Quality of care predicts outcome in systemic lupus erythematosus: a cross-sectional analysis of a German long-term study (LuLa cohort)

Elucidating the mechanisms and efficacy of antimalarial drugs in Systemic lupus erythematosus

INTRODUCTION

Antimalarials (AMs) are old drugs with a wide range of beneficial effects in systemic lupus erythematosus (SLE) beyond the control of lupus activity, including protection against damage accrual and improved survival. Nowadays, hydroxychloroquine (HCQ) is considered the background therapy for every patient with SLE. Despite this well-proven long-term efficacy, 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, with special attention put on the pharmacokinetics, in order to better understand the conflicting results regarding HCQ dosing. Also, we have updated the beneficial and toxic effects of HCQ and also discussed 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 full-text articles, including 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, which are below 4 mg/kg/d for most patients, and also for the early combination therapy with mepacrine, used as an add-on drug, to assure a good control of SLE activity, and also a durable and safe use of these essential drugs for the management of SLE.

Use of Glucocorticoids in SLE: A Clinical Approach

Glucocorticoids (GCs) are one of the most effective first-line treatments for systemic lupus erythematosus (SLE). However, GC burden is associated with damage. The initial GC dose and tapering schedule should be tailored to the severity of the clinical scenario. As lupus therapy should prompt remission while minimising damage, recent guidelines recommend a more accurate approach to the use of GCs, setting lower starting doses and rapid tapering schemes, and encouraging maintenance prednisolone doses <5 mg/day. Methylprednisolone pulses (MP) help to reduce the dose of oral GCs and improve the clinical response in both severe and non-severe manifestations, without significant side effects. Fixed-tapering GC scheme provides a useful strategy to reduce GCs exposure. Long-term antimalarial treatment and early initiation of immunosuppressive drugs improve clinical efficacy while reducing GC toxicity. Besides, withdrawal of GCs is an achievable goal in patients in prolonged remission on stable treatment, and recent studies have attempted to identify the most suitable candidates. In this article, we review the pharmacological basis, clinical evidence of efficacy, dose-related harms, and potential withdrawal of GCs. We also review guidelines recommendations and finally give a personal and practical approach to dealing with the use of GCs in SLE patients.

Quality indicators and satisfaction with care in patients with systemic lupus erythematosus

Grading the quality of care in patients with systemic lupus erythematosus and determining its relationship with care satisfaction may recognize gaps that could lead to better clinical practice. Eighteen quality indicators (QIs) were recently developed and validated for patients with SLE based on the 2019 EULAR management recommendations. Few studies have analyzed the relationship between quality of care and care satisfaction in patients with lupus. This was a cross-sectional study. We included patients at least 18 years old who met the EULAR/ACR 2019 classification criteria for SLE. We interviewed patients and retrieved data from medical records to assess their compliance with a set of 18 EULAR-based QIs. We calculated each QI fulfillment as the proportion of fulfilled QI divided by the number of eligible patients for each indicator. Care satisfaction was evaluated with the satisfaction domain of LupusPRO version 1.7. Spearman correlation coefficient was used to determine the relationship between quality of care and care satisfaction. Seventy patients with a median age of 33 (IQR 23-48) were included, 90% were women. Overall adherence was 62.29%. The median care satisfaction was 100. Global adherence to the 18-QIs and the care satisfaction score revealed no correlation (r = 0.064, p = 0.599). Higher QI fulfillment was found in the group with remission versus the moderate-high activity group (p = 0.008). In our study, SLE patients in remission had higher fulfillment of quality indicators. We found no correlation between the quality of care and satisfaction with care.

Balancing risks and benefits in the use of hydroxychloroquine and glucocorticoids in systemic lupus erythematosus

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.

[Current patient care of systematic lupus erythematosus in Rhineland-Palatinate and Saarland]

BACKGROUND

Systemic lupus erythematosus (SLE) is a clinically heterogeneous autoimmune disease that is associated with great suffering for those affected, as well as high socioeconomic costs. Early diagnosis and adequate medical care are essential for a mild course of the disease. However, there is a lack of current figures and data on the care situation of patients in the area.

METHODOLOGY

A total of 1546 general practitioners, rheumatologists, neurologists, nephrologists and dermatologists in Rhineland-Palatinate and Saarland were interviewed by fax or mail using a questionnaire regarding epidemiology, symptoms, therapy and therapy success. In addition, there was the possibility of making suggestions for improvement.

RESULTS

Five out of six of the 635 reported SLE patients were female. The most common main symptoms were arthralgia, fatigue, myalgia, and skin changes. Of the patients, 68% received antimalarials (AMs), whereas 46% were treated with glucocorticoids (GCs) and 50% with an immunosuppressant (IS), mainly methotrexate. In terms of comorbidities, patients suffered mainly from cardiovascular disease, fibromyalgia syndrome and depression. Rheumatologists also frequently described anaemia, diabetes mellitus and osteoporosis.

DISCUSSION

Compared with guideline recommendations, the low rate of AMs in therapy was particularly striking in patients not treated by rheumatologists (35% on average compared with 81% for rheumatologists). Additionally, (sustained) high doses of GCs are not in line with literature recommendations. In the free text field, the main requests were for more rheumatologists in private practice and faster appointment scheduling, as well as better communication and networking. In addition, the desire for more training and education was frequently expressed..

Nationwide patterns of hydroxychloroquine dosing and monitoring of retinal toxicity in patients with systemic lupus erythematosus

This study identified trends in hydroxychloroquine (HCQ) prescription and retinopathy screening in patients with systemic lupus erythematosus (SLE) according to clinical practice guidelines to minimise the risk of HCQ retinopathy. We used data from patients diagnosed with SLE between 2004 and 2019 from the National Health Insurance Service in Korea. To assess trends of daily dose per actual body weight (ABW), we performed an interrupted time-series analysis and identified effects after revision of guidelines. Among 38,973 patients with SLE, 28,415 (72.9%) were prescribed HCQ from 2004 to 2019. The proportion of patients using HCQ among SLE patients was 63% in 2004 and increased to 76% in 2019. The median daily dose per ABW for HCQ users decreased from 5.88 mg/kg in 2004 to 3.98 mg/kg in 2019, and from 5.45 mg/kg in 2005 to 4.17 mg/kg in 2019 for HCQ new users. The annual implementation rate of screening tests among HCQ new users increased from 3.5% in 2006 to 22.5% in 2019. Study results indicated that HCQ dosing management was adequate based on the revised guidelines. Although the implementation rate of retinal screening has increased, it is necessary to enhance awareness of retinal screening in clinical settings.

Does higher quality of care in systemic lupus erythematosus translate to better patient outcomes?

PURPOSE

To assess if high quality of care (QOC) in SLE results in improved outcomes of quality of life (QOL) and non-routine health care utilization (HCU).

METHODS

One hundred and forty consecutive SLE patients were recruited from the Rheumatology clinic at an academic center. Data on QOC and QOL were collected along with demographics, socio-economic, and disease characteristics at baseline. LupusPRO assessing health-related (HR) QOL and non (N)HRQOL was utilized. Follow up QOL and HCU were collected prospectively at 6 months. High QOC was defined as those meeting ≥80% of the eligible quality indicators. Univariate and multivariate regression analyses were performed with QOC and high QOC as independent variables and HRQOL and NHRQOL as dependent variables at baseline and follow up. Multivariable models were adjusted for demographics and disease characteristics. Secondary outcomes included non-routine HCU and disease activity at follow up.

RESULTS

Baseline and follow up data on 140 and 94 patients, respectively, were analyzed. Mean (SD) performance rate (QOC) was 78.6 (13.4) with 52% patients in the high QOC group. QOC was associated with better NHRQOL at baseline and follow up but not with HRQOL. Of all the NHRQOL domains, QOC was positively associated with treatment satisfaction. QOC or high QOC were not associated with non-routine HCU and were instead associated with higher disease activity at follow up.

CONCLUSION

Higher QOC predicted better NHRQOL by directly impacting treatment satisfaction in SLE patients in this cohort. Higher QOC, however, was not associated with HRQOL, HCU, or improvement in disease activity at follow up.

A survey of systemic lupus erythematosus patients' attitudes toward influenza and pneumococcal vaccination in Southwest China

Introduction

Vaccination is the most effective measure for prevention against infectious diseases in patients with systemic lupus erythematosus (SLE). Therefore, it is important to know SLE patients' attitudes toward influenza and pneumococcal vaccination. This study aimed to investigate the attitude toward influenza and pneumococcal vaccination among SLE patients in Southwest China and its influencing factors.

Methods

A web-based questionnaire was conducted to collect data regarding SLE patients' demographics, history of infections, medications, comorbidities, attitudes toward infection and vaccination, rates of influenza and pneumococcal vaccination, and role of health professionals in promoting vaccination. Univariate and multivariate logistic regression analyses were conducted to assess the vaccination willingness-associated factors.

Results

A total of 251 patients participated in the survey and 240 questionnaires were completed and statistically analyzed. The influenza and pneumococcal vaccination rates were 8.3 and 1.7%, respectively. The top three reasons for non-vaccination were worrying about the SLE exacerbation or flare resulting from the vaccine or its adjuvants, being concerned about adverse events, and the lack of awareness of vaccine availability. More than half of the participants were willing to be vaccinated against influenza (56.2%) and pneumococcus (52.9%). Factors associated to the willingness to receive the influenza vaccine and pneumococcal vaccine were being afraid of infection, believing in the efficacy of influenza vaccination, lower family income, less perceived care from family members, perceived susceptibility to pneumococcal infection, and perceiving influenza and pneumococcal vaccination as beneficial for health.

Conclusions

The influenza and pneumococcal vaccination rates are low among SLE patients in Southwest China. The positive perspective of vaccination on health represented the most impacting factor on their willingness to undergo influenza and pneumococcal vaccination. Non-vaccinated patients were mainly concerned about exacerbation of the disease or adverse events caused by vaccines. It is important to improve the compliance with the guideline-recommended roles of health professionals and to promote the collaboration between rheumatology and primary care teams.

Why lupus patients discontinue antimalarials in real life: A 50 years-experience from a reference centre

Background

Because of the efficacy and good safety profile of antimalarials in systemic lupus erythematosus (SLE), hydroxychloroquine (HCQ) is currently recommended in all SLE patients. However, patients’ compliance was reported as suboptimal. This study aims to elucidate the reasons for discontinuing antimalarials in a large series of SLE patients followed in a single centre during the last 50 years.

Material and methods

Among all patients diagnosed between 1968 and 2017 at our reference centre, retrospective data were obtained from electronic medical records of SLE patients consecutively visited during 2015–2017 and controlled for at least 1 year. Demographic, clinical, laboratory and therapeutic data at disease onset and during the follow-up in the whole cohort and differences between SLE patients discontinuing and continuing on antimalarials were analysed.

Results

Five-hundred thirty-nine patients followed during a median of 19 years were analysed. Median age at disease diagnosis was 29 years and 91.8% were women. Antimalarials were initiated by 521 (96.7%) patients and 18 (3.3%) cases did not start them mainly because of a quiescent or life-threatening SLE disease. In the 129 (24.7%) patients starting antimalarials with subsequent discontinuation, median treatment duration was 8.4 years. The main reason leading to treatment cessation was drug toxicity in 97 (18.6%) patients, of which macular toxicity was the most frequent adverse effect (n = 80; 15.3%). Treatment was stopped because of patient’s preference in 13 (2.5%) cases. The factors independently associated with antimalarial discontinuation were age at the end of follow-up (OR 1.130, 95% CI 1.005–1.269, p = 0.040), duration on antimalarials (OR 0.872, 95% CI 0.841–0.903, p < 0.001), presence of hepatitis C virus infection (HCV) (OR 13.948, 95% CI 1.321–147.324, p = 0.028) and anti-β2-glycoprotein 1 antibodies (OR 2.275, 95% CI 1.146–4.517, p = 0.019).

Conclusions

In our 50 years-experience, almost all SLE patients underwent antimalarials. These drugs are usually stopped because of adverse effects, particularly macular toxicity. After a long-term follow-up, patients’ compliance to antimalarials was considerably high in our SLE patients.

Association of clinic setting with quality indicator performance in systemic lupus erythematosus: a cross-sectional study

BACKGROUND

Healthcare quality for systemic lupus erythematosus (SLE) is a modifiable target for improving patient outcomes. We aimed to assess the quality of care processes in different clinic settings, comparing a subspecialty lupus clinic with hospital-based and private general rheumatology clinics.

METHODS

Patients with SLE (n = 258) were recruited in 2016 from a subspecialty lupus clinic (n = 147), two hospital general rheumatology clinics (n = 56) and two private rheumatology clinics (n = 55). Data were collected from medical records and patient questionnaires. Quality of care was assessed using 31 validated SLE quality indicators (QI) encompassing diagnostic work-up, disease and comorbidity assessments, drug monitoring, preventative care and reproductive health. Per-QI performance was measured as a percentage of patients that met the QI relative to the number of patients eligible. Per-patient QI performance was calculated as a percentage of QIs met relative to the number of eligible QIs for each patient. Per-QI and per-patient QI performance were compared between the three clinic settings, and multiple regression performed to adjust for sociodemographic, disease and healthcare factors.

RESULTS

Per-QI performance was generally high across all clinic settings for diagnostic work-up, comorbidity assessment, lupus nephritis, drug monitoring, prednisolone taper, osteoporosis and pregnancy care. Median [IQR] per-patient performance on eligible QIs was higher in the subspeciality lupus clinic (66.7% [57.1-74.1]) than the hospital general rheumatology (52.7% [47.5-58.1]) and private rheumatology (50.0% [42.9-60.9]) clinics (p <0.001) and the difference remained significant after multivariable adjustment. The subspecialty lupus clinic recorded higher per-QI performance for documentation of disease activity, disease damage, cardiovascular risk factor and drug toxicity assessments, pre-immunosuppression hepatitis and tuberculosis screening, new medication counselling, vaccinations, sun avoidance education and contraception counselling.

CONCLUSIONS

SLE patients managed in a subspecialty lupus clinic recorded higher per-patient QI performance compared to hospital general rheumatology and private rheumatology clinics, in part related to better documentation on certain QIs.

Associations between quality of health care and clinical outcomes in patients with rheumatic and musculoskeletal diseases: a rehabilitation cohort study

BACKGROUND

The quality of provided health care may be an important source of variation in rehabilitation outcomes, increasing the interest in associations between quality indicators (QIs) and improved patient outcomes. Therefore, we examined the associations between the quality of rehabilitation processes and subsequent clinical outcomes among patients with rheumatic and musculoskeletal diseases (RMDs).

METHODS

In this multicentre prospective cohort study, adults with RMDs undergoing multidisciplinary rehabilitation at eight participating centres reported the quality of rehabilitation after 2 months and outcomes after 2, 7, and 12 months. We measured perceived quality of rehabilitation by 11 process indicators that cover the domains of initial assessments, patient participation and individual goal-setting, and individual follow-up and coordination across levels of health care. The patients responded "yes" or "no" to each indicator. Scores were calculated as pass rates (PRs) from 0 to 100% (best score). Clinical outcomes were goal attainment (Patient-Specific Functional Scale), physical function (30 s sit-to-stand test), and health-related quality of life (EuroQoL 5D-5L). Associations between patient-reported quality of care and each outcome measure at 7 months was analysed by linear mixed models.

RESULTS

A total of 293 patients were enrolled in this study (mean age 52 years, 76% female). Primary diagnoses were inflammatory rheumatic disease (64%), fibromyalgia syndrome (18%), unspecific neck, shoulder, or low back pain (8%), connective tissue disease (6%), and osteoarthritis (4%). The overall median PR for the process indicators was 73% (range 11-100%). The PR was lowest (median 40%) for individual follow-up and coordination across levels of care. The mixed model analyses showed that higher PRs for the process indicators were not associated with improved goal attainment or improved physical function or improved health-related quality of life.

CONCLUSIONS

The quality of rehabilitation processes was not associated with important clinical outcomes. An implication of this is that measuring only the outcome dimension of quality may result in incomplete evaluation and monitoring of the quality of care, and we suggest using information from both the structure, process, and outcome dimensions to draw inferences about the quality, and plan future quality initiatives in the field of complex rehabilitation.

TRIAL REGISTRATION

The study is part of the larger BRIDGE trial (ClinicalTrials.gov NCT03102814 ).

Relationship between care model and disease activity states and health-related quality of life in systemic lupus erythematosus patients

OBJECTIVE

To assess whether the care model (comprehensive vs regular) has any impact on the clinical outcomes of systemic lupus erythematosus patients.

METHODS

Between August 2019 and January 2020, we evaluated SLE patients being cared for at two Peruvian hospitals to define the impact of care model on disease activity state and health-related quality of life (HRQoL). Disease activity was ascertained with the SLEDAI-2K and the Physician Global Assessment (PGA) which allows to define Lupus Low Disease Activity State (LLDAS) and Remission. HRQoL was measured with the LupusQoL. The association between care model and disease activity (Remission and LLDAS) state was examined using a binary logistic regression model. The association with HRQoL was examined with a linear regression model. All multivariable analyses were adjusted for possible confounders.

RESULTS

266 SLE patients were included, 227 from the comprehensive care model and 39 from the regular care model. The regular care model was associated with a lower probability of achieving remission (OR 0.381; CI: 95% 0.163-0.887) and LLDAS (OR 0.363; CI: 95% 0.157-0.835). Regular care was associated with a better HRQoL in two domains (pain and emotional health). We found no association between the care model and the other HRQoL domains.

CONCLUSION

A comprehensive care model was associated with the probability of achieving remission and LLDAS but had no apparent impact on the patients' HRQoL.

Factors detrimental to work productivity and daily activities in systemic lupus erythematosus patients - Analysis of the German LuLa study

OBJECTIVE

The aim of this study was to identify factors associated with impaired work productivity and impaired daily activities in patients with systemic lupus erythematosus (SLE).

METHODS

The LuLa study is a longitudinal patient-reported study. Beyond sociodemographic data, work productivity, daily activities and fatigue, several other clinical outcome parameters (e.g. mental health-related quality of life and physical functioning, disease activity, damage and pain) were surveyed with validated questionnaires. The effects of confounders on work productivity (WPAI 2) and daily activity domains (WPAI 4) were studied by multivariate regression analysis.

RESULTS

A total of 585 patients completed the questionnaire of whom 259 were employed and analysed. The median impairment in work productivity (WPAI 2) was 20% (Q1-3 0-40), and the median impairment in daily activities (WPAI 4) was 30% (Q1-3 10-50%). Multivariate regression analysis revealed that fatigue, pain, disease activity and health-related quality of life affected WPAI 2 and 4. Furthermore, we observed distinct synergistic effects of fatigue, disease activity and pain on both work productivity and daily activities: a higher impact of fatigue was associated with the reported extent of pain or disease activity.

CONCLUSION

In employed patients with SLE, impaired work productivity and impaired daily activities were frequently reported. Fatigue, pain, disease activity and health-related quality of life demonstrated a detrimental impact, with a synergistic effect of fatigue, disease activity and pain. Hence, both optimized pain management and targeted immunomodulatory therapy are important for preserving active participation in life among patients with fatigue.

The PICASO cloud platform for improved holistic care in rheumatoid arthritis treatment-experiences of patients and clinicians

Background

Multimorbidity raises the number of essential information needed for delivery of high-quality care in patients with chronic diseases like rheumatoid arthritis (RA). We evaluated an innovative ICT platform for integrated care which orchestrates data from various health care providers to optimize care management processes.

Methods

The Horizon2020-funded research project PICASO (picaso-project.eu) established an ICT platform that offers integration of care services across providers and supports patients’ management along the continuum of care, leaving the data with the owner. Strict conformity with ethical and legal legislations was augmented with a usability-driven engineering process, user requirements gathering from relevant stakeholders, and expert walkthroughs guided developments. Developments based on the HL7/FHIR standard granting interoperability. Platform’s applicability in clinical routine was an essential aim. Thus, we evaluated the platform according to an evaluation framework in an observational 6-month proof-of-concept study with RA patients affected by cardiovascular comorbidities using questionnaires, interviews, and platform data.

Results

Thirty RA patients (80% female) participated, mean age 59 years, disease duration 13 years, average number of comorbidities 2.9. Home monitoring data demonstrated high platform adherence. Evaluations yielded predominantly positive feedback: The innovative dashboard-like design offering time-efficient data visualization, comprehension, and personalization was well accepted, i.e., patients rated the platform “overall” as 2.3 (1.1) (mean (SD), Likert scales 1–6) and clinicians recommended further platform use for 93% of their patients. They managed 86% of patients’ visits using the clinician dashboard. Dashboards were valued for a broader view of health status and patient-physician interactions. Platform use contributed to improved disease and comorbidity management (i.e., in 70% physicians reported usefulness to assess patients’ diseases and in 33% potential influence on treatment decisions; risk manager was used in 59%) and empowered patients (i.e., 48% set themselves new health-related goals, 92% stated easier patient-physician communications).

Conclusion

Comprehensive aggregation of clinical data from distributed sources in a modern, GDPR-compliant cloud platform can improve physicians’ and patients’ knowledge of the disease status and comorbidities as well as patients’ management. It empowers patients to monitor and positively contribute to their disease management. Effects on patients’ outcome, behavior, and changes in the health care systems should be explored by implementing ICT-based platforms enriched by upcoming Artificial Intelligence features where possible.

Trial registration

DRKS—German Clinical Trials Register, DRKS00013637, prospectively registered. 17 January 2018.

Delayed diagnosis adversely affects outcome in systemic lupus erythematosus: Cross sectional analysis of the LuLa cohort

Objective

Despite increased physician’s awareness and improved diagnostic and serological testing in the recent years, the interval between the initial symptoms and the diagnosis of Systemic lupus erythematosus (SLE) is still very long. Our aim was to study this delay and its association to the outcome of the disease.

Methods

Information on demographics, onset of first symptoms, first physicians visit and time of diagnosis was assessed by self-reported questionnaires among SLE patients in Germany (LuLa cohort, n = 585) in the year 2012. Disease activity (Systemic Lupus Activity Questionnaire; SLAQ), disease related damage (Brief Index of Lupus Damage; BILD), health related quality of life (Short Form 12) and fatigue (FSS) were chosen as proxies for outcome. Linear regression analysis was used to analyze the association of the delay in diagnosis to the outcome, adjusted for age, disease duration and sex.

Results

Mean duration between the onset of symptoms and the diagnosis of SLE was 47 months (SD 73). The longer the time to diagnosis, the higher the disease activity (β = 0.199, p < 0.0001), the disease-related damage (β = 0.137, p = 0.002) and fatigue (β 0.145, p = 0.003) and the lower the health-related quality of life (physical β = −0.136, p = 0.004, mental β = −0.143, p = 0.004).

Conclusion

In systemic lupus erythematosus, longer time to diagnosis was associated with worse outcome. Concepts in care with the intention to shorten the time to diagnosis are needed to improve the long-term outcome of the disease.

Update on antimalarials and systemic lupus erythematosus

PURPOSE OF REVIEW

The purpose of this review is highlighting the most recent evidence on the clinical efficacy and toxicity of antimalarials in systemic lupus erythematosus (SLE).

RECENT FINDINGS

New data confirm the effects of antimalarials in preventing SLE activity, damage and infections and in decreasing mortality. An important reduction in use of health resources is related to continued antimalarial use. Hydroxychloroquine (HCQ) may prevent preeclampsia in pregnant women with SLE. HCQ ocular toxicity is infrequent and could be associated with blood levels. Gastrointestinal and skin toxicity are underrecognized and could influence adherence. Prolongation of QT interval is extremely unusual with HCQ. Doses of HCQ of 200 mg/day seem to offer a good efficacy/toxicity balance. HCQ protection against herpes zoster and Pneumocystis jirovecii infection has been shown. On the contrary, HCQ prescription by doctors and adherence by patients are both under recommended standards. The recent coronavirus disease 2019 pandemic has resulted in a significant shortage of HCQ in many countries with possible consequences in the correct treatment of lupus patients.

SUMMARY

Recent evidence reinforces the central role of HCQ in SLE therapy. The reduction in activity, damage accrual and mortality is consistent across studies, countries and ethnical groups. On the contrary, and despite the well established beneficial effects of prolonged regular HCQ therapy, many SLE patients do never take this drug or it is eventually stopped in the setting of severe flares, pregnancy or presumed toxicity. Every effort must be made to assure the correct prescription of HCQ and not to withdraw the drug unless unequivocal signs of toxicity are present.

Use of Quality Measures to Identify Disparities in Health Care for Systemic Lupus Erythematosus

Assessment of quality of care for people with systemic lupus erythematosus (SLE) provides opportunities to identify gaps in health care and address disparities. Poor access to specialty care has been shown to negatively impact care in SLE and is associated with poor disease outcomes. Racial/ethnic minorities and those with low socioeconomic status are at higher risk for poor access and lower quality of care. Quality measures evaluating processes of care have shown significant deficiencies in care of SLE patients across studies. High SLE patient volume correlates with better quality of care for providers in hospital and ambulatory settings.