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Zhu XY, Tang XH, Yu H. Amiodarone-induced muscle tremor in an elderly patient: A case report. World J Clin Cases 2022; 10:12726-12733. [PMID: 36579101 PMCID: PMC9791518 DOI: 10.12998/wjcc.v10.i34.12726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 10/09/2022] [Accepted: 11/04/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Amiodarone is a Class III antiarrhythmic drug, which has been adopted for the treatment of atrial fibrillation and ventricular arrhythmia. However, the use of amiodarone can cause lower limb muscle tremors, which is recognized as a rare side effect of this medication.
CASE SUMMARY An 84-year-old female was administrated with amiodarone for paroxysmal supraventricular tachycardia and frequent ventricular tachycardia. The patient developed a bilateral gastrocnemius tremor in the course of medication, and the strength of the patient’s bilateral knee flexor and extensor reached 4/5 and 3/5, respectively. After the use of amiodarone was stopped, and the patient was given a small dose of levetiracetam, the lower limb tremor symptoms were significantly mitigated, along with activity and function.
CONCLUSION Attention should be paid to the significance of the side effects of drugs in the elderly, which may be atypical in the elderly. The relevant side effects of drugs may not be as rare as reported due to individual differences and different pharmacokinetics. If the side effects are generated, the medication should be adjusted in time, and the progress of the side effects should be intervened.
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Affiliation(s)
- Xiao-Yong Zhu
- Department of Cardiology, Jiujiang University Affiliated Hospital, Jiujiang 332000, Jiangxi Province, China
| | - Xin-Hu Tang
- Department of Cardiology, Jiujiang University Affiliated Hospital, Jiujiang 332000, Jiangxi Province, China
| | - Hua Yu
- Department of Cardiology, Jiujiang University Affiliated Hospital, Jiujiang 332000, Jiangxi Province, China
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Neurobehavioral, neurochemical and synaptic plasticity perturbations during postnatal life of rats exposed to chloroquine in-utero. Neurotoxicol Teratol 2021; 86:106982. [PMID: 33845156 DOI: 10.1016/j.ntt.2021.106982] [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: 08/18/2020] [Revised: 02/26/2021] [Accepted: 04/06/2021] [Indexed: 11/23/2022]
Abstract
Despite reports that quinoline antimalarials including chloroquine (Chq) exhibit idiosyncratic neuropsychiatric effects even at low doses, the drug continues to be in widespread use during pregnancy. Surprisingly, very few studies have examined the potential neurotoxic action of Chq exposure at different points of gestation or how this phenomenon may affect neurophysiological well-being in later life. We therefore studied behavior, and the expression of specific genes and neurochemicals modulating crucial neural processes in offspring of rats exposed to prophylactic dose of Chq during different stages of gestation. Pregnant rats were injected 5 mg/kg/day (3 times) of Chq either during early- (first week), mid- (second week), late- (third week), or throughout- (all weeks) gestation, while controls received PBS injection. Behavioral characterization of offspring between postnatal days 15-20 in the open field, Y-maze, elevated plus and elevated zero mazes revealed that Chq evoked anxiogenic responses and perturbed spatial memory in rats, although locomotor activity was generally unaltered. In the prefrontal cortex (PFC), hippocampus and cerebellum of rats prenatally exposed to Chq, RT-qPCR analysis revealed decreased mRNA expression of presynaptic marker synaptophysin, which was accompanied by downregulation of postsynaptic marker PSD95. Synaptic marker PICK1 expression was also downregulated in the hippocampus but was unperturbed in the PFC and cerebellum. In addition to recorded SOD downregulation in cortical and hippocampal lysates, induction of oxidative stress in rats prenatally exposed to Chq was corroborated by lipid peroxidation as evinced by increased MDA levels. Offspring of rats infused with Chq at mid-gestation and weekly treatment throughout gestation were particularly susceptible to neurotoxic changes, especially in the hippocampus. Interestingly, Chq did not cause histopathological changes in any of the brain areas. Taken together, our findings causally link intrauterine exposure to Chq with postnatal behavioral impairment and neurotoxic changes in rats.
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Noureddine O, Issaoui N, Medimagh M, Al-Dossary O, Marouani H. Quantum chemical studies on molecular structure, AIM, ELF, RDG and antiviral activities of hybrid hydroxychloroquine in the treatment of COVID-19: Molecular docking and DFT calculations. JOURNAL OF KING SAUD UNIVERSITY SCIENCE 2021; 33:101334. [PMID: 33432258 PMCID: PMC7787522 DOI: 10.1016/j.jksus.2020.101334] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 12/21/2020] [Accepted: 12/25/2020] [Indexed: 01/18/2023]
Abstract
Structure-activity relationships for hydroxychloroquine compound and its derivatives resulted in a potent antiviral activity. Where hydroxychloroquine derivatives showed an apparent efficacy against coronavirus related pneumonia. For this reason, the current study is focused on the structural properties of hydroxychloroquine and hydroxychloroquine sulfate. Optimized structures of these molecules have been reported by using DFT method at B3LYP/6-31G* level of theory. The geometric were determined and compared with the experimental crystal structure. The intra and intermolecular interactions which exist within these compounds are analyzed by different methods namely the topological analysis AIM, ELF and the reduced gradient of the density. These approaches make it possible in particular to study the properties of hydrogen bonds. The highest occupied molecular orbital and the lowest unoccupied molecular orbital energy levels are constructed and the corresponding frontier energy gaps are determined to realize the charge transfer within the molecule. The densities of state diagrams were determined to calculate contributions to the molecular orbitals. The molecular electrostatic potential surfaces are determined to give a visual representation of charge distribution of these ligands and to provide information linked to electrophilic and nucleophilic sites localization. Finally, these derivatives were evaluated for the inhibition of COVID-19 activity by using the molecular docking method.
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Affiliation(s)
- Olfa Noureddine
- University of Monastir, Laboratory of Quantum and Statistical Physics (LR18ES18), Faculty of Sciences, Monastir 5079, Tunisia
| | - Noureddine Issaoui
- University of Monastir, Laboratory of Quantum and Statistical Physics (LR18ES18), Faculty of Sciences, Monastir 5079, Tunisia
| | - Mouna Medimagh
- University of Monastir, Laboratory of Quantum and Statistical Physics (LR18ES18), Faculty of Sciences, Monastir 5079, Tunisia
| | - Omar Al-Dossary
- Department of Physics and Astronomy, College of Science, King Saud University, PO Box 2455, Riyadh 11451, Saudi Arabia
| | - Houda Marouani
- University of Carthage, Laboratory of Chemistry of Materials (LR13ES08), Faculty of Sciences of Bizerte, 7021, Tunisia
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4
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Mechanisms of action of hydroxychloroquine and chloroquine: implications for rheumatology. Nat Rev Rheumatol 2020; 16:155-166. [PMID: 32034323 DOI: 10.1038/s41584-020-0372-x] [Citation(s) in RCA: 797] [Impact Index Per Article: 199.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2020] [Indexed: 12/15/2022]
Abstract
Despite widespread clinical use of antimalarial drugs such as hydroxychloroquine and chloroquine in the treatment of rheumatoid arthritis (RA), systemic lupus erythematosus (SLE) and other inflammatory rheumatic diseases, insights into the mechanism of action of these drugs are still emerging. Hydroxychloroquine and chloroquine are weak bases and have a characteristic 'deep' volume of distribution and a half-life of around 50 days. These drugs interfere with lysosomal activity and autophagy, interact with membrane stability and alter signalling pathways and transcriptional activity, which can result in inhibition of cytokine production and modulation of certain co-stimulatory molecules. These modes of action, together with the drug's chemical properties, might explain the clinical efficacy and well-known adverse effects (such as retinopathy) of these drugs. The unknown dose-response relationships of these drugs and the lack of definitions of the minimum dose needed for clinical efficacy and what doses are toxic pose challenges to clinical practice. Further challenges include patient non-adherence and possible context-dependent variations in blood drug levels. Available mechanistic data give insights into the immunomodulatory potency of hydroxychloroquine and provide the rationale to search for more potent and/or selective inhibitors.
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Tincani A, Bompane D, Danieli E, Doria A. Pregnancy, lupus and antiphospholipid syndrome (Hughes syndrome). Lupus 2016; 15:156-60. [PMID: 16634369 DOI: 10.1191/0961203306lu2279rr] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Autoimmune diseases (AD) occur frequently in women during their childbearing years and may influence pregnancy outcome and neonatal health. Patients with systemic lupus erythematosus (SLE) can experience a disease flare-up during pregnancy with potential negative effects on the product of conceptus, especially if the disease is active. Recurrent pregnancy loss is now considered as a treatable clinical condition associated with the presence of circulating antiphospholipid antibodies (aPL). The neonatal lupus syndromes (NLS), caused by the transplacental passage of maternal IgG anti-Ro/SS-A and anti-La/SS-B antibodies to the fetus, carry significant morbidity and mortality in case of cardiac manifestations. Immunosuppressive agents are often administered during pregnancy in order to control maternal disease and to ensure a better pregnancy outcome. Nowadays, owing to our increasing knowledge of the disease pathophysiological mechanisms and the development of combined medical-obstetric clinics, pregnancy outcome in patients with AD has notably improved.
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Affiliation(s)
- A Tincani
- Rheumatology and Clinical Immunology, Brescia Hospital and University, Italy.
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6
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Meroni PL. Prevention & treatment of obstetrical complications in APS: Is hydroxychloroquine the Holy Grail we are looking for? J Autoimmun 2016; 75:1-5. [PMID: 27496152 DOI: 10.1016/j.jaut.2016.07.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2016] [Accepted: 07/05/2016] [Indexed: 12/30/2022]
Abstract
Pregnancy morbidity is part of the clinical spectrum of the anti-phospholipid syndrome (APS), with an important social and economical cost. Antiplatelet and anticoagulant agents are effective in preventing the clinical manifestations in the majority of the patients. However, a consistent proportion of the pregnant women present recurrences in spite of the standard therapy. Observational studies and anecdotal reports raised the issue of additional therapeutic strategies in these refractory cases. Among these, anti-malarials (AMs) and in particular hydroxychloroquine (HCQ) are becoming more and more popular in APS as well as in other systemic autoimmune rheumatic conditions. AMs display a pleiotropic activity spanning from immunomodulation effect to anti-inflammatory and anti-thrombotic activities, all of which potentially useful in APS. The well-known safety of HCQ in pregnancy encouraged its use in pregnant women with autoimmune rheumatic disorders including APS and observational reports suggested a protective effect on obstetrical recurrences. Since thrombosis does not seem to be the main pathogenic mechanism in obstetric APS, effectiveness of the treatment with HCQ should be related to other pharmacological effects rather than to the anti-platelet or anti-thrombotic activity of the molecule. Experimental models showed that HCQ may restore some defective biological functions induced by anti-phospholipid antibodies (aPL) on trophoblasts and a recent study reported a protective effect on in vivo aPL-mediated placental and foetal neurodevelopmental abnormalities. Although the rational behind the use of HCQ in obstetric APS is sound, the evidence from the real life is not conclusive and a critical appraisal through clinical trials is mandatory.
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Affiliation(s)
- Pier Luigi Meroni
- Department of Clinical Sciences and Community Health, University of Milan, Division of Rheumatology, ASST G. Pini, Pini Piazza C. Ferrari 1, 20122, Milan, Italy; IRCCS, Istituto Auxologico Italiano, Milan, Italy.
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7
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Abstract
Rheumatic diseases occur frequently in women of childbearing years necessitating drug treatment also during a concurrent pregnancy in order to control maternal disease activity and to ensure a successful pregnancy outcome. This survey reviews maternal and fetal side effects of nonsteroidal anti-inflammatory drugs (NSAID) and immunosuppressive agents in pregnant patients. The classic nonselective nonsteroidal anti-inflammatory drugs are not teratogenic, but given in late pregnancy they can induce renal and cardiac side effects in the fetus. Similar effects must be expected of the new, selective Cox2-inhibitors. NSAID should therefore be stopped by gestational week 32. Corticosteroids are frequently necessary to control rheumatic disease flares and for prevention of serious organ manifestations. However, due to an increased risk of oral clefts, high doses (1-2 mg/kg) should be avoided in the first trimester. Among disease modifying drugs, sulfasalazine and antimalarials have the safest record. Cyclosporine and azathioprine can be given throughout pregnancy if disease control requires it. Insufficient data exist for treatment of pregnant patients with TNF-inhibitors and mycophenolate mofetil. The severity of the disease under treatment decides if continuation of one of these drugs is justified. Prophylactic withdrawal of drugs before pregnancy is mandatory for leflunomide and the cytotoxic agents methotrexate and cyclophosphamide. Prepregnancy counselling and careful monitoring during pregnancy help to tailor necessary drug treatment for the benefit of mother and child.
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Affiliation(s)
- M Ostensen
- Department of Rheumatology, Clinical Immunology and Allergy, University Hospital of Berne, Switzerland.
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Tincani A, Danieli E, Nuzzo M, Scarsil M, Motta M, Cimaz R, Lojacono A, Nacinovich R, Taddei F, Doria A, Brucato A, Meroni P. Impact of in utero environment on the offspring of lupus patients. Lupus 2016; 15:801-7. [PMID: 17153854 DOI: 10.1177/0961203306071005] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The number of patients affected by systemic lupus erythematosus (SLE) that decide to have children has greatly increased probably because of recent improvements in the diagnosis and management of the disease. This has stimulated our interest in defining the outcome of children, focusing both on neonatal problems and long term development. SLE patients still carry a risk of pregnancy loss. However, due to careful monitoring and treatment by a multidisciplinary team, the number of losses has dramatically decreased, but an increased number of preterm deliveries is still a problem. Neonatal lupus is linked to the presence of anti-Ro/SS-A and anti-La/SS-B antibodies in the mother, although other factors probably of fetal origin are important. Neonatal lupus is a complex condition whose most serious manifestation is the congenital heart block (CHB). Usually, children with complete CHB need permanent pacing, but apparently do not have neuropsychological problems. Studies focusing on the neuropsychological development of SLE offspring show an increased number of learning disabilities in children with normal intelligence levels. Fetal consequence of maternal treatment need to be considered choosing non teratogenic drugs, but the withdrawal of medications just because the patient is pregnant should be avoided to avoid SLE flares.
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Affiliation(s)
- A Tincani
- Spedali Civili and University of Brescia, Brescia, Italy.
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Borba EF, Turrini-Filho JR, Kuruma KAM, Bertola C, Pedalini MEB, Lorenzi MC, Bonfá E. Chloroquine gestational use in systemic lupus erythematosus: assessing the risk of child ototoxicity by pure tone audiometry. Lupus 2016; 13:223-7. [PMID: 15176656 DOI: 10.1191/0961203304lu528oa] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The objective of this study was to assess child chloroquine ototoxicity after its use during the gestational period in systemic lupus erythematosus (SLE). Nineteen children over four years old were evaluated: nine were exposed to chloroquine diphosphate (CDP) during gestation and 10 were born from mothers that did not take this drug before conception or anytime during pregnancy (CONTROL). Pure tone audiometry was performed in all children and high and low frequency threshold means were compared to evaluate the hearing status. All nine mothers taking CDP were exposed to this drug at least during the first trimester of pregnancy (56% during the whole gestational period) and the mean time of CDP use was 6.1 + 2.9 months. No significant difference was found in children of CDP and CONTROL groups regarding age (7.6 + 4.4 versus 12.3 + 7.2 years; P 0.10, respectively) and gender (P 0.65). Pure tone high frequency thresholds, which are the first to be affected by ototoxic drugs, presented within normal limits in children exposed or not to CDP (8.5 + 5.0 versus 7.4 + 3.6 dBHL; P 0.55, respectively). Likewise, the mean hearing thresholds at low frequencies were also similar in both groups (11.4 + 4.5 versus 11.9 + 3.0 dBHL; P 0.66). In conclusion, child in utero exposure to chloroquine diphosphate does not seem to induce hearing impairment as measured by pure tone audiometry, reinforcing its safe use during pregnancy of lupus patients.
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Affiliation(s)
- E F Borba
- Rheumatology Division, University of São Paulo, São Paulo, SP, Brazil.
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10
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Al Hammadi A, Al-Haddab M, Sasseville D. Dermatologic Treatment during Pregnancy: Practical Overview. J Cutan Med Surg 2016; 10:183-92. [PMID: 17234117 DOI: 10.2310/7750.2006.00043] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background: This article provides a practical overview of dermatologic medication use in pregnancy. Objective: The therapeutics of the following common dermatoses are reviewed: acne, psoriasis, and bacterial, fungal, viral, and parasitic infections. Antipruritic, analgesic, and topical anesthetic use in pregnancy is reviewed as well. Conclusions: At the end, the reader is challenged with a series of applied clinical scenarios that highlight the presented material and provide information on additional important medications.
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Affiliation(s)
- Anwar Al Hammadi
- Division of Dermatology, Mcgill University Health Centre, Montreal, QC, Canada.
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Wallenius M, Salvesen KÅ, Daltveit AK, Skomsvoll JF. Secular trends of pregnancies in women with inflammatory connective tissue disease. Acta Obstet Gynecol Scand 2015; 94:1195-202. [DOI: 10.1111/aogs.12722] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 07/24/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Marianne Wallenius
- National Advisory Unit on Pregnancy and Rheumatic Diseases; Department of Rheumatology; Trondheim University Hospital; Trondheim Norway
- Department of Neuroscience; Norwegian University of Science and Technology; Trondheim Norway
| | - Kjell Å. Salvesen
- National Center for Fetal Medicine; Department of Obstetrics and Gynecology; Trondheim University Hospital; Trondheim Norway
- Department of Laboratory Medicine; Women's and Child Health; Norwegian University of Science and Technology; Trondheim Norway
| | - Anne K. Daltveit
- Department of Global Public Health and Primary Health Care; University of Bergen; Bergen Norway
- Medical Birth Registry of Norway; Division of Epidemiology; Norwegian Institute of Public Health; Bergen Norway
| | - Johan F. Skomsvoll
- National Advisory Unit on Pregnancy and Rheumatic Diseases; Department of Rheumatology; Trondheim University Hospital; Trondheim Norway
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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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Abstract
The 4-aminoquinolines are weak bases that are completely absorbed from the gastrointestinal tract, sequestered in peripheral tissues, metabolized in the liver to pharmacologically active by-products, and excreted via the kidneys and the feces. The parent drugs and metabolites are excreted with a half-life of elimination of approximately 40 days. However, slow release from sequestered stores of the drugs means that after discontinuation, they continue to be released into the plasma for years. Correct dosing is based on the ideal body weight of the patient, which depends on height. The 4AQs diminish autoimmunity without compromising immunity to infections.
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Affiliation(s)
- David J. Browning
- grid.490463.cCharlotte Eye Ear Nose & Throat Associates, Charlotte, NC USA
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Abstract
Systemic lupus erythematosus was diagnosed in a 34-year-old pregnant woman because of leukopenia, typical skin rash, clinical and biochemical signs of muscle involvement, and positive serology (antinuclear antibodies and anti-double-stranded DNA). Corticosteroids and hydroxychloroquine (HCQ) were started at 18 weeks of gestation with overall benefit except for muscle involvement, which proved resistant even to higher dose of corticosteroids and high-dose intravenous immunoglobulin. Muscle biopsy showed signs of HCQ toxicity, and the drug was stopped. After withdrawal, muscle involvement disappeared. Hydroxychloroquine could be safely reintroduced some months after delivery. It is hypothesized that pregnancy may have represented the second "hit" in this patient with systemic lupus erythematosus necessary for the rapid development of HCQ-related myopathy.
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Abarientos C, Sperber K, Shapiro DL, Aronow WS, Chao CP, Ash JY. Hydroxychloroquine in systemic lupus erythematosus and rheumatoid arthritis and its safety in pregnancy. Expert Opin Drug Saf 2011; 10:705-14. [PMID: 21417950 DOI: 10.1517/14740338.2011.566555] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION The antimalarial drug hydroxychloroquine (HCQ) is widely used to treat various rheumatic diseases. Many autoimmune diseases occur in women of child-bearing age who may become pregnant while on therapy, which raises concerns regarding the teratogenicity of HCQ and its effect on the outcome of the pregnancy. There is a lack of data regarding the safety of HCQ during pregnancy. AREAS COVERED In this review, the authors attempt to identify relevant publications by searching MEDLINE, Cochrane database, Ovid-Currents Clinical Medicine, Ovid-Embase:Drugs and Pharmacology, EBSCO, Web of Science and SCOPUS using the search terms HCQ and/or pregnancy. A basis for the mechanism of action of HCQ is provided. EXPERT OPINION HCQ has been shown by numerous studies over the past 15 years to be efficacious in the treatment of autoimmune diseases, including systemic lupus erythematosus, discoid lupus erythematosus and rheumatoid arthritis. HCQ does not appear to be associated with any increased risk of congenital defects, spontaneous abortions, fetal death, prematurity or decreased numbers of live births in patients with autoimmune diseases. Therefore, in the author's opinion, HCQ is safe for the treatment of autoimmune diseases during pregnancy.
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Affiliation(s)
- Crispin Abarientos
- New York Medical College, Division of Allergy, Immunology and Rheumatology, Munger Pavilion, Valhalla, NY 10595, USA
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Sperber K, Hom C, Chao CP, Shapiro D, Ash J. Systematic review of hydroxychloroquine use in pregnant patients with autoimmune diseases. Pediatr Rheumatol Online J 2009; 7:9. [PMID: 19439078 PMCID: PMC2690583 DOI: 10.1186/1546-0096-7-9] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2008] [Accepted: 05/13/2009] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVE The purpose of this study is to compare the incidence of congenital defects, spontaneous abortions, number of live births, fetal death and pre-maturity in women with autoimmune diseases taking HCQ during pregnancy. METHODS The authors searched MEDLINE, Cochrane data base, Ovid-Currents Clinical Medicine, Ovid-Embase:Drugs and Pharmacology, EBSCO, Web of Science, and SCOPUS using the search terms HCQ and/or pregnancy. We attempted to identify all clinical trials from 1980 to 2007 regardless of language or publication status. We also searched Cochrane Central Library and http://www.Clinical trials.gov for clinical trials of HCQ and pregnancy. Data were extracted onto standardized forms and were confirmed. RESULTS The odds ratio (OR) of congenital defects in live births of women taking HCQ during pregnancy was 0.66, 95% confidence intervals (CI) 0.25, 1.75. The OR of a live birth for women taking HCQ during pregnancy was 1.05 (95% CI 0.58, 1.93). The OR of spontaneous abortion in women taking HCQ during pregnancy was 0.92 (95% CI 0.49, 1.72). The OR of fetal deaths in women taking HCQ during pregnancy was 0.97 (95% CI 0.14, 6.54). The OR of pre-mature birth defined as birth before 37 weeks in women taking HCQ during pregnancy was 1.10 (95% CI 0.75, 1.61). CONCLUSION HCQ is not associated with any increased risk of congenital defects, spontaneous abortions, fetal death, pre-maturity and decreased numbers of live births in patients with auto-immune diseases.
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Affiliation(s)
- Kirk Sperber
- Division of Allergy, Immunology, and Rheumatology, Department of Medicine, New York Medical College, Munger Pavilion, Valhalla, NY 10595, USA
| | - Christine Hom
- Division of Rheumatology, Department of Pediatrics, New York Medical College, Munger Pavilion, Valhalla, NY 10595, USA
| | - Chun Peng Chao
- Division of Rheumatology, Department of Pediatrics, New York Medical College, Munger Pavilion, Valhalla, NY 10595, USA
| | - Deborah Shapiro
- Division of Allergy, Immunology, and Rheumatology, Department of Medicine, New York Medical College, Munger Pavilion, Valhalla, NY 10595, USA
| | - Julia Ash
- Division of Allergy, Immunology, and Rheumatology, Department of Medicine, New York Medical College, Munger Pavilion, Valhalla, NY 10595, USA
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Wong CH, Chen TL, Lee CS, Lin CJ, Chen CP. Outcome of pregnancy in patients with systemic lupus erythematosus. Taiwan J Obstet Gynecol 2007; 45:120-3. [PMID: 17197351 DOI: 10.1016/s1028-4559(09)60208-4] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
OBJECTIVE To study the maternal and fetal outcomes in women with systemic lupus erythematosus (SLE). MATERIALS AND METHODS Over a period of 10 years, 24 pregnancies in 17 females with SLE in a single center were enrolled. Fetal and maternal outcomes were studied retrospectively. RESULTS The mean patient age was 27.7 years. Twenty-one of the 24 pregnancies occurred in the period of disease remission at the time of conception. Proteinuria presented in 12 pregnancies; however, no patient developed acute renal failure or deterioration of renal function. There were three cases of preeclampsia in this study. Two patients had their disease flare up and delivered stillborns. One woman with secondary antiphospholipid syndrome (APS) had a fetal loss. There was no maternal mortality. The mean gestation age was 34.3 weeks (range, 17-41 weeks), and the mean birth weight was 2,179 g. The mean APGAR scores were 8 and 9 at 1 and 5 minutes, respectively. One baby with congenital atrioventricular block was born to a mother with positive anti-SSA antibody. There were five cases (20.8%) of intrauterine growth retardation and 10 preterm deliveries (41.6%) in this study. CONCLUSION Pregnancy is relatively safe in women with SLE in remission but should be considered as a high-risk pregnancy. APS is associated with poor pregnancy outcome. The patient needs to cooperate with obstetricians and physicians for optimal disease control and detailed monitoring throughout the gestation.
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Affiliation(s)
- Chiong-Hee Wong
- Department of Rheumatology, Mackay Memorial Hospital, Taipei, Taiwan
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Østensen M, Khamashta M, Lockshin M, Parke A, Brucato A, Carp H, Doria A, Rai R, Meroni P, Cetin I, Derksen R, Branch W, Motta M, Gordon C, Ruiz-Irastorza G, Spinillo A, Friedman D, Cimaz R, Czeizel A, Piette JC, Cervera R, Levy RA, Clementi M, De Carolis S, Petri M, Shoenfeld Y, Faden D, Valesini G, Tincani A. Anti-inflammatory and immunosuppressive drugs and reproduction. Arthritis Res Ther 2006; 8:209. [PMID: 16712713 PMCID: PMC1526635 DOI: 10.1186/ar1957] [Citation(s) in RCA: 342] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Rheumatic diseases in women of childbearing years may necessitate drug treatment during a pregnancy, to control maternal disease activity and to ensure a successful pregnancy outcome. This survey is based on a consensus workshop of international experts discussing effects of anti-inflammatory, immunosuppressive and biological drugs during pregnancy and lactation. In addition, effects of these drugs on male and female fertility and possible long-term effects on infants exposed to drugs antenatally are discussed where data were available. Recommendations for drug treatment during pregnancy and lactation are given.
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Affiliation(s)
- Monika Østensen
- Department of Rheumatology and Clinical Immunology/Allergology, University Hospital of Bern, Switzerland.
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Ostensen M. [Antirheumatic therapy and reproduction. The influence on fertility, pregnancy and breast feeding]. Z Rheumatol 2006; 65:217-20, 222-4. [PMID: 16670813 DOI: 10.1007/s00393-006-0052-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Antirheumatic drugs can have a negative effect on reproduction in both men and women. Possible negative effects are impairment of fertility, harmful effects on the fetus and adverse effects on the breastfed child. In women non-steroidal antiinflammatory drugs (NSAID) and cyclophosphamide can impair fertility. In men infertility can result from the use of salazopyrine and cyclophosphamide. A desire for children should be taken into account before the start of disease modifying drugs (DMARD). Treatment with NSAID is possible at some stages of pregnancy as well as during lactation. A limited number of DMARD is compatible with pregnancy and is presented. Cytostatic drugs and leflunomide must be prophylactically withdrawn before a planned pregnancy. TNF alpha antagonists should be discontinued at the start of pregnancy. Safe birth control must be practised during therapy with drugs that are gonadotoxic or teratogenic. Treatment with immunosuppressive drugs during lactation is limited because of insufficient documentation of safety for the breastfed child.
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Affiliation(s)
- M Ostensen
- Klinik für Rheumatologie und Klinische Immunologie/Allergologie, Inselspital Bern, Universitätsklinik, Bern.
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Andrade RM, Alarcón GS. Antimalarials in systemic lupus erythematosus: benefits beyond disease activity. ACTA ACUST UNITED AC 2006. [DOI: 10.2217/17460816.1.2.225] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Abstract
When systemic lupus erythematosus (SLE) is first suspected during pregnancy, though rare, the diagnostic criteria are not different from those for nonpregnant women. The pregnancy outcome is good if treatment with adequate immunosuppressive agents starts as soon as the diagnosis is made. There are 4 cases in this report who had SLE onset during pregnancy. Although 2 of them suffered from preeclampsia, all 4 pregnancies resulted in favorable outcomes after the lupus was controlled by medical treatment.
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Affiliation(s)
- Ming-Jie Yang
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, National Yang-Ming University School of Medicine, Taipei, Taiwan, ROC.
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Tincani A, Rebaioli CB, Frassi M, Taglietti M, Gorla R, Cavazzana I, Faden D, Taddei F, Lojacono A, Motta M, Trepidi L, Meroni P, Cimaz R, Ghirardello A, Doria A, Pisoni MP, Muscarà M, Brucato A. Pregnancy and autoimmunity: Maternal treatment and maternal disease influence on pregnancy outcome. Autoimmun Rev 2005; 4:423-8. [PMID: 16137607 DOI: 10.1016/j.autrev.2005.03.001] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2004] [Accepted: 03/09/2005] [Indexed: 11/25/2022]
Abstract
If a woman suffers from autoimmune disease (AD), several factors can affect pregnancy or neonatal outcome: repeated spontaneous pregnancy losses (frequently related to antiphospholipid antibodies (aPL)), neonatal lupus with complete congenital heart block (CHB) (linked to transplacental passage of IgG anti Ro/SS-A antibodies) and the disease activity itself that can affect the mother, the pregnancy and fetal outcome. If appropriately managed, the antiphospholipid syndrome (APS) is "one of the few tractable causes of pregnancy losses." A recent case control study, on babies from APS-mothers and healthy mothers, did not show any difference in the occurrence of neonatal complications. There are few data about the long-term outcome of babies born to patients with AD. We recently reported increased occurrence of learning disabilities in children born to aPL positive mothers with systemic lupus erythematosus (SLE). The modern management of pregnancy in patients with AD includes the treatment of disease flares, using drugs effective but safe for fetus. Corticosteroids and some immunosuppressive drugs can be used in pregnancy to control maternal disease. A prolonged fetal exposure to dexamethasone was reported to impair cerebral development, but we recently studied 6 children, born to patients treated with dexamathasone because of CHB, showing a normal intelligence quotient. The last 10-year experience shows that fetal exposure to antimalarial drugs should not be regarded as an important risk factor for gestational nor neonatal complications. However, information about long-term outcome of children exposed to immunosuppressive drugs "in utero" are still lacking and more efforts are needed in this research area.
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Bolaños-Meade J, Zhou L, Hoke A, Corse A, Vogelsang G, Wagner KR. Hydroxychloroquine causes severe vacuolar myopathy in a patient with chronic graft-versus-host disease. Am J Hematol 2005; 78:306-9. [PMID: 15795921 DOI: 10.1002/ajh.20294] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
A 51-year-old man developed progressive debilitating limb and respiratory muscle weakness while undergoing treatment for chronic graft-versus-host disease secondary to allogeneic bone marrow transplant for mantle cell lymphoma. He had a normal serum creatine kinase level and acetylcholine receptor antibodies were negative. Electromyography showed a severe, nonirritable myopathy and a sensory motor axonal polyneuropathy. A muscle biopsy showed a necrotizing, vacuolar myopathy with many fibers containing autophagic and red-rimmed vacuoles, suggestive of an amphiphilic drug myopathy. The patient's strength and function improved significantly after discontinuation of hydroxychloroquine.
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Affiliation(s)
- Javier Bolaños-Meade
- Department of Oncology, The Johns Hopkins Hospital, Baltimore, Maryland 21287, USA
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Cheng HH, Ho CM, Huang CJ, Hsu SS, Jiann BP, Chen JS, Huang JK, Chang HT, Lo YK, Yeh JH, Jan CR. Defect in regulation of Ca2+ movement in platelets from patients with systemic lupus erythematosus. Pharmacology 2004; 73:169-74. [PMID: 15591819 DOI: 10.1159/000082610] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2004] [Accepted: 10/08/2004] [Indexed: 11/19/2022]
Abstract
The differences in the intracellular Ca(2+) responses to hormones in platelets from systemic lupus erythematosus (SLE) patients compared to normal humans have not been explored. This study examined the Ca(2+) signaling and density of platelets in normal, inactive and active SLE patients. The platelet number per mul in inactive and normal groups did not differ, whereas the number in active SLE patients was smaller than the other two groups by 60%. The intracellular free Ca(2+) levels ([Ca(2+)](i)) in response to stimulation of four endogenous Ca(2+) mobilizing hormones, 100 microM arachidonic acid (AA), 10 microM ADP, 10 nM platelet activation factor (PAF) and 1 microM thrombin, were investigated using the Ca(2+)-sensitive fluorescent dye, fura-2. The AA-induced [Ca(2+)](i) rises in normal and inactive groups were similar. In contrast, the AA-induced [Ca(2+)](i) rises in the active SLE group were significantly smaller than in the normal and inactive groups. The defect in the AA-induced [Ca(2+)](i) rises in active SLE groups appears to be caused by defective Ca(2+) influx and Ca(2+) releasing pathways because the AA-induced responses were not altered by removal of extracellular Ca(2+), whereas the AA-induced responses in normal and inactive SLE groups were reduced by removal of extracellular Ca(2+), and the AA-induced Ca(2+) release was smaller in the active SLE group. PAF, ADP and thrombin all induced [Ca(2+)](i) rises in the three groups, but no significant differences were found among the three groups. Together, the results indicate that cell density and Ca(2+) signaling in platelets from active SLE patients are altered in response to particular stimulators. In these regards, platelets from inactive SLE patients appear to be similar to those from normal humans.
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Affiliation(s)
- He-Hsiung Cheng
- Department of Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
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Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2002; 11:529-44. [PMID: 12426939 DOI: 10.1002/pds.662] [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]
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