital management [odds ratio 2.283 (1.003, 5.198), P = 0.049]. CONCLUSIONS There were no significant negative outcomes in children exposed to HCQ in pregnancy. AZA use was associated with increased reporting of childhood infection, which warrants further study.
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Affiliation(s)
- John A Reynolds
- Correspondence to: John A. Reynolds, Rheumatology Research Group, Institute of Inflammation and Ageing, University of Birmingham Research Laboratories, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, UK. E-mail:
| | - Mary Gayed
- Rheumatology Department, University Hospitals Birmingham NHS Foundation Trust, Birmingham
| | - Munther A Khamashta
- Lupus Research Unit, St Thomas Hospital,Department of Women and Children’s Health, King’s College London, London
| | - Francesca Leone
- Lupus Research Unit, St Thomas Hospital,Department of Women and Children’s Health, King’s College London, London
| | | | - Ian N Bruce
- Centre for Epidemiology Versus Arthritis, Division of Musculoskeletal & Dermatological Sciences, The University of Manchester,NIHR Manchester Biomedical Research Centre, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester
| | - Ian Giles
- Centre for Rheumatology, Department of Inflammation, Division of Medicine, University College London,Department of Rheumatology, University College London Hospital, London
| | - Lee-Suan Teh
- Rheumatology Department, Royal Blackburn Teaching Hospital, Blackburn,University of Central Lancashire, Preston
| | - Neil McHugh
- Department of Pharmacy and Pharmacology, University of Bath, Bath
| | - Mohammed Akil
- Rheumatology Department, Sheffield Teaching Hospitals NHS Trust, Sheffield
| | - Christopher J Edwards
- NIHR Southampton Clinical Research Facility, University Hospital Southampton NHS Trust, Southampton
| | - Caroline Gordon
- Rheumatology Research Group, Institute of Inflammation and Ageing, University of Birmingham,Rheumatology Department, Sandwell and West Birmingham NHS Trust,NIHR/Wellcome Trust Clinical Research Facility, Queen Elizabeth Hospital Birmingham, Birmingham, UK
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Abstract
PURPOSE OF REVIEW This review summarizes the recent literature exploring hydroxychloroquine levels and their relationship with disease activity and risk of toxicity. RECENT FINDINGS There is no clear correlation between weight-based dosing of hydroxychloroquine and the resulting blood levels of the medication. Recent studies have shown that increased hydroxychloroquine levels are associated with lower lupus disease activity and likely also increased risk of medication toxicity. SUMMARY Mounting evidence supports use of hydroxychloroquine levels in clinical practice to document adherence and ensure safety.
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Affiliation(s)
- Katherine Chakrabarti
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
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31
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Chambers CD, Johnson DL, Xu R, Luo Y, Felix R, Fine M, Lessard C, Adam MP, Braddock SR, Robinson LK, Burke L, Jones KL. Birth Outcomes in Women Who Have Taken Hydroxycholoroquine During Pregnancy: A Prospective Cohort Study. Arthritis Rheumatol 2022; 74:711-724. [PMID: 34725951 DOI: 10.1002/art.42015] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 10/13/2021] [Accepted: 10/26/2021] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Findings from previous small studies have been reassuring regarding the safety of treatment with hydroxychloroquine (HCQ) during pregnancy. In one recent study, it was demonstrated that the frequency of major birth defects was increased in women who had received HCQ at a dose of ≥400 mg/day during pregnancy. This study was undertaken to examine pregnancy outcomes among women following the use of HCQ. METHODS The study cohort comprised pregnant women who were prospectively enrolled in the MotherToBaby/Organization of Teratology Information Specialists Autoimmune Diseases in Pregnancy Study and were receiving treatment with HCQ. For the control groups, disease-matched women without HCQ exposure and healthy women were randomly selected from the same source, with subject matching using a 1:1 ratio. Data were collected through interviews, medical records, and dysmorphology examinations. Pregnancy outcome measures included the presence or absence of major and minor birth defects, rates of spontaneous abortion, rates of preterm delivery, and infant growth measures. RESULTS Between 2004 and 2018, 837 pregnant women met the criteria for study inclusion, including 279 women exposed to HCQ during pregnancy and 279 women in each unexposed control group. Sixty pregnant women (7.2%) were lost to follow-up. Among the women with live births, major birth defects occurred as a pregnancy outcome in 20 (8.6%) of 232 women with HCQ exposure in the first trimester, compared to 19 (7.4%) of 256 disease-matched unexposed controls (odds ratio [OR] 1.18, 95% confidence interval [95% CI] 0.61-2.26) and 13 (5.4%) of 239 healthy controls (adjusted OR 0.76, 95% CI 0.28-2.05). Risks did not differ in women who were receiving an HCQ dose of ≥400 mg/day. No pattern of birth defects was identified. There were no differences in the rates of spontaneous abortion or preterm delivery between groups. Occurrence of infant growth deficiencies did not differ in the HCQ-exposed group compared to the disease-matched unexposed control group, except in the infant's head circumference at birth (adjusted OR 1.85, 95% CI 1.07-3.20). CONCLUSION In this study, there was no evidence of an increased risk of structural birth defects or other adverse outcomes among women receiving HCQ during pregnancy, with the exception of infant head circumference at birth. For pregnant women being treated with HCQ, these findings are reassuring.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Leah Burke
- University of Vermont Medical Center, Burlington
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32
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Maria Merz W, Fischer-Betz R, Hellwig K, Lamprecht G, Gembruch U. Pregnancy and Autoimmune Disease. DEUTSCHES ARZTEBLATT INTERNATIONAL 2022; 119:145-156. [PMID: 34874264 PMCID: PMC9201458 DOI: 10.3238/arztebl.m2021.0353] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 04/19/2021] [Accepted: 10/01/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Pregnancies in women with chronic disease are on the rise. This pertains to autoimmune diseases in particular since these tend to affect women of childbearing age. The interaction between pregnancy and autoimmune disease may increase the risk of maternal, fetal, and obstetric complications; additional care may be required. METHODS This review is based on a selective literature search in PubMed (2015-2020). RESULTS In women with autoimmune diseases, the course of pregnancy is highly variable. Some autoimmune diseases tend to improve during pregnancy and do not to result in any serious obstetric complications. Others may worsen during pregnancy, with deterioration of the maternal condition as well as obstetric and perinatal complications. In systemic lupus erythematosus and myasthenia gravis, placental transfer of specific autoantibodies may cause fetal or neonatal disease. CONCLUSION The care of pregnant women with chronic diseases requires collaboration between specialists of the pertinent levels of care. A stable course of disease before conception, close interdisciplinary care, and pregnancy-compatible medication contribute to a reduction in maternal and perinatal complications.
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Affiliation(s)
- Waltraut Maria Merz
- Department of Obstetrics and Prenatal Medicine, Center for Obstetrics and Gynecology, University Hospital Bonn
| | - Rebecca Fischer-Betz
- Department of Rheumatology and Hiller, Forschungszentrum University Hospital Düsseldorf
| | - Kerstin Hellwig
- Katholisches Klinikum Bochum, Neurology Clinic,Clinic of Ruhr-Universität Bochum
| | - Georg Lamprecht
- Department of Medicine II, Division of Gastroenterology and Endocrinology, University Medical Center Rostock
| | - Ulrich Gembruch
- Department of Obstetrics and Prenatal Medicine, Center for Obstetrics and Gynecology, University Hospital Bonn
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Clowse MEB, Eudy AM, Balevic S, Sanders-Schmidler G, Kosinski A, Fischer-Betz R, Gladman DD, Molad Y, Nalli C, Mokbel A, Tincani A, Urowitz M, Bay C, van Noord M, Petri M. Hydroxychloroquine in the pregnancies of women with lupus: a meta-analysis of individual participant data. Lupus Sci Med 2022; 9:9/1/e000651. [PMID: 35318256 PMCID: PMC8935175 DOI: 10.1136/lupus-2021-000651] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 02/26/2022] [Indexed: 11/21/2022]
Abstract
Objective Multiple guidelines recommend continuing hydroxychloroquine (HCQ) for SLE during pregnancy based on observational data. The goal of this individual patient data meta-analysis was to identify the potential benefits and harms of HCQ use within lupus pregnancies. Methods Eligible studies included prospectively collected pregnancies in women with lupus. After a systematic literature search, seven datasets meeting inclusion criteria were obtained. Pregnancy outcomes and lupus activity were compared for pregnancies with a visit in the first trimester in women who did or did not take HCQ throughout pregnancy. Birth defects were not systematically collected. This analysis was conducted in each dataset, and results were aggregated to provide a pooled OR. Results Seven cohorts provided 938 pregnancies in 804 women. After selecting one pregnancy per patient with a first trimester visit, 668 pregnancies were included; 63% took HCQ throughout pregnancy. Compared with pregnancies without HCQ, those with HCQ had lower odds of highly active lupus, but did not have different odds of fetal loss, preterm delivery or pre-eclampsia. Among women with low lupus activity, HCQ reduced the odds of preterm delivery. Conclusions This large study of prospectively-collected lupus pregnancies demonstrates a decrease in lupus activity among woman who continue HCQ through pregnancy and no harm to pregnancy outcomes. Like all studies of HCQ in lupus pregnancy, this study is confounded by indication and non-adherence. As this study confirms the safety of HCQ and diminished SLE activity with use, it is consistent with current recommendations to continue HCQ throughout pregnancy.
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Affiliation(s)
| | - Amanda M Eudy
- Medicine, Duke University, Durham, North Carolina, USA
| | - Stephen Balevic
- Rheumatology and Clinical Immunology, Duke University, Durham, North Carolina, USA.,The Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Gillian Sanders-Schmidler
- Duke-Margolis Center for Health Policy, Duke Clinical Research Institute and Department of Population Health Sciences, Duke University, Durham, North Carolina, USA
| | - Andrzej Kosinski
- Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
| | | | - Dafna D Gladman
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Yair Molad
- Rheumtology, Beilinson Hospital, Rabin Medical Center, Petach Tikva, Israel
| | - Cecilia Nalli
- Rheumatology and Clinical Immunology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | | | - Angela Tincani
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Murray Urowitz
- Center for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital, University of Toronto, Lupus Clinic, Toronto, Ontario, Canada
| | | | - Megan van Noord
- Library, University of California Davis, Davis, California, USA
| | - Michelle Petri
- Rheumatology, Johns Hopkins University, Baltimore, Maryland, USA
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Dima A, Jurcut C, Chasset F, Felten R, Arnaud L. Hydroxychloroquine in systemic lupus erythematosus: overview of current knowledge. Ther Adv Musculoskelet Dis 2022; 14:1759720X211073001. [PMID: 35186126 PMCID: PMC8848057 DOI: 10.1177/1759720x211073001] [Citation(s) in RCA: 54] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 12/17/2021] [Indexed: 12/22/2022] Open
Abstract
The antimalarial hydroxychloroquine (HCQ) has demonstrated several crucial properties for the treatment of systemic lupus erythematosus (SLE). Herein, we reviewed the main HCQ pharmacologic features, detailed its mechanism of action, and summarized the existing guidelines and recommendations for HCQ use in rheumatology with a systematic literature search for the randomized controlled trials focused on lupus. HCQ has been shown to decrease SLE activity, especially in mild and moderate disease, to prevent disease flare and to lower the long-term glucocorticoid need. The numerous benefits of HCQ are extended to pregnancy and breastfeeding period. Based on cohort studies, antithrombotic and metabolic HCQ’s effects were shown, including lipid-lowering properties, which might contribute to an improved cardiovascular risk. Moreover, early HCQ use in antinuclear antibodies positive individuals might delay the progression to SLE. Finally, HCQ has a significant favorable impact on long-term outcomes such as damage accrual and mortality in SLE. Based on these multiple benefits, HCQ is now the mainstay long-term treatment in SLE, recommended by current guidelines in all patients unless contraindications or side effects. The daily dose associated with the best compromise between efficacy and safety is matter of debate. The concern regarding retinal toxicity rather than proper efficacy data is the one that dictated the daily dosage of ⩽5 mg/kg/day actual body weight currently agreed upon.
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Affiliation(s)
- Alina Dima
- Department of Rheumatology, Colentina Clinical Hospital, Bucharest, Romania
| | - Ciprian Jurcut
- Department of Internal Medicine, Dr. Carol Davila Central Military Emergency University Hospital, Bucharest, Romania
| | - François Chasset
- Department of Dermatology and Allergology, Hôpital Tenon, Paris, France; Faculté de Médecine, Sorbonne Université, Paris, France
| | - Renaud Felten
- National Reference Center for Rare Auto-immune and Systemic Diseases Est Sud-Est (RESO), Strasbourg, France
- Department of Rheumatology, Les Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Laurent Arnaud
- National Reference Center for Rare Auto-immune and Systemic Diseases Est Sud-Est (RESO), Strasbourg, France
- Department of Rheumatology, Les Hôpitaux Universitaires de Strasbourg, Strasbourg, France
- Université de Strasbourg, Inserm UMR-S 1109, Strasbourg, France
- Service de Rhumatologie, Hôpital de Hautepierre, 1, avenue Molière BP 83049, 67098 Strasbourg Cedex, France
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35
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Park JS, Chung MK, Lim H, Lee J, Lee CH. Risk of Pregnancy Complications and Low Birth Weight Offsprings in Korean Women With Rheumatic Diseases: A Nationwide Population-Based Study. J Korean Med Sci 2022; 37:e18. [PMID: 35014229 PMCID: PMC8748664 DOI: 10.3346/jkms.2022.37.e18] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 11/18/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND To determine the risk of pregnancy complications and adverse offspring outcomes in Korean women with rheumatic diseases (RDs). METHODS Women aged 20-44 years with pregnancies ending in delivery were identified from the National Health Insurance Service-National Health Information Database (2009-2016). Women with RD including systemic lupus erythematosus (SLE), seropositive rheumatoid arthritis (SPRA), and ankylosing spondylitis (AS) (n = 4,284) were age-matched with controls (n = 26,023). Outcome variables included threatened abortion (TA), preterm birth (PB), preeclampsia/eclampsia (PE/E), intrauterine growth retardation (IGR), urinary tract infection, low birth weight (LBW) offsprings, and offspring death within 1 year of birth. RESULTS Women with RDs had increased risks for cesarean section delivery (odds ratio [OR], 1.5; 95% confidence interval [CI], 1.4-1.6), TA (OR, 1.4; 95% CI, 1.2-1.5), PB (OR, 2.4; 95% CI, 1.9-3.2), PE/E (OR, 4.4; 95% CI, 3.3-5.9), and IGR (OR, 2.4; 95% CI, 2.0-3.1) than the controls. The risk of pregnancy complications was increased in SLE and SPRA pregnancies but not in AS pregnancies. Offsprings of women with RDs had an increased risk of LBW (OR, 4.0; 95% CI, 3.2-4.9). The offspring mortality rate within 1 year of birth was higher in women with RDs (6.2/10,000 persons) than in the controls (4.9/10,000 persons). CONCLUSION Women with RDs are at a risk of developing pregnancy complications, and the risk of LBW offsprings and offspring death within 1 year of birth is increased in these women. Therefore, this population requires special attention during their childbearing years.
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Affiliation(s)
- Jin-Su Park
- Division of Rheumatology, Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Min Kyung Chung
- Division of Rheumatology, Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea
| | - Hyunsun Lim
- Research and Analysis Team, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Jisoo Lee
- Division of Rheumatology, Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea.
| | - Chan Hee Lee
- Division of Rheumatology, Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea.
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36
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Richez C, Cordel N, Maillard H, Willems A, Chasset F, Belot A, Arnaud L, Lazaro E, Hachulla E, Costedoat-Chalumeau N. Practical management of patients on hydroxychloroquine. Joint Bone Spine 2022; 88:105316. [PMID: 34969505 DOI: 10.1016/j.jbspin.2021.105316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Christophe Richez
- Department of Rheumatology, Centre National de Référence des Maladies Auto-immunes Systémiques Rares RESO, Pellegrin Hospital, 33000 Bordeaux, France; Bordeaux University, CNRS 5164, 33000 Bordeaux, France.
| | - Nadège Cordel
- Department of Dermatology and Clinical Immunology, Guadeloupe University Hospital, Pointe-à-Pitre, Guadeloupe and Normandie University, UNIROUEN, IRIB, Inserm U1234, Rouen, France
| | - Hélène Maillard
- Department of Internal Medicine and Clinical Immunology, Referral Centre for Centre for rare systemic autoimmune diseases North and North-West of France (CeRAINO), CHU Lille, University of Lille, Inserm U1286 - INFINITE - Institute for Translational Research in Inflammation, F-59000 Lille, France
| | | | - François Chasset
- Sorbonne Université, faculté de médecine, Service de dermatologie et allergologie, hôpital Tenon, AP-HP, 75020 Paris, France
| | - Alexandre Belot
- University of Lyon, CIRI, INSERM U1111, National Referee Centre RAISE, Pediatric Rheumatology, HFME, Hospices Civils de Lyon, Lyon, France
| | - Laurent Arnaud
- Department of Rheumatology, Hôpitaux Universitaires de Strasbourg, INSERM UMR-S 1109, Centre National de Référence des Maladies Auto-immunes Systémiques Rares RESO, Strasbourg, France
| | - Estibaliz Lazaro
- Department of Internal Medicine, Centre National de Référence des Maladies Auto-immunes Systémiques Rares RESO, Haut-Lévêque Hospital, 33604 Pessac, France; Bordeaux University, CNRS 5164, 33000 Bordeaux, France
| | - Eric Hachulla
- Department of Internal Medicine and Clinical Immunology, Referral Centre for Centre for rare systemic autoimmune diseases North and North-West of France (CeRAINO), CHU Lille, University of Lille, Inserm U1286 - INFINITE - Institute for Translational Research in Inflammation, F-59000 Lille, France
| | - Nathalie Costedoat-Chalumeau
- Service de médecine interne, Centre de référence maladies autoimmunes et systémiques rares Île de France, APHP, Hôpital Cochin, F-75014 Paris, France; Université de Paris, Centre de recherche épidémiologie et biostatistiques de Sorbonne Paris Cité, F-75004 Paris, France
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37
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Allen ME, Golding A, Rus V, Karabin NB, Li S, Lescott CJ, Bobbala S, Scott EA, Szeto GL. Targeted Delivery of Chloroquine to Antigen-Presenting Cells Enhances Inhibition of the Type I Interferon Response. ACS Biomater Sci Eng 2021; 7:5666-5677. [PMID: 34813288 DOI: 10.1021/acsbiomaterials.1c01047] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Systemic lupus erythematosus (SLE) causes damaging inflammation in multiple organs via the accumulation of immune complexes. These complexes activate plasmacytoid dendritic cells (pDCs) via toll-like receptors (TLRs), contributing to disease pathogenesis by driving the secretion of inflammatory type I interferons (IFNs). Antimalarial drugs, such as chloroquine (CQ), are TLR antagonists used to alleviate inflammation in SLE. However, they require ∼3 months of continuous use before achieving therapeutic efficacy and can accumulate in the retinal pigment epithelium with chronic use, resulting in retinopathy. We hypothesized that poly(ethylene glycol)-b-poly(propylene sulfide) filamentous nanocarriers, filomicelles (FMs), could directly deliver CQ to pDCs via passive, morphology-based targeting to concentrate drug delivery to specific immune cells, improve drug activity by increased inhibition of type I IFN, and enhance efficacy per dose. Healthy human peripheral blood mononuclear cells were treated with soluble CQ or CQ-loaded FMs, stimulated with TLR agonists or SLE patient sera, and type I IFN secretion was quantified via multi-subtype IFN-α ELISA and MX1 gene expression using real-time reverse transcription-quantitative polymerase chain reaction. Our results showed that 50 μg CQ/mg FM decreased MX1 expression and IFN-α production after TLR activation with either synthetic nucleic acid agonists or immune complex-rich sera from SLE patients. Cellular uptake and biodistribution studies showed that FMs preferentially accumulate in human pDCs and monocytes in vitro and in tissues frequently damaged in SLE patients (i.e., kidneys), while sparing the eye in vivo. These results showed that nanocarrier morphology enables drug delivery, and CQ-FMs may be equally effective and more targeted than soluble CQ at inhibiting SLE-relevant pathways.
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Affiliation(s)
- Marilyn E Allen
- Department of Chemical, Biochemical & Environmental Engineering, University of Maryland, Baltimore County, 1000 Hilltop Circle, Baltimore, Maryland 21250, United States
| | - Amit Golding
- Department of Medicine, Division of Rheumatology & Clinical Immunology, University of Maryland School of Medicine, 655 W. Baltimore Street, Baltimore, Maryland 21201, United States
| | - Violeta Rus
- Department of Medicine, Division of Rheumatology & Clinical Immunology, University of Maryland School of Medicine, 655 W. Baltimore Street, Baltimore, Maryland 21201, United States
| | - Nicholas B Karabin
- Department of Biomedical Engineering, Northwestern University, 633 Clark Street, Evanston, Illinois 60208, United States
| | - Sophia Li
- Department of Biomedical Engineering, Northwestern University, 633 Clark Street, Evanston, Illinois 60208, United States
| | - Chamille J Lescott
- Department of Biomedical Engineering, Northwestern University, 633 Clark Street, Evanston, Illinois 60208, United States
| | - Sharan Bobbala
- Department of Pharmaceutical Sciences, School of Pharmacy, West Virginia University, 1 Medical Center Drive, Morgantown, West Virginia 26506, United States
| | - Evan A Scott
- Department of Biomedical Engineering, Northwestern University, 633 Clark Street, Evanston, Illinois 60208, United States
| | - Gregory L Szeto
- Allen Institute for Immunology, 615 Westlake Avenue North, Seattle, Washington 98109, United States
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38
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Agostinis C, Mangogna A, Balduit A, Aghamajidi A, Ricci G, Kishore U, Bulla R. COVID-19, Pre-Eclampsia, and Complement System. Front Immunol 2021; 12:775168. [PMID: 34868042 PMCID: PMC8635918 DOI: 10.3389/fimmu.2021.775168] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 10/25/2021] [Indexed: 12/15/2022] Open
Abstract
COVID-19 is characterized by virus-induced injury leading to multi-organ failure, together with inflammatory reaction, endothelial cell (EC) injury, and prothrombotic coagulopathy with thrombotic events. Complement system (C) via its cross-talk with the contact and coagulation systems contributes significantly to the severity and pathological consequences due to SARS-CoV-2 infection. These immunopathological mechanisms overlap in COVID-19 and pre-eclampsia (PE). Thus, mothers contracting SARS-CoV-2 infection during pregnancy are more vulnerable to developing PE. SARS-CoV-2 infection of ECs, via its receptor ACE2 and co-receptor TMPRSS2, can provoke endothelial dysfunction and disruption of vascular integrity, causing hyperinflammation and hypercoagulability. This is aggravated by bradykinin increase due to inhibition of ACE2 activity by the virus. C is important for the progression of normal pregnancy, and its dysregulation can impact in the form of PE-like syndrome as a consequence of SARS-CoV-2 infection. Thus, there is also an overlap between treatment regimens of COVID-19 and PE. C inhibitors, especially those targeting C3 or MASP-2, are exciting options for treating COVID-19 and consequent PE. In this review, we examine the role of C, contact and coagulation systems as well as endothelial hyperactivation with respect to SARS-CoV-2 infection during pregnancy and likely development of PE.
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Affiliation(s)
- Chiara Agostinis
- Institute for Maternal and Child Health, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Burlo Garofolo, Trieste, Italy
| | - Alessandro Mangogna
- Institute for Maternal and Child Health, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Burlo Garofolo, Trieste, Italy
| | - Andrea Balduit
- Department of Life Sciences, University of Trieste, Trieste, Italy
| | - Azin Aghamajidi
- Department of Immunology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Giuseppe Ricci
- Institute for Maternal and Child Health, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Burlo Garofolo, Trieste, Italy.,Department of Medical, Surgical and Health Science, University of Trieste, Trieste, Italy
| | - Uday Kishore
- Biosciences, College of Health, Medicine and Life Sciences, Brunel University London, Uxbridge, United Kingdom
| | - Roberta Bulla
- Department of Life Sciences, University of Trieste, Trieste, Italy
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39
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Tang C, Si FL, Yao YX, Lv JC, Shi SF, Chen YQ, Liu LJ, Zhang H. The efficacy and safety of hydroxychloroquine in pregnant patients with IgA nephropathy: A retrospective cohort study. Nephrology (Carlton) 2021; 27:155-161. [PMID: 34713949 DOI: 10.1111/nep.13991] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 10/21/2021] [Accepted: 10/21/2021] [Indexed: 11/29/2022]
Abstract
AIM Hydroxychloroquine (HCQ) is used to control proteinuria in IgA Nephropathy (IgAN) However, its efficacy and safety in pregnant IgAN patients remains unknown. This study aimed to verify the safety of HCQ in pregnant IgAN patients and compare renal function and pregnancy outcomes with those of patients not treated with HCQ. METHODS We retrospectively reviewed medical records of all pregnant IgAN patients and singleton gestations at Peking University First Hospital from 2003-2021. Patients who did and did not receive HCQ treatment during pregnancy were compared. RESULTS We found no significant pre- or post-pregnancy differences in proteinuria or renal function between the two groups. However, the HCQ (+) group had higher proteinuria at the time of kidney biopsy (2.04 [1.26, 2.56] g/d vs. 0.80 [0.44, 1.11] g/d, P < .001); the proteinuria level at HCQ therapy initiation was also higher than that at the beginning of pregnancy (1.87 [1.30, 2.59] g/d vs. 1.08 [0.75, 1.50] g/d, P = .001). Despite no difference in preterm birth, birth weight, preeclampsia or postpartum haemorrhage, the proportion of patients with a previous history of spontaneous abortion was higher in the HCQ (+) group than in the HCQ (-) group (48.0% vs. 20.6%, P = .010). The eGFR (regression coefficient, 0.981; 95%CI 0.964-0.998) was a predictive factor for obstetrical complications. CONCLUSION HCQ is safe for IgAN treatment during pregnancy with effective reduction of proteinuria. HCQ might also be helpful in patients with a history of spontaneous abortion.
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Affiliation(s)
- Chen Tang
- Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China.,Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Feng-Lei Si
- Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China.,Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Yu-Xuan Yao
- Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China.,Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Ji-Cheng Lv
- Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China.,Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Su-Fang Shi
- Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China.,Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Yu-Qing Chen
- Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China.,Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Li-Jun Liu
- Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China.,Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Hong Zhang
- Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China.,Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
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40
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Miranda-Hernández D, Sánchez A, Sánchez-Briones RE, Rivas-Ruiz R, Cruz-Reynoso L, Cruz-Domínguez P, Jara LJ, Saavedra MÁ. Impact of Systemic Lupus Erythematosus on Pregnancy: Analysis of a Large 10-Year Longitudinal Mexican Cohort. J Clin Rheumatol 2021; 27:S217-S223. [PMID: 33264243 DOI: 10.1097/rhu.0000000000001626] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Pregnancy in patients with systemic lupus erythematosus is considered a high risk one since it is associated with a higher rate of maternal-fetal complications compared with the pregnancies in healthy women. OBJECTIVES The aim of this study was to describe the maternal-fetal outcomes in a cohort of Mexican patients with systemic lupus erythematosus and to identify risk factors associated with adverse maternal and fetal outcomes. PATIENTS AND METHODS A cohort of pregnant lupus patients was analyzed. Maternal-fetal complications were described, and clinical, biochemical, and immunological variables associated with obstetric adverse outcomes were studied. Descriptive statistics, comparison of variables using appropriate tests, and finally logistic regression analysis were performed to identify potential risk factors for adverse maternal and fetal outcomes. RESULTS A total of 351 pregnancies were included in a 10-year period. The most frequently observed maternal adverse outcomes were lupus flare (35%) and preeclampsia (14.5%). Active lupus before pregnancy (hazards ratio [HR], 3.7; 95% confidence interval [CI], 1.1-12.5; p = 0.003) was a predictor for these complications, whereas the use of antimalarial drugs (HR, 0.4; 95% CI, 0.2-0.7; p = 0.007) was a protective factor. The most frequent fetal adverse outcomes were preterm birth (38.1%), miscarriages (10%), and low birth weight babies (28%), and very low birth weight newborns (11%). Proteinuria in early pregnancy (HR, 7.1; 95% CI, 1.01-50.3; p = 0.04) and preeclampsia (HR, 9.3; 95% CI, 1.7-49.7; p = 0.009) were risk factors associated with these complications. CONCLUSIONS Variables related to systemic lupus erythematosus activity predict an adverse maternal outcome, whereas proteinuria in early pregnancy and preeclampsia are associated with an adverse fetal outcome.
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Affiliation(s)
- Dafhne Miranda-Hernández
- From the Rheumatology Unit, Hospital de Especialidades Dr. Antonio Fraga Mouret, Centro Médico Nacional La Raza
| | - Antonio Sánchez
- From the Rheumatology Unit, Hospital de Especialidades Dr. Antonio Fraga Mouret, Centro Médico Nacional La Raza
| | - Reyna E Sánchez-Briones
- From the Rheumatology Unit, Hospital de Especialidades Dr. Antonio Fraga Mouret, Centro Médico Nacional La Raza
| | | | | | | | - Luis Javier Jara
- Direction of Education and Health Research, Hospital de Especialidades Dr. Antonio Fraga Mouret, Centro Médico Nacional La Raza, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Miguel Ángel Saavedra
- From the Rheumatology Unit, Hospital de Especialidades Dr. Antonio Fraga Mouret, Centro Médico Nacional La Raza
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41
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Li X, Shopit A, Wang J. Biochemical and clinical predictors in pregnant women with antiphospholipid syndrome and systemic lupus erythematosus: comprehensive update. Arch Gynecol Obstet 2021; 304:1153-1160. [PMID: 34390384 DOI: 10.1007/s00404-021-06178-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 08/04/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Autoimmune diseases as antiphospholipid syndrome (APS) and systemic lupus erythematosus (SLE) could cause many maternal complications. The most common maternal complications of autoimmune diseases are lupus flare, hypertension, nephritis, preeclampsia (PE), eclampsia, and poor pregnancy outcomes which including preterm delivery and pregnancy loss. Only the lupus anticoagulant in the greatest prospective multicenter study has been associated with adverse pregnancy outcomes of the APS. PURPOSE This review aims to provide a comprehensive update for predictors in pregnant women with APS/SLE. METHODS These data have been collected from clinical and pathological studies, systematic reviews, and meta-analysis. RESULTS In recent years the SLE and APS demonstrated to have different and valuable clinical and biomarker predictors for the pregnancy outcome. Treatment of pregnant women with APS is low molecular weight heparin (LMWH) and aspirin; however, around 75% of this management is considered successful. CONCLUSION This review summarizes recent research that focuses on biochemical and clinical predictors of adverse pregnancy outcomes (APOs) of pregnant women with SLE and APS. Furthermore, we have collected more evidence that confirms the safety and efficacy of hydroxychloroquine (HCQ) preventing APOs.
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Affiliation(s)
- Xiaodong Li
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Dalian Medical University, Dalian, 116044, China
| | - Abdullah Shopit
- Department of Pharmacology, Academic Integrated Medicine and College of Pharmacy, Dalian Medical University, Dalian, 116044, China
| | - Jingmin Wang
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Dalian Medical University, Dalian, 116044, China.
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42
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Fogacci S, Fogacci F, Favari E, Toth PP, Borghi C, Cicero AFG. Management of pregnancy-related hypertensive disorders in patients infected with SARS CoV-2: pharmacological and clinical issues. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2021; 7:346-351. [PMID: 33155016 PMCID: PMC7499576 DOI: 10.1093/ehjcvp/pvaa105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 08/20/2020] [Accepted: 08/31/2020] [Indexed: 12/23/2022]
Abstract
Aims Coronavirus-19 disease (COVID-19) continues to spread throughout the world. It is known that among patients with hypertension, diabetes, chronic respiratory disease, or cardiovascular diseases, COVID-19 is associated with greater morbidity and mortality compared with patients without these conditions. This correlation is of great importance in pregnant women affected by COVID-19, since it usually leads to the development of a serious clinical complication. In particular, managing hypertensive disorders in pregnancy can be problematic because antihypertensive medications may interact pharmacologically with drugs used to treat COVID-19. This review focuses on the safety of drug treatment for COVID-19 in pregnant women treated with antihypertensive medication. Methods and results Several databases were searched to identify relevant literature. A few antihypertensive drugs and antithrombotic treatments are known for having a beneficial effect in the management of hypertension and hypertensive disorders in pregnancy. In this review, we focus on the expected drug–drug interactions with the experimental agents most often used to treat COVID-19. Conclusions The current indications for the management of hypertension-related disorders in pregnancy maintain their validity, while the risk of pharmacological interaction with the currently tested anti-SARS-CoV-2 medications is relatively low.
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Affiliation(s)
- Silvia Fogacci
- Hypertension and Cardiovascular Risk Research Group, Medical and Surgical Sciences Department, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Federica Fogacci
- Hypertension and Cardiovascular Risk Research Group, Medical and Surgical Sciences Department, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Elda Favari
- Department of Food and Drug, University of Parma, Parma, Italy
| | - Peter P Toth
- CGH Medical Center, Sterling, IL, and Cicarrone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Claudio Borghi
- Hypertension and Cardiovascular Risk Research Group, Medical and Surgical Sciences Department, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Arrigo F G Cicero
- Hypertension and Cardiovascular Risk Research Group, Medical and Surgical Sciences Department, Alma Mater Studiorum University of Bologna, Bologna, Italy
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Graham JJ, Longhi MS, Heneghan MA. T helper cell immunity in pregnancy and influence on autoimmune disease progression. J Autoimmun 2021; 121:102651. [PMID: 34020252 PMCID: PMC8221281 DOI: 10.1016/j.jaut.2021.102651] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 04/30/2021] [Accepted: 05/02/2021] [Indexed: 02/07/2023]
Abstract
Pregnancy presents the maternal immune system with a unique immunological challenge since it has to defend against pathogens while tolerating paternal allo-antigens expressed by fetal tissues. T helper (Th) cells play a central role in modulating immune responses and recent advances have defined distinct contributions of various Th cell subsets throughout each phase of human pregnancy, while dysregulation in Th responses show association with multiple obstetrical complications. In addition to localized decidual mechanisms, modulation of Th cell immunity during gestation is mediated largely by oscillations in sex hormone concentrations. Aberrant Th cell responses also underlie several autoimmune disorders while pregnancy-induced changes in the balance of Th cell immunity has been shown to exert favorable outcomes in the progression Th1 and Th17 driven autoimmune conditions only to be followed by post-partal exacerbations in disease.
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Affiliation(s)
- Jonathon J Graham
- Institute of Liver Studies, King's College Hospital, London, SE5 9RS, United Kingdom
| | - Maria Serena Longhi
- Department of Anesthesia, Critical Care & Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA
| | - Michael A Heneghan
- Institute of Liver Studies, King's College Hospital, London, SE5 9RS, United Kingdom.
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44
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Metalloproteinase 1 downregulation in neurofibromatosis 1: Therapeutic potential of antimalarial hydroxychloroquine and chloroquine. Cell Death Dis 2021; 12:513. [PMID: 34011935 PMCID: PMC8134427 DOI: 10.1038/s41419-021-03802-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 04/30/2021] [Accepted: 04/30/2021] [Indexed: 02/07/2023]
Abstract
Neurofibromatosis type 1 is an autosomal dominant genetic disorder caused by mutation in the neurofibromin 1 (NF1) gene. Its hallmarks are cutaneous findings including neurofibromas, benign peripheral nerve sheath tumors. We analyzed the collagen and matrix metalloproteinase 1 (MMP1) expression in Neurofibromatosis 1 cutaneous neurofibroma and found excessive expression of collagen and reduced expression of MMP1. To identify new therapeutic drugs for neurofibroma, we analyzed phosphorylation of components of the Ras pathway, which underlies NF1 regulation, and applied treatments to block this pathway (PD184352, U0126, and rapamycin) and lysosomal processes (chloroquine (CQ), hydroxychloroquine (HCQ), and bafilomycin A (BafA)) in cultured Neurofibromatosis 1 fibroblasts. We found that downregulation of the MMP1 protein was a key abnormal feature in the neurofibromatosis 1 fibroblasts and that the decreased MMP1 was restored by the lysosomal blockers CQ and HCQ, but not by the blockers of the Ras pathway. Moreover, the MMP1-upregulating activity of those lysosomal blockers was dependent on aryl hydrocarbon receptor (AHR) activation and ERK phosphorylation. Our findings suggest that lysosomal blockers are potential candidates for the treatment of Neurofibromatosis 1 neurofibroma.
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Duan J, Ma D, Wen X, Guo Q, Gao J, Zhang G, Xu K, Zhang L. Hydroxychloroquine prophylaxis for preeclampsia, hypertension and prematurity in pregnant patients with systemic lupus erythematosus: A meta-analysis. Lupus 2021; 30:1163-1174. [PMID: 33853420 DOI: 10.1177/09612033211007199] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES This meta-analysis aimed to evaluate the effectiveness of HCQ in improving the maternal and fetal outcomes in pregnancies with SLE. METHODS A literature search was conducted using PubMed, MEDLINE, EMBASE, and the Cochrane database for relevant English language articles, and Wanfang, CNKI and VIP for Chinese articles, from the databases' inception to April 30, 2020. These studies compared the maternal and/or fetal outcomes between pregnant patients with SLE who were administered HCQ during pregnancy (HCQ+ group) and those who were not administered HCQ (HCQ- group). Two investigators extracted the data and assessed the quality using the Newcastle-Ottawa Scale (NOS) and GRADE criteria independently. Odds ratio (OR) and 95% confidence intervals (CIs) were calculated. All statistical analyses were conducted using the Stata 12.0 software. RESULTS Nine studies involving 1132 pregnancies were included in the study (3 case controls, 2 prospective cohorts, 4 retrospective cohorts). Preeclampsia, gestational hypertension, and prematurity were significantly lower in the HCQ+ group than in the HCQ- group (OR 0.35, 95% CI 0.21-0.59), (OR 0.41, 95% CI 0.19-0.89) and (OR 0.55, 95% CI 0.36-0.86), respectively. There were no significant differences in the rates of HELLP Syndrome (OR 0.88, 95% CI 0.19-3.96), gestational diabetes (OR 2.3, 95% CI 0.44-12.12), thrombotic events (OR 0.26, 95% CI 0.05-1.51), spontaneous abortion (OR 1.77, 95% CI 0.96-3.26), premature rupture of membranes (OR 0.58, 95% CI 0.24-1.39), oligohydramnios (OR 0.90, 95% CI 0.38-2.14), live birth (OR 1.22, 95% CI 0.60-2.47), stillbirth (OR 1.00, 95% CI 0.50-2.00), congenital malformation (OR 0.53, 95% CI 0.14-2.04), low birth weight (OR 0.77, 95% CI 0.43-1.39), intrauterine distress (OR 1.07, 95% CI 0.41-2.76,), intrauterine growth restriction (OR 0.57, 95% CI 0.06-5.43), or five-minute APGAR score <7 (OR 0.72, 95% CI 0.20-2.58) between the two groups. CONCLUSIONS HCQ treatment during pregnancy could reduce the risk of preeclampsia, pregnancy hypertension and prematurity in SLE patients. The certainty of evidence is high but majority of the studies included are retrospective studies and not randomized controlled trials. Therefore, the multidisciplinary management of pregnant patients with SLE should promote HCQ use, irrespective of disease activity or severity.
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Affiliation(s)
- Jiaoniu Duan
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Taiyuan, China
| | - Dan Ma
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Taiyuan, China.,Tongji Shanxi Hospital, Tongji Medical College, Huazhong University of Science and Technology, Taiyuan, China
| | - Xiaoting Wen
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Taiyuan, China
| | - Qianyu Guo
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Taiyuan, China.,Tongji Shanxi Hospital, Tongji Medical College, Huazhong University of Science and Technology, Taiyuan, China
| | - Jinfang Gao
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Taiyuan, China.,Tongji Shanxi Hospital, Tongji Medical College, Huazhong University of Science and Technology, Taiyuan, China
| | - Gailian Zhang
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Taiyuan, China
| | - Ke Xu
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Taiyuan, China
| | - Liyun Zhang
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Taiyuan, China
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Bremme K, Honkanen S, Gunnarsson I, Chaireti R. The presence of lupus nephritis additionally increases the risk of preeclampsia among pregnant women with systemic lupus erythematosus. Lupus 2021; 30:1031-1038. [PMID: 33840282 PMCID: PMC8120629 DOI: 10.1177/09612033211004716] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Introduction Pregnant women with systematic lupus erythematosus (SLE) have an increased risk of obstetric complications, such as preeclampsia and premature births. Previous studies have suggested that renal involvement could further increase the risk for adverse obstetric outcomes. Aims: The aim of this study was to compare the obstetric outcomes in a Swedish cohort of patients with SLE with and without lupus nephritis (LN). Patients and methods The study was conducted as a retrospective observational study on 103 women with SLE, who gave birth at the Karolinska University Hospital between the years 2000-2017. Thirty-five women had previous or active LN and 68 women had non-renal lupus. Data was collected from digital medical records. The outcomes that were analysed included infants born small for gestational age (SGA), premature birth, preeclampsia, SLE- or nephritis flare and caesarean section. Results Women with LN, both with previous and with renal flare during pregnancy suffered from pre-eclampsia more often compared to women with non-renal lupus (25.7% vs 2.9%, p = 0.001) and this complication was associated with premature birth (p = 0.021) and caesarean section (p = 0.035). Conclusions Lupus nephritis is a significant risk factor for adverse obstetric outcomes in women with SLE, including preeclampsia. Those patients could benefit from more frequent antenatal controls and more vigorous follow-up.
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Affiliation(s)
- Katarina Bremme
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Division of Obstetrics and Gynaecology, Karolinska University Hospital, Stockholm, Sweden
| | - Sonja Honkanen
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Iva Gunnarsson
- Division of Rheumatology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden.,Division of Rheumatology, Karolinska University Hospital, Stockholm, Sweden
| | - Roza Chaireti
- Department of Molecular Medicine and Surgery, Karolinska Institute, Solna, Sweden.,Department of Hematology, Karolinska University Hospital, Stockholm, Sweden
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de Jesús GR, Lacerda MI, Rodrigues BC, Dos Santos FC, do Nascimento AP, Cristóvão Porto L, de Jesús NR, Levy RA, Klumb EM. Soluble Flt-1, Placental Growth Factor, and Vascular Endothelial Growth Factor Serum Levels to Differentiate Between Active Lupus Nephritis During Pregnancy and Preeclampsia. Arthritis Care Res (Hoboken) 2021; 73:717-721. [PMID: 32583963 DOI: 10.1002/acr.24360] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 05/13/2020] [Accepted: 06/16/2020] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To evaluate mean serum levels of vascular endothelial growth factor (VEGF), placental growth factor (PlGF), and soluble Flt-1 (sFlt-1) in pregnant patients with systemic lupus erythematosus (SLE) with inactive disease, active lupus nephritis, and preeclampsia for differential diagnosis between these conditions. METHODS Pregnant women with SLE, with singleton pregnancies and no other autoimmune diseases, were classified according to disease activity (inactive SLE and active lupus nephritis) and the presence of preeclampsia. Serum samples were collected within 3 weeks of delivery and frozen for subsequent blinded analysis through the enzyme-linked immunosorbent assay method. RESULTS A total of 71 women were included, with 41 classified as having inactive SLE (group 1; Systemic Lupus Erythematosus Pregnancy Disease Activity Index [SLEPDAI] score <4), 15 with a diagnosis of active lupus nephritis (group 2, SLEPDAI score ≥4, including renal criteria), and 15 with a diagnosis of preeclampsia (group 3). Patients in group 3 had higher mean levels of sFlt-1 and lower mean levels of PlGF compared to groups 1 and 2, both findings with statistical significance. The sFlt-1:PlGF ratio was also significantly higher in patients with preeclampsia, while mean VEGF levels were higher in pregnant woman with active lupus nephritis compared to patients with preeclampsia or inactive SLE. CONCLUSION Evaluation of serum VEGF, PlGF, and sFlt-1 levels can differentiate between preeclampsia, inactive SLE, and active lupus nephritis during pregnancy.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Evandro M Klumb
- Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
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Rato IR, Barbosa AR, Afonso DJ, Beça S. Catastrophic antiphospholipid syndrome presented as ruptured papillary muscle during puerperium in a patient with systemic lupus erythematosus. Lupus 2021; 30:1017-1021. [PMID: 33736518 DOI: 10.1177/09612033211002273] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Catastrophic antiphospholipid syndrome (CAPS) is a rare and serious phenomenon that requires prompt recognition and treatment. CASE PRESENTATION The authors present the case of a puerperal woman with systemic lupus erythematosus (SLE) admitted to the emergency room with headache, blurred vision, thoracic pain, and purpuric lesions on both ears. Echocardiogram revealed global decrease in left ventricular function while cardiac and inflammatory markers were elevated. Three days after admission she developed cardiogenic shock due to rupture of mitral papillary muscle which required emergent cardiac surgery, with replacement of the mitral valve; treatment with anticoagulation, high-dose glucocorticoids, and intravenous immunoglobulins were initiated. Cardiac and brain MRI revealed signs of ischemic lesions in both organs. Histopathology analysis of the placenta and papillary muscle showed signs of ischemia secondary to microvascular thrombosis. Based on the clinical demonstration of thrombosis in three organs, and the presence of lupus anticoagulant antibodies, a diagnosis of probable CAPS was established. CONCLUSION This case highlights the importance of a high level of suspicion of CAPS, particularly in patients with risk factors, and the value of immediate adequate treatment. Moreover, the rupture of a papillary muscle with histologically consistent signs of antiphospholipid syndrome expands the spectrum of involvement of this disease and should be considered as a rare but life-threatening possibility in patients with myocardial injury.
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Affiliation(s)
- Inês Rueff Rato
- Department of Internal Medicine, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Ana Rita Barbosa
- Department of Internal Medicine, Centro Hospitalar Baixo Vouga, Aveiro, Portugal
| | - David João Afonso
- Department of Anatomic Pathology, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Sara Beça
- Department of Internal Medicine, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
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Dörks M, Jobski K, Hoffmann F, Douros A. Global COVID-19 pandemic and reporting behavior - An analysis of the Food and Drug Administration adverse events reporting system. Pharmacoepidemiol Drug Saf 2021; 30:707-715. [PMID: 33650210 PMCID: PMC8012989 DOI: 10.1002/pds.5217] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 02/18/2021] [Indexed: 12/11/2022]
Abstract
PURPOSE To describe the characteristics of adverse event reporting in the United States (US) Food and Drug Administration Adverse Event Reporting System (FAERS) before and after the outbreak of the COVID-19 pandemic. METHODS We included all FAERS reports from the US and Canada from November 7, 2019 to July 15, 2020 and divided the study period into three equal time intervals (pre-pandemic, first pandemic, second pandemic). We focused on methotrexate, a broadly used drug unrelated to COVID-19, and (hydroxy)chloroquine, another broadly used drug implicated in COVID-19 treatment. Using descriptive statistics, we compared reporting characteristics before and after the COVID-19 outbreak. RESULTS During the study period, 366 998 cases (60% female, median age: 59 years) were submitted to FAERS. The daily median number of reports (1796 in the pre-pandemic, 1810 in the second pandemic time interval) and other characteristics remained stable. The daily median number of reports for methotrexate decreased from 28 in the pre-pandemic to 15 in the second pandemic time interval, with no considerable differences in other characteristics. The daily median number of reports for (hydroxy)chloroquine increased slightly from 1 in the pre-pandemic to 3 in the second pandemic time interval, while there were also changes in the demographics of cases and an increase in the proportion of cases reported by health professionals. CONCLUSIONS The overall reporting to FAERS did not change after the outbreak of the COVID-19 pandemic. However, some stimulated reporting was observed for (hydroxy)chloroquine, highlighting the need for caution when conducting pharmacovigilance analyses with substances related to COVID-19.
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Affiliation(s)
- Michael Dörks
- Department of Health Services Research, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Kathrin Jobski
- Department of Health Services Research, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Falk Hoffmann
- Department of Health Services Research, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Antonios Douros
- Departments of Medicine and Epidemiology, McGill University, Montreal, Quebec, Canada.,Centre for Clinical Epidemiology, Lady Davis Institute - Jewish General Hospital, Montreal, Quebec, Canada.,Institute of Clinical Pharmacology and Toxicology, Charité-Universitätsmedizin Berlin, Berlin, Germany
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50
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Taulaigo AV, Moschetti L, Ganhão S, Gerardi MC, Franceschini F, Tincani A, Andreoli L. Safety considerations when using drugs in pregnant patients with systemic lupus erythematosus. Expert Opin Drug Saf 2021; 20:523-536. [PMID: 33599570 DOI: 10.1080/14740338.2021.1893298] [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: 10/22/2022]
Abstract
Introduction: Systemic lupus erythematosus (SLE) mainly affects young females during childbearing age; therefore, reproductive issues are of major interest.Areas covered: Pregnancy planning is crucial to adjust the treatment toward drugs that are safe throughout pregnancy and breastfeeding. The evidence about drug safety is limited to post-marketing surveillance, registries, case series, and case reports, as pregnant patients are excluded from randomized clinical trials. The aim of this review is to report the safety considerations when treating pregnant SLE patients. Regarding maternal side effects of drugs, we focused on metabolic, infectious, and hemorrhagic complications. Fetal safety was analyzed looking at drugs teratogenicity, their possible effects on immune system, and on the long-term neuropsychological development of children.Expert opinion: The management of pregnancy in SLE has changed when knowledge about the safety of drugs has become available. Keeping SLE disease activity under control before, during and after pregnancy is of fundamental importance to ensure the best possible outcomes for mother and child. All these issues must be discussed with the patient and her family during preconception counseling. International efforts in terms of pregnancy registries and reproductive health guidelines help physicians improve their communication with SLE patients.
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Affiliation(s)
- Anna Viola Taulaigo
- Unidade De Doenças Auto-imunes/Medicina 7.2, Hospital Curry Cabral, Centro Hospitalar Universitário De Lisboa Central, Lisboa, Portugal
| | - Liala Moschetti
- Unit of Rheumatology and Clinical Immunology, ASST Spedali Civili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Sara Ganhão
- Rheumatology Department, Centro Hospitalar E Universitário De São João, Porto, Portugal
| | - Maria-Chiara Gerardi
- Unit of Rheumatology and Clinical Immunology, ASST Spedali Civili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Franco Franceschini
- Unit of Rheumatology and Clinical Immunology, ASST Spedali Civili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Angela Tincani
- Unit of Rheumatology and Clinical Immunology, ASST Spedali Civili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.,Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Laura Andreoli
- Unit of Rheumatology and Clinical Immunology, ASST Spedali Civili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
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