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SCUCCIMARRI ROSIE, SUTTON EVELYN, FITZCHARLES MARYANN. Hydroxychloroquine: A Potential Ethical Dilemma for Rheumatologists during the COVID-19 Pandemic. J Rheumatol 2020; 47:783-786. [DOI: 10.3899/jrheum.200369] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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de Moreuil C, Alavi Z, Pasquier E. Hydroxychloroquine may be beneficial in preeclampsia and recurrent miscarriage. Br J Clin Pharmacol 2020; 86:39-49. [PMID: 31633823 PMCID: PMC6983516 DOI: 10.1111/bcp.14131] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 08/30/2019] [Accepted: 09/05/2019] [Indexed: 02/06/2023] Open
Abstract
Recurrent miscarriage (RM) and vasculoplacental disorders, such as preeclampsia (PE), affect women of childbearing age worldwide. Vascular endothelial dysfunction and immunological impairment are associated with both RM and PE. To date, there is no effective or optimal therapeutic approach for these conditions. Notably, aspirin use is only partially effective in the prevention of PE. Hydroxychloroquine (HCQ) has demonstrated beneficial effects on disease flares, pregnancy outcomes and cardiovascular impairment in systemic erythaematosus lupus (SLE) through its immunomodulatory, vasculoprotective and antithrombotic properties. Here, in the context of the underlying physiological dysregulation associated with PE and RM, the beneficial properties and potential therapeutic efficacy of HCQ are reviewed in anticipation of the results of current and future trials. Two related trials addressing RM in the absence of maternal autoimmune disease are ongoing. Other trials addressing pregnancy outcomes in the presence of maternal autoimmune disease are forthcoming. In this review, we hypothesise that the immunological and endothelial effects of HCQ may be beneficial in the context of PE and RM, regardless of the maternal autoimmune status.
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Affiliation(s)
- Claire de Moreuil
- EA 3878, Groupe d'Etude de la Thrombose de Bretagne OccidentaleBrestFrance
- Département de médecine interne et pneumologieCHRU de Brest, Hôpital de la Cavale BlancheBrestFrance
| | - Zarrin Alavi
- INSERM, Centre d'Investigation Clinique – 1412, CHRU de BrestBrestFrance
| | - Elisabeth Pasquier
- EA 3878, Groupe d'Etude de la Thrombose de Bretagne OccidentaleBrestFrance
- Département de médecine interne et pneumologieCHRU de Brest, Hôpital de la Cavale BlancheBrestFrance
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Braslow RA, Shiloach M, Macsai MS. Adherence to Hydroxychloroquine Dosing Guidelines by Rheumatologists. Ophthalmology 2017; 124:604-608. [DOI: 10.1016/j.ophtha.2016.12.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 12/15/2016] [Accepted: 12/16/2016] [Indexed: 12/01/2022] Open
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Abd Rahman R, DeKoninck P, Murthi P, Wallace EM. Treatment of preeclampsia with hydroxychloroquine: a review. J Matern Fetal Neonatal Med 2017; 31:525-529. [DOI: 10.1080/14767058.2017.1289511] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Rahana Abd Rahman
- Department of Obstetrics and Gynecology, Faculty of Medicine, National University of Malaysia, Kuala Lumpur, Malaysia
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - Philip DeKoninck
- Department of Medicine, School of Clinical Sciences, Monash University, Monash Medical Centre, Clayton, Victoria, Australia
| | - Padma Murthi
- Department of Medicine, School of Clinical Sciences, Monash University, Monash Medical Centre, Clayton, Victoria, Australia
| | - Euan M. Wallace
- Department of Medicine, School of Clinical Sciences, Monash University, Monash Medical Centre, Clayton, Victoria, Australia
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
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Magro-Checa C, Zirkzee EJ, Huizinga TW, Steup-Beekman GM. Management of Neuropsychiatric Systemic Lupus Erythematosus: Current Approaches and Future Perspectives. Drugs 2016; 76:459-83. [PMID: 26809245 PMCID: PMC4791452 DOI: 10.1007/s40265-015-0534-3] [Citation(s) in RCA: 110] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Neuropsychiatric systemic lupus erythematosus (NPSLE) is a generic definition referring to a series of neurological and psychiatric symptoms directly related to systemic lupus erythematosus (SLE). NPSLE includes heterogeneous and rare neuropsychiatric (NP) manifestations involving both the central and peripheral nervous system. Due to the lack of a gold standard, the attribution of NP symptoms to SLE represents a clinical challenge that obligates the strict exclusion of any other potential cause. In the acute setting, management of these patients does not differ from other non-SLE subjects presenting with the same NP manifestation. Afterwards, an individualized therapeutic strategy, depending on the presenting manifestation and severity of symptoms, must be started. Clinical trials in NPSLE are scarce and most of the data are extracted from case series and case reports. High-dose glucocorticoids and intravenous cyclophosphamide remain the cornerstone for patients with severe symptoms that are thought to reflect inflammation or an underlying autoimmune process. Rituximab, intravenous immunoglobulins, or plasmapheresis may be used if response is not achieved. When patients present with mild to moderate NP manifestations, or when maintenance therapy is warranted, azathioprine and mycophenolate may be considered. When symptoms are thought to reflect a thrombotic underlying process, anticoagulation and antiplatelet agents are the mainstay of therapy, especially if antiphospholipid antibodies or antiphospholipid syndrome are present. Recent trials on SLE using new biologicals, based on newly understood SLE mechanisms, have shown promising results. Based on what we currently know about its pathogenesis, it is tempting to speculate how these new therapies may affect the management of NPSLE patients. This article provides a comprehensive and critical review of the literature on the epidemiology, pathophysiology, diagnosis, and management of NPSLE. We describe the most common pharmacological treatments used in NPSLE, based on both a literature search and our expert opinion. The extent to which new drugs in the advanced development of SLE, or the blockade of new targets, may impact future treatment of NPSLE will also be discussed.
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Affiliation(s)
- César Magro-Checa
- Department of Rheumatology, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands
| | - Elisabeth J Zirkzee
- Department of Rheumatology, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands.,Department of Rheumatology, Maasstad Hospital, Rotterdam, The Netherlands
| | - Tom W Huizinga
- Department of Rheumatology, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands
| | - Gerda M Steup-Beekman
- Department of Rheumatology, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands.
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Abstract
Systemic lupus erythematosus (SLE) is a rare, severe, multisystem autoimmune disorder. Childhood-onset SLE (cSLE) follows a more aggressive course with greater associated morbidity and mortality than adult-onset SLE. Its aetiology is yet to be fully elucidated. It is recognised to be the archetypal systemic autoimmune disease, arising from a complex interaction between the innate and adaptive immune systems. Its complexity is reflected by the fact that there has been only one new drug licensed for use in SLE in the last 50 years. However, biologic agents that specifically target aspects of the immune system are emerging. Immunosuppression remains the cornerstone of medical management, with glucocorticoids still playing a leading role. Treatment choices are led by disease severity. Immunosuppressants, including azathioprine and methotrexate, are used in mild to moderate manifestations. Mycophenolate mofetil is widely used for lupus nephritis. Cyclophosphamide remains the first-line treatment for patients with severe organ disease. No biologic therapies have yet been approved for cSLE, although they are being used increasingly as part of routine care of patients with severe lupus nephritis or with neurological and/or haematological involvement. Drugs influencing B cell survival, including belimumab and rituximab, are currently undergoing clinical trials in cSLE. Hydroxychloroquine is indicated for disease manifestations of all severities and can be used as monotherapy in mild disease. However, the management of cSLE is hampered by the lack of a robust evidence base. To date, it has been principally guided by best-practice guidelines, retrospective case series and adapted adult protocols. In this pharmacological review, we provide an overview of current practice for the management of cSLE, together with recent advances in new therapies, including biologic agents.
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Ding HJ, Denniston AK, Rao VK, Gordon C. Hydroxychloroquine-related retinal toxicity. Rheumatology (Oxford) 2015; 55:957-67. [PMID: 26428520 DOI: 10.1093/rheumatology/kev357] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Indexed: 11/12/2022] Open
Abstract
HCQ is widely used for the treatment of rheumatic diseases, particularly lupus and RA. It is generally well tolerated, but retinopathy is a concern. Retinopathy is rare, but is sight threatening, generally irreversible and may progress even after cessation of therapy. Damage may be subclinical. Although a number of risk factors have been proposed (such as duration of therapy and cumulative dose), the many exceptions (e.g. retinopathy on low-dose HCQ, or no retinopathy after a very large cumulative dose of HCQ) highlight our limited understanding of the disease process. Novel technologies such as optical coherence tomography (OCT), fundus autofluorescence (FAF) and multifocal electroretinogram (mfERG) may provide the earliest structural and functional evidence of toxicity in these stages. Along with the well-established technique of central visual field testing (10-2 visual fields), these modalities are increasingly being used as part of screening programmes. The ideal single test with high sensitivity and high specificity for HCQ retinopathy has still not been achieved. Screening for HCQ retinopathy remains an area of considerable debate, including issues of when, who and how to screen. Commonly accepted risk factors include receiving >6.5 mg/kg/day or a cumulative dose of >1000 g of HCQ, being on treatment for >5 years, having renal or liver dysfunction, having pre-existing retinopathy and being elderly. HCQ continues to be a valuable drug in treating rheumatic disease, but clinicians need to be aware of the associated risks and to have arrangements in place that would enable early detection of toxicity.
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Affiliation(s)
- Hui Jen Ding
- Department of Medicine, Putrajaya Hospital, Putrajaya, Malaysia, Rheumatology Research Group, School of Immunity and Infection, College of Medical and Dental Sciences, The Medical School, University of Birmingham
| | - Alastair K Denniston
- Ophthalmology Department, University Hospitals Birmingham NHS Trust, Queen Elizabeth Hospital Birmingham, Centre for Translational Inflammation Research, College of Medical and Dental Sciences, The Medical School, University of Birmingham and
| | - Vijay K Rao
- Rheumatology Research Group, School of Immunity and Infection, College of Medical and Dental Sciences, The Medical School, University of Birmingham
| | - Caroline Gordon
- Rheumatology Research Group, School of Immunity and Infection, College of Medical and Dental Sciences, The Medical School, University of Birmingham, Department of Rheumatology, City Hospital, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
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Rainsford KD, Parke AL, Clifford-Rashotte M, Kean WF. Therapy and pharmacological properties of hydroxychloroquine and chloroquine in treatment of systemic lupus erythematosus, rheumatoid arthritis and related diseases. Inflammopharmacology 2015; 23:231-69. [PMID: 26246395 DOI: 10.1007/s10787-015-0239-y] [Citation(s) in RCA: 349] [Impact Index Per Article: 38.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Accepted: 06/23/2015] [Indexed: 12/15/2022]
Abstract
OBJECTIVES This review examines the pharmacokinetics, modes of action and therapeutic properties of the anti-malarial drugs, hydroxychloroquine (HCQ) and chloroquine (CQ), in the treatment of systemic lupus erythematosus (SLE), rheumatoid arthritis (RA) and related conditions, as well as osteoarthritis (OA). KEY FINDINGS Both HCQ and CQ have historically been employed successfully for the treatment of SLE and RA for over 70 years. HCQ has been used extensively for SLE where it has a good reputation for controlling the dermatological complications in SLE. It has also been reported to effectively control the symptoms of Sjøgren's syndrome, as well as preventing thrombosis in phospholipid antibody (aPL) syndrome. In RA and SLE, HCQ is preferred because of the lower incidence of gastrointestinal adverse reactions compared with CQ and it might have a lower risk of ocular adverse reactions. There is increasing evidence that HCQ may reduce atherosclerosis and risks of cardiovascular disease in rheumatic patients. Both HCQ and CQ have been shown to improve glycaemia and reduce the risks of type II diabetes mellitus. Although both HCQ and CQ are effective in low-moderate RA, HCQ is now preferred as part of combination therapy for more severe disease. The advantages of combination therapy are that the doses of the individual drugs may be lowered so reducing adverse reactions. Both HCQ and CQ are diastereoisomers, have basic properties and are given as the sulphate and phosphate salts. While being relatively well absorbed orally and with good bioavailability, they have long and variable plasma terminal elimination half-lives (approximately 40-60 days). This reflects their high volume of distribution, V D (HCQ 44,000L; CQ 65,000L) which extends into aqueous compartments, long mean residence time (HCQ 1300 h; CQ 900 h) and with about half the drugs (metabolites) undergoing renal clearance. The strong binding to melanin reflects the ocular injury and dermatological properties of these drugs. The consensus is that the occurrence of ocular adverse reactions can be minimised by close attention to the dose (which should be set on a body weight basis) with regular (e.g. quarterly) retinal examination. Although HCQ and CQ can pass through the placenta, the use of these drugs during pregnancy does not appear to risk harm to the baby and might be beneficial to the mother with SLE and her child by controlling the SLE disease activity, which is known to be an important factor affecting pregnancy outcome. The modes of action of HCQ and CQ in these arthritides represent somewhat of an enigma. Undoubtedly, these drugs have multiple actions related, in part, their ability to accumulate in lysosomes and autophagosomes of phagocytic cells as well as affecting MHC Class II expression and antigen presentation; actions of the production of pro-inflammatory cytokines [e.g. interleukin-1 (IL-1) tumour necrosis factor-α (TNFα)]; control of toll-like receptor-9 activation; and leucocyte generation of reactive oxygen species (ROS); i.e. antioxidant activity. The actions of these drugs on T and B cells are less clear but may depend on these leucocyte-mediated actions. Anti-malarials also protect against cytokine-mediated cartilage resorption. This and other actions may underlie the potential benefits in treating OA. The exact relationships of these various actions, mostly determined in vitro, have not been specifically defined in vivo or ex vivo in relation to clinical efficacy. OUTCOMES HCQ and CQ have a good reputation for being effective and relatively safe treatments in SLE, mild-moderate RA and Sjøgren's syndrome. There is need for (a) more information on their mode of action in relation to the control of these diseases, (b) scope for developing formulations that have improved pharmacokinetic and therapeutic properties and safety, and (c) further exploring their use in drug combinations not only with other disease modifying agents but also with biologics.
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Affiliation(s)
- K D Rainsford
- Biomedical Research Centre, Sheffield Hallam University, Howard Street, Sheffield, S1 1WB, UK
| | - Ann L Parke
- Department of Rheumatology, St Francis Hospital and Medical Center, Hartford, CT, 06105, USA
| | | | - W F Kean
- Department of Medicine (Rheumatology), McMaster University Faculty of Health Sciences, Hamilton, ON, L8S 4K9, Canada.
- Department of Medicine (Rheumatology), McMaster University Faculty of Health Sciences, Suite #708, 1 Young Street, Hamilton, ON, L8N 1T8, Canada.
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Bailey K, McKee D, Wismer J, Shear N. Acute generalized exanthematous pustulosis induced by hydroxychloroquine: first case report in Canada and review of the literature. J Cutan Med Surg 2014; 17:414-8. [PMID: 24138979 DOI: 10.2310/7750.2013.12105] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Acute generalized exanthematous pustulosis (AGEP) is a rare drug eruption presenting with an acute, extensive formation of nonfollicular sterile pustules on an erythematous and edematous base. Typically, the rash is accompanied by fever and leukocytosis, with spontaneous resolution in < 15 days. The incidence of AGEP is estimated at one to five cases per million people per year. Only 18% of these are from nonantibiotics. Hydroxychloroquine (HCQ) is an antimalarial agent that is also used to treat various dermatologic and rheumatologic conditions. OBJECTIVE We report the first observation in Canada of a patient with AGEP induced by HCQ. METHODS AND RESULTS AGEP was diagnosed in a 48-year-old female who had been taking HCQ for 2 weeks and then developed a diffuse erythematous and edematous pustular eruption. Clinical and pathologic findings were consistent with a diagnosis of AGEP. The patient was treated with steroids and supportive measures. The rash resolved after 18 days and a complicated course in hospital. CONCLUSION AGEP is a rare drug eruption, usually to antibiotics. We report the first case in Canada of AGEP as an adverse reaction to HCQ. Clinicians should keep in mind the possibility of this severe skin eruption.
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Suspected hydroxychloroquine-associated QT-interval prolongation in a patient with systemic lupus erythematosus. J Clin Rheumatol 2013; 19:286-8. [PMID: 23872551 DOI: 10.1097/rhu.0b013e31829d5e50] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Venuturupalli S, Gudsoorkar V, Wallace D. Reconsidering antimalarials in systemic lupus erythematosus: developments of translational clinical interest. J Rheumatol 2013; 39:1769-71. [PMID: 22942300 DOI: 10.3899/jrheum.111616] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Hydroxychloroquine as treatment for inflammatory subglottic stenosis: a second successful case. Case Rep Otolaryngol 2012. [PMID: 23198227 PMCID: PMC3502770 DOI: 10.1155/2012/754308] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Inflammatory sub-glottic stenosis is a life threatening condition that represents a therapeutic challenge. Recently, hydroxychloroquine has been suggested as one efficient medical treatment option. This report describes the second case of successful treatment of inflammatory sub-glottic stenosis using hydroxychloroquine.
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Abstract
Quinine was first recognized as a potent antimalarial agent hundreds of years ago. Since then, the beneficial effects of quinine and its more advanced synthetic forms, chloroquine and hydroxychloroquine, have been increasingly recognized in a myriad of other diseases in addition to malaria. In recent years, antimalarials were shown to have various immunomodulatory effects, and currently have an established role in the management of rheumatic diseases, such as systemic lupus erythematosus and rheumatoid arthritis, skin diseases, and in the treatment of chronic Q fever. Lately, additional metabolic, cardiovascular, antithrombotic, and antineoplastic effects of antimalarials were shown. In this review, we discuss the known various immunomodulatory mechanisms of antimalarials and the current evidence for their beneficial effects in various diseases and in potential novel applications.
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Tang C, Godfrey T, Stawell R, Nikpour M. Hydroxychloroquine in lupus: emerging evidence supporting multiple beneficial effects. Intern Med J 2012; 42:968-78. [DOI: 10.1111/j.1445-5994.2012.02886.x] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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KISHIMOTO MITSUMASA, DESHPANDE GAUTAMA, YOKOGAWA NAOTO, BUYON JILLP, OKADA MASATO. Use of Hydroxychloroquine in Japan. J Rheumatol 2012; 39:1296. [DOI: 10.3899/jrheum.111569] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Abstract
Over the past several decades, rheumatology has directed its focus to understanding and countering the immune dysregulation underlying autoimmune diseases with rheumatologic manifestations. Older therapies, effective though poorly understood, are being scrutinized anew and are yielding the immune-modulating mechanisms behind their efficacy. New therapies, the "biologics," are drugs tailored to address specific immune defects and imbalances. This article discusses the current standard and biologic immunotherapies of the rheumatic diseases, correlating our current understanding of their mechanisms with dysfunctions believed to be present in the major autoimmune syndromes, especially rheumatoid arthritis and systemic lupus erythematosus.
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Affiliation(s)
- Anne V Miller
- Division of Rheumatology, Department of Internal Medicine, Southern Illinois University School of Medicine, PO Box 19636, Springfield, IL 62794-9636, USA.
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Abstract
In contrast to many other medications, chloroquine and hydroxychloroquine are approved treatment options for systemic lupus erythematosus (SLE). Antimalarials reduce the frequency of disease flares and contribute to the maintenance of remission. Apart from its direct effects on SLE activity, antimalarials seem to protect against thrombotic events and have a beneficial effect on glucose and lipid profiles, which might help reduce the high cardiovascular risk of SLE. Hydroxychloroquine is the only treatment shown to be effective in reducing the risk of damage accrual in SLE patients. Finally, antimalarials are inexpensive, especially compared with more recent treatments, and are well tolerated in SLE. Despite all these benefits, still only about 40%-50% of SLE patients are treated with (hydroxy)chloroquine. Particularly in early disease phases, antimalarials should be considered for every lupus patient, assuming there are no contraindications.
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Paradisi A, Bugatti L, Sisto T, Filosa G, Amerio PL, Capizzi R. Acute generalized exanthematous pustulosis induced by hydroxychloroquine: Three cases and a review of the literature. Clin Ther 2008; 30:930-40. [DOI: 10.1016/j.clinthera.2008.05.014] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/27/2008] [Indexed: 10/21/2022]
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Affiliation(s)
- G Ruiz-Irastorza
- Service and Department of Internal Medicine, Hospital De Cruces, University of the Basque Country, Bizkaia, Spain
| | - MA Khamashta
- Lupus Research Unit, The Rayne Institute, St Thomas Hospital, King’s College, London, UK
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Abstract
ABSTRACT: Although chloroquine, hydroxychloroquine and quinacrine were originally developed for the treatment of malaria, these medications have been used to treat skin disease for over 50 years. Recent clinical data have confirmed the usefulness of these medications for the treatment of lupus erythematosus. Current research has further enhanced our understanding of the pharmacologic mechanisms of action of these drugs involving inhibition of endosomal toll‐like receptor (TLR) signaling limiting B cell and dendritic cell activation. With this understanding, the use of these medications in dermatology is broadening. This article highlights the different antimalarials used within dermatology through their pharmacologic properties and mechanism of action, as well as indicating their clinical uses. In addition, contraindications, adverse effects, and possible drug interactions of antimalarials are reviewed.
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Affiliation(s)
- Sunil Kalia
- Department of Dermatology and Skin Science, University of British Columbia, Vancouver, BC, Canada
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Wenzel J, Tüting T. Identification of type I interferon-associated inflammation in the pathogenesis of cutaneous lupus erythematosus opens up options for novel therapeutic approaches. Exp Dermatol 2007; 16:454-63. [PMID: 17437489 DOI: 10.1111/j.1600-0625.2007.00556.x] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Cutaneous lupus erythematosus (CLE) is one of the most common dermatological autoimmune disorders worldwide. Recently, several studies provided evidence for a pathogenic role of type I interferons (IFNs) in this disease. Plasmacytoid dendritic cells are major type I IFN producers in CLE skin lesions. Type I IFNs are able to induce the expression of several proinflammatory chemokines, including CXCL9 and 10, and enhance the cytotoxic capacity of infiltrating cells. Additionally, adhesion molecules and chemokine receptors, such as intercellular adhesion molecule-1, cutaneous lymphocyte antigen, E-selectin, CCR4 and CXCR3, are involved in the recruitment of potentially autoreactive lymphocytes into the skin. Here, we review the role of type I IFNs, adhesion molecules and chemokine receptors in CLE and discuss options for novel therapeutic approaches.
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Affiliation(s)
- Joerg Wenzel
- Department of Dermatology, University of Bonn, Sigmund-Freud-Strasse 25, 53105 Bonn, Germany.
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Jiménez Palop M. Antipalúdicos: actualización de su uso en enfermedades reumáticas. ACTA ACUST UNITED AC 2006; 2:190-201. [DOI: 10.1016/s1699-258x(06)73045-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2005] [Accepted: 10/04/2005] [Indexed: 11/29/2022]
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Hinz B. [Immunomodulators for treatment of rheumatoid arthritis]. ACTA ACUST UNITED AC 2005; 34:304-12. [PMID: 16041958 DOI: 10.1002/pauz.200500130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Burkhard Hinz
- Institüt für Experimentelle und Klinische Pharmakologie und Toxikologie, Friedrich-Alexander-Universität Erlangen-Numbërg, Fahrstrasse.
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Fessler BJ, Alarcón GS, McGwin G, Roseman J, Bastian HM, Friedman AW, Baethge BA, Vilá L, Reveille JD. Systemic lupus erythematosus in three ethnic groups: XVI. Association of hydroxychloroquine use with reduced risk of damage accrual. ACTA ACUST UNITED AC 2005; 52:1473-80. [PMID: 15880829 DOI: 10.1002/art.21039] [Citation(s) in RCA: 248] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To examine whether hydroxychloroquine (HCQ) usage is associated with a reduced risk of damage accrual in patients with systemic lupus erythematosus (SLE). METHODS Patients (n = 518) meeting the American College of Rheumatology criteria for diagnosis of SLE and with </=5 years disease duration at study entry were followed up annually. Socioeconomic, demographic, clinical, and serologic manifestations as well as disease activity (by the Systemic Lupus Activity Measure [SLAM]) and damage (by the Systemic Lupus International Collaborating Clinics damage index [SDI]) were measured. Propensity scores were calculated to adjust for confounding factors affecting treatment assignment. A Cox proportional hazards model was used to compare the risk of developing new damage according to HCQ use at enrollment into the study. RESULTS Fifty-six percent of the patients were treated with HCQ at the time of study enrollment. Patients who were not treated with HCQ on enrollment had higher SLAM and SDI scores than patients who were treated. Untreated patients were significantly more likely to have major organ involvement such as renal disease (P < 0.0001) or central nervous system disease (P < 0.0025). Results of unadjusted analysis suggested that treated patients were less likely to accrue damage (hazard ratio [HR] 0.68). With adjustment for differences in treatment assignment, HCQ usage was still associated with a reduced risk of developing new damage, with an HR of 0.68 (95% confidence interval [95% CI] 0.53-0.93) (P = 0.014). With adjustment for differences in treatment assignment, HCQ usage was still associated with a reduced risk of developing new damage (HR 0.73 [95% CI 0.52-1.00]) (P = 0.05). However, patients receiving HCQ who had no damage at study entry had a statistically significant decrease in the risk of damage accrual (HR 0.55 [95% CI 0.34-0.87]) (P = 0.0111), whereas those receiving HCQ who had damage at study entry did not (HR 1.106 [95% CI 0.70-1.74]) (P = 0.6630). CONCLUSION These findings indicate that, after adjustment for propensity to receive HCQ, HCQ usage is independently associated with a reduced risk of damage accrual in SLE patients who had not yet accrued damage at the time of treatment initiation.
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Abstract
Antimalarials have been used to treat cutaneous and systemic lupus erythematosus (LE) for decades. Although controlled studies comparing the efficacy of antimalarials versus placebo and other treatments are generally lacking, many case reports and series support the therapeutic efficacy of these agents in treating both LE-specific and -nonspecific skin lesions. Currently, the two most frequently used antimalarial agents are chloroquine and hydroxychloroquine. There may be a delay of weeks to months in the onset of therapeutic effects of antimalarials when treating LE. Smoking appears to inhibit the therapeutic efficacy of antimalarials when treating cutaneous LE. Antimalarials have been associated with a number of potentially serious adverse effects, including irreversible loss of vision. The aim of this review is to discuss the many facets of antimalarials that will help clinicians optimally utilize these agents when treating cutaneous LE.
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Affiliation(s)
- Anna Wozniacka
- Department of Dermatology, Medical University of Łódź, Krzemieniecka, Poland
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Kinsley-Scott TR, Norton SA. Useful plants of dermatology. VII: Cinchona and antimalarials. J Am Acad Dermatol 2003; 49:499-502. [PMID: 12963916 DOI: 10.1067/s0190-9622(03)01281-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Wozniacka A, Carter A, McCauliffe DP. Antimalarials in cutaneous lupus erythematosus: mechanisms of therapeutic benefit. Lupus 2002; 11:71-81. [PMID: 11958581 DOI: 10.1191/0961203302lu147rr] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Antimalarials are arguably the best modality currently available for treating patients with cutaneous lupus erythematosus (LE). Although antimalarials have been used for decades in treating cutaneous LE, the precise mechanisms by which they provide therapeutic benefit are not well defined. The putative mechanisms by which antimalarials might provide therapeutic benefit to patients with cutaneous LE include a number of interrelated anti-inflammatory and immunosuppressive effects that include photoprotection, lysosomal stabilization, suppression of antigen presentation, and inhibition of prostaglandin and cytokine synthesis. If we had a more precise understanding of how antimalarials provide therapeutic benefit in cutaneous LE we might gain better insight into the pathogenic mechanisms of LE and ways of developing better therapies for afflicted patients.
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Affiliation(s)
- A Wozniacka
- Department of Dermatology, Medical University of Lodz, Krzemieniecka, Poland
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Carbone J, Sarmiento E, Segovia P, Rodríguez-Mahou M, Rodríguez-Molina JJ, Fernández-Cruz E. [Antiphospholipid antibodies evolving into connective tissue disease: follow-up study of women with recurrent misscarriage]. Med Clin (Barc) 2002; 119:681-5. [PMID: 12459104 DOI: 10.1016/s0025-7753(02)73541-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND OBJECTIVE The aim of this study was to evaluate the clinical and immunologic profile, the rate of progression to connective tissue disease and the possible predictors of evolution in patients with antiphospholipid antibodies and abortions. PATIENTS AND METHOD In a prospective follow-up study, we determined the prevalence of antiphospholipid antibodies as well as other autoimmune abnormalities and the evolution to connective tissue disease in 200 women with unexplained recurrent abortions. IgG and IgM anticardiolipin antibodies were determined by ELISA and the lupus anticoagulant was determined by means of coagulometric tests. RESULTS Of 200 women with pregnancy losses, 69 (34.5%) had antiphospholipid antibodies. Thirty-one of 200 women (15.5%) had high or moderate positive anticardiolipin antibodies. During a mean follow-up of 32 months, 9 (13%) antiphospholipid-antibody-positive patients developed features of lupus- like disease or systemic lupus erythematosus. A low total hemolytic complement, increased circulating immune complexes and positive antinuclear antibodies (ANA) were more common in those patients evolving to a connective tissue disorder (p < 0.001, p = 0.003 and p < 0.001, respectively). Positive ANA in women with antiphospholipid antibodies predicted independently the evolution to a connective tissue disorder [Cox proportional hazard model; relative hazard = 4.92, p = 0.04]. CONCLUSIONS A subgroup of patients with antiphospholipid antibodies and abortions may progress to a connective tissue disorder. A positive antinuclear antibody test result could be useful to identify those patients with antiphospholipid antibodies and abortions who are prone to evolve into a systemic autoimmune disease.
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Affiliation(s)
- Javier Carbone
- Unidad de Inmunología Clínica. Servicio de Inmunología. Hospital General Universitario Gregorio Marañón. Madrid. España.
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Affiliation(s)
- D J Wallace
- Cedars-Sinai/University of California, Los Angeles, USA.
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Abstract
Antimalarial medications have become the parenteral drugs of choice for treating the cutaneous manifestations of lupus erythematosus. The immune-modulating activity of these agents makes them useful in a variety of other dermatoses. With prudent dosage and monitoring, these agents can be used safely and effectively in the treatment and management of dermatologic disease.
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Affiliation(s)
- M J Van Beek
- Department of Dermatology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
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Alarcón-Segovia D, Cabral AR. The anti-phospholipid antibody syndrome: clinical and serological aspects. Best Pract Res Clin Rheumatol 2000; 14:139-50. [PMID: 10882219 DOI: 10.1053/berh.1999.0082] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The association of thromboses and/or cytopenias with anti-phospholipid antibodies (aPL), the anti-phospholipid syndrome (APS), is well recognized. The syndrome may be primary or occur within systemic lupus erythematosus (SLE). The notion of the syndrome occurring within SLE is important since patients found to have aPL may be at risk for developing APS manifestations, those who develop some manifestations may be at risk for developing others and, finally, SLE patients with this syndrome may need special treatment. There are subtle differences between the primary and the secondary forms, mostly due to the frequently higher and more persistent autoantibody levels in the primary and the influence of lupus in the secondary. These syndromes may be related to various antigen/antibody systems in which phospholipids participate either directly or through their effect on the proteins that bind them. Similar clinical manifestations also occur in patients who have serum antibodies to such proteins (e.g. beta2-glycoprotein-I) in the absence of phospholipid. Some of these antibodies may even be more important pathogenically than the antibodies against cardiolipin that were originally described. Testing for the latter is, however, still the first choice when suspecting an antiphospholipid syndrome. If this is negative in this situation, a search for the other autoantibodies is indicated.
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Affiliation(s)
- D Alarcón-Segovia
- Department of Immunology and Rheumatology, Faculty of Medicine, Instituto Nacional de la Nutrición Salvador Zubirán, México DF, México
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Carbone J, Orera M, Rodríguez-Mahou M, Rodríguez-Pérez C, Sánchez-Ramón S, Seoane E, Rodríguez JJ, Zabay JM, Fernández-Cruz E. Immunological abnormalities in primary APS evolving into SLE: 6 years follow-up in women with repeated pregnancy loss. Lupus 1999; 8:274-8. [PMID: 10413205 DOI: 10.1191/096120399678847777] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We have performed a prospective study to determine the prevalence of immunological abnormalities and the evolution from primary antiphospholipid syndrome (APS) into systemic lupus erythematosus (SLE) in women who had had unexplained repeated pregnancy loss (PL) and APS. Of 105 women with abortions or fetal deaths, 33(31%) fulfilled criteria for APS. Among these patients with primary APS, 24% had antinuclear antibodies (ANA), 91% had elevated circulating immune complexes (CIC), 70% had low total haemolytic complement (CH100), 52% had low levels of complement 4 (C4) and 30% had low levels of complement 3 (C3), in a significantly higher prevalence than women whose pregnancies were successful (control group). Through out a 6 y follow-up, 3 (9%) of the patients with APS who had autoimmune related abnormalities when entered into the study developed features of lupus like disease (LLD) or fullblown SLE. Our findings suggest that women with unexplained repeated PL with APS who presented with positive ANA, high levels of CIC, low levels of CH100, C3 and C4, may define a subset of patients exhibiting immunological alterations similar to those of SLE. These parameters may help in the assessment of prognosis in APS patients with PL. Those patients should be carefully surveyed with regard to the development of connective tissue diseases.
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Affiliation(s)
- J Carbone
- Division of Immunology, Horpital General Universitario Gregorio Marañón, Community of Madrid, Spain
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Amoroso A, Del Porto F, Garzia P, Mariotti A, Addessi MA, Afeltra A. Primary antiphospholipid syndrome and cerebral atrophy: a rare association? Am J Med Sci 1999; 317:425-8. [PMID: 10372845 DOI: 10.1097/00000441-199906000-00013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Neurologic complications are common in patients with antiphospholipid syndrome. In this article, we report the case of a young woman with neurologic disorders, a history of hypertension and transient ischemic attacks, and cerebral atrophy associated with primary antiphospholipid syndrome (PAPS). Magnetic resonance imaging of the brain showed multiple ischemic lesions and remarkable atrophy of frontal and parietal lobes. Cerebral atrophy in patients with PAPS can be considered as a feature of this disease. The case is discussed on the basis of relevant past literature. Although there are few reports on neuroradiologic findings in patients with PAPS, cerebral atrophy has been described. Because PAPS is more frequently recognized today than in the past, this condition should be included in the differential diagnosis of cerebral atrophy, particularly in young patients.
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Affiliation(s)
- A Amoroso
- Department of Clinical Medicine, University of Rome La Sapienza, Italy
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Amoroso A, Del Porto F, Garzia P, Mariotti A, Addessi MA, Afeltra A. Primary Antiphospholipid Syndrome Cerebral Atrophy: A Rare Association? Am J Med Sci 1999. [DOI: 10.1016/s0002-9629(15)40558-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Seisdedos L, Muñoz-Rodríguez FJ, Cervera R, Font J, Ingelmo M. Primary antiphospholipid syndrome evolving into systemic lupus erythematosus. Lupus 1997; 6:285-6. [PMID: 9104739 DOI: 10.1177/096120339700600314] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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