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Yang T, Shi Y, Wang Y, Feng Y, Shao Q, Jiang C, Wang L, Liu J. Hydroxychloroquine blood concentrations and effects in Chinese patients with IgA nephropathy. J Nephrol 2024:10.1007/s40620-024-02029-z. [PMID: 39048780 DOI: 10.1007/s40620-024-02029-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 07/09/2024] [Indexed: 07/27/2024]
Abstract
BACKGROUND Hydroxychloroquine (HCQ) is recommended for Chinese patients with immunoglobulin A nephropathy (IgAN). However, the relationship between HCQ blood concentration and the therapeutic effect for IgAN has not yet been defined. This study investigates the optimal and efficacious range of HCQ blood concentrations in Chinese patients with IgAN. METHODS Seventy-three patients with biopsy-proven IgAN who were at risk of progression were included in this study. Thirty-eight patients with IgAN were treated with HCQ plus an optimized renin-angiotensin-aldosterone system inhibitor (RAASi), and thirty-five patients received only RAASi. Blood HCQ concentration and 24-h proteinuria were examined at three and six months after treatment. RESULTS The baseline proteinuria levels were comparable between the RAASi and HCQ groups. The HCQ group had lower 24-h proteinuria than the RAASi group three months after treatment, though the difference was not significant (p = 0.38). After six months, the median proteinuria level was significantly lower in the HCQ group than in the RAASi group (p < 0.05). The percentage reduction in 24-h proteinuria in the HCQ group was greater than that in the RAASi group at three (p < 0.05) and six months (p < 0.05). Hydroxychlorquine blood concentration and efficacy were positively correlated at three months (r = 0.428, p < 0.05) and six months (r = 0.48, p < 0.05). Moreover, the optimal blood concentration of HCQ for three-month efficacy was 418.96 ng/mL and that for six-month efficacy was 582.48 ng/mL. No serious adverse events were reported during HCQ treatment. CONCLUSIONS Hydroxyhloroquine safely reduces proteinuria in Chinese patients with IgAN. The efficacy of HCQ is positively correlated with its blood concentration.
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Affiliation(s)
- Ting Yang
- Department of Nephrology, Affiliated Hospital of Medical School, Nanjing Drum Tower Hospital, Nanjing University, Nanjing, China
- Department of Pharmacy, Affiliated Hospital of Medical School, Nanjing Drum Tower Hospital, Nanjing University, Nanjing, China
| | - Yaotong Shi
- Department of Nephrology, Affiliated Hospital of Medical School, Nanjing Drum Tower Hospital, Nanjing University, Nanjing, China
- Department of Nephrology, Nanjing Drum Tower Hospital Clinical College of Jiangsu University, Zhenjiang, China
| | - Ye Wang
- Department of Pharmacy, Nanjing Brain Hospital, Nanjing, China
| | - Yuan Feng
- Department of Nephrology, Affiliated Hospital of Medical School, Nanjing Drum Tower Hospital, Nanjing University, Nanjing, China
| | - Qiuyuan Shao
- Department of Nephrology, Affiliated Hospital of Medical School, Nanjing Drum Tower Hospital, Nanjing University, Nanjing, China
| | - Chunming Jiang
- Department of Nephrology, Affiliated Hospital of Medical School, Nanjing Drum Tower Hospital, Nanjing University, Nanjing, China
| | - Lulu Wang
- Department of Nephrology, Affiliated Hospital of Medical School, Nanjing Drum Tower Hospital, Nanjing University, Nanjing, China.
- Department of Pharmacy, Affiliated Hospital of Medical School, Nanjing Drum Tower Hospital, Nanjing University, Nanjing, China.
| | - Jing Liu
- Department of Nephrology, Affiliated Hospital of Medical School, Nanjing Drum Tower Hospital, Nanjing University, Nanjing, China.
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Pasoto SG, Villamarín LEB, de Vinci Kanda Kupa L, Deveza GBH, Ribeiro CT, Emi Aikawa N, Leon EP, de Oliveira Martins VA, Silva CA, Bonfa E. Assessment of hydroxychloroquine blood levels in Sjögren's disease patients: drug adherence and clinical associations. Rheumatol Int 2024; 44:1305-1315. [PMID: 38294544 DOI: 10.1007/s00296-024-05545-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 01/18/2024] [Indexed: 02/01/2024]
Abstract
Hydroxychloroquine (HCQ) has been used to treat Sjögren's disease (SjD) patients. However, there are no studies evaluating drug adherence through HCQ blood levels, pharmacy refill (PR) and medication adherence questionnaires. The relationship of HCQ blood levels with glandular/extraglandular disease parameters was also poorly assessed. This cross-sectional observational study included 74 adult SjD patients, who were receiving a stable HCQ dose (4-5.5 mg/kg/day, actual weight) for at least 3 months before study inclusion. HCQ blood levels were quantified by high-performance liquid chromatography coupled to mass spectrometry. Adherence was assessed by PR and Medida de Adesão aos Tratamentos (MAT) questionnaire. The following parameters were evaluated: Xerostomia Inventory, Ocular Surface Disease Index, EULAR (European League Against Rheumatism) Sjögren's Syndrome Disease Activity Index, EULAR Sjögren's Syndrome Patient Reported Index, Schirmer's I test and non-stimulated/stimulated salivary flow rates. HCQ blood levels were 775.3(25.0-2,568.6)ng/mL. Eleven patients (14.9%) had HCQ blood levels < 200ng/mL (non-adherent group); 11(14.9%), 200-499ng/mL (sub-therapeutic levels group); and 52(70.2%), ≥ 500ng/mL (adherent group). PR classified incorrectly all non-adherent/sub-therapeutic patients and 2/52(3.9%) adherent patients. Using MAT, the overall misclassification was 24/52(46.2%) in the adherent group, and were correctly identified 9/11(81.8%) patients in non-adherent and 7/11(63.6%) in sub-therapeutic groups. MAT sensitivity and specificity to identify non-adherent/sub-therapeutic patients were 72.7% and 53.9%, respectively. The three groups were comparable regarding glandular/extraglandular disease parameters (p > 0.05). The assessment of HCQ blood levels is a promising tool for evaluating drug adherence in SjD. This is particularly crucial as one-third of patients exhibited non-adherence/sub-therapeutic levels, and neither PR nor MAT reliably identified these patients.
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Affiliation(s)
- Sandra Gofinet Pasoto
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil.
- Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Arnaldo, 455, 3o andar (Disciplina de Reumatologia), sala 3192, São Paulo, 01246-903, SP, Brazil.
| | | | - Léonard de Vinci Kanda Kupa
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Giordano Bruno Henriques Deveza
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Carolina Torres Ribeiro
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Nádia Emi Aikawa
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
- Pediatric Rheumatology Unit, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Elaine Pires Leon
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | | | - Clovis Artur Silva
- Pediatric Rheumatology Unit, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Eloisa Bonfa
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
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Yazdany J, Shiboski S, Schmajuk G. The Hydroxychloroquine Conundrum: Striking the Right Balance Between Safety and Efficacy in Rheumatology Practice. Arthritis Rheumatol 2024. [PMID: 38923852 DOI: 10.1002/art.42930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Revised: 05/30/2024] [Accepted: 05/30/2024] [Indexed: 06/28/2024]
Affiliation(s)
- Jinoos Yazdany
- University of California, San Francisco and Zuckerberg San Francisco General Hospital, San Francisco, California
| | | | - Gabriela Schmajuk
- University of California, San Francisco and San Francisco Veterans Affairs Medical Center, San Francisco, California
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4
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Coelho PS, Sousa AJO, Rodrigues ISR, Nascimento HS, Pantoja LC, Miranda MS. Preimplantation development of in vitro-produced bovine embryos treated with hydroxychloroquine. Toxicol In Vitro 2024; 98:105847. [PMID: 38759936 DOI: 10.1016/j.tiv.2024.105847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 04/29/2024] [Accepted: 05/14/2024] [Indexed: 05/19/2024]
Abstract
Hydroxychloroquine (HCQ) is a safe antimalarial drug but its overdosage or inappropriate use, such as during the pandemic, may cause adverse effects once this drug is considered a potent inhibitor of autophagy. Information about HCQ's effects on the reproductive field, including gametes and initial embryos, is limited. In this study, we evaluated the effect of HCQ (1, 6, 12, and 24 μM) on pre-implantation embryo development, autophagy, and apoptosis of bovine embryos produced in vitro. A dose-response experiment showed a reduction (p < 0.05) in cleavage only at the highest concentration. Blastocyst rate was gradually reduced (p < 0.05) with the increase of HCQ dosage starting at 6 μM, with no embryo formation occurring at 24 μM. Further analysis showed that embryos treated with 12 μM of HCQ had a higher (p < 0.05) accumulation of acidic autophagic vesicles on Days 5 and 7 of development and a higher (p < 0.01) apoptotic index on Day 7. To our knowledge, this is the first study to evaluate the effects of HCQ on embryo pre-implantation development in mammals. The results contribute with more information related to the study of autophagy in embryology as well as add some discussion on HCQ toxicology and its effects on reproductive cells.
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Affiliation(s)
- P S Coelho
- Laboratory of Amazon Animal Biotechnology and Medicine (BIOMEDAM), Veterinary Medicine Institute, Federal University of Pará, City of Castanhal 68741-740, Pará State, Brazil
| | - A J O Sousa
- Laboratory of Amazon Animal Biotechnology and Medicine (BIOMEDAM), Veterinary Medicine Institute, Federal University of Pará, City of Castanhal 68741-740, Pará State, Brazil
| | - I S R Rodrigues
- Laboratory of Amazon Animal Biotechnology and Medicine (BIOMEDAM), Veterinary Medicine Institute, Federal University of Pará, City of Castanhal 68741-740, Pará State, Brazil
| | - H S Nascimento
- Laboratory of Amazon Animal Biotechnology and Medicine (BIOMEDAM), Veterinary Medicine Institute, Federal University of Pará, City of Castanhal 68741-740, Pará State, Brazil
| | - L C Pantoja
- Laboratory of Amazon Animal Biotechnology and Medicine (BIOMEDAM), Veterinary Medicine Institute, Federal University of Pará, City of Castanhal 68741-740, Pará State, Brazil
| | - M S Miranda
- Laboratory of Amazon Animal Biotechnology and Medicine (BIOMEDAM), Veterinary Medicine Institute, Federal University of Pará, City of Castanhal 68741-740, Pará State, Brazil.
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Rúa-Figueroa Í, Salman-Monte TC, Pego Reigosa JM, Galindo Izquierdo M, Díez Álvarez E, Fernández-Nebro A, Román Ivorra JA, Calvo Penades I, Artaraz Beobide J, Calvo Alén J. Multidisciplinary consensus on the use of hydroxychloroquine in patients with systemic lupus erythematosus. REUMATOLOGIA CLINICA 2024; 20:312-319. [PMID: 38991825 DOI: 10.1016/j.reumae.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 03/12/2024] [Accepted: 03/21/2024] [Indexed: 07/13/2024]
Abstract
BACKGROUND Hydroxychloroquine (HCQ) is the first-line treatment for systemic lupus erythematosus (SLE); however, there is heterogeneity in its clinical use. This consensus aims to bridge the gap in SLE treatment by providing practical and valuable recommendations for health professionals. METHODS The methodology used is based on a systematic literature review and a nominal group technique (NGT). A ten-member scientific committee formulated eight clinically relevant questions. First, a systematic review was conducted to identify the available evidence, which the scientific committee evaluated to developed recommendations based on their expertise, achieving consensus through NGT. RESULTS 1673 titles and abstracts were screened, and 43 studies were included for meeting the inclusion criteria. The scientific committee established 11 recommendations for HCQ use in initiation, maintenance, and monitoring, considering benefits and potential adverse effects of HCQ. Unanimous agreement was achieved on all recommendations. CONCLUSIONS The available evidence supports HCQ's effectiveness and safety for SLE. Individualized assessment of the initial HCQ dose is important, especially in situations requiring dose reduction or discontinuation. This risk-benefit assessment, specifically focusing on the balance between retinal toxicity and the risk of SLE relapse, should guide decisions regarding medication withdrawal, considering disease activity, risk factors, and HCQ potential benefits. Close monitoring is essential for optimal disease management and minimize potential risks, such as QT prolongation or retinal toxicity.
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Affiliation(s)
- Íñigo Rúa-Figueroa
- Rheumatology Department, Gran Canaria University Hospital Doctor Negrin, Las Palmas de Gran Canaria, Spain
| | | | - José María Pego Reigosa
- Rheumatology Department, University Hospital of Vigo, IRIDIS-VIGO Group (Investigation in Rheumatology and Immune-Mediated Diseases), Galicia South Health Research Institute (IISGS), Vigo, Spain
| | | | | | - Antonio Fernández-Nebro
- Biomedical Research Institute of Malaga (IBIMA) - Plataforma Bionand, UGC of Rheumatology, Regional University Hospital of Malaga, Department of Medicine and Dermatology, University of Malaga, Malaga, Spain
| | | | | | - Joseba Artaraz Beobide
- Department of Ophthalmology, BioCruces Bizkaia Health Research Institute, Cruces University Hospital, Barakaldo, Spain
| | - Jaime Calvo Alén
- Rheumatology Department, Araba University Hospital, Vitoria, Spain; Research Institute BIOARABA, Spain; País Vasco University, Spain.
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Théate N, Geoffroy M, Kanagaratnam L, Gozalo C, Charlot I, Bolko L, Hittinger-Roux A, Djerada Z, Salmon JH. Urinary methotrexate dosage in rheumatoid arthritis, in patients treated for at least 6 months: a potential marker of adherence. RMD Open 2024; 10:e004024. [PMID: 38772677 PMCID: PMC11328664 DOI: 10.1136/rmdopen-2023-004024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 04/28/2024] [Indexed: 05/23/2024] Open
Abstract
OBJECTIVES Non-adherence to rheumatoid arthritis (RA) treatments must be identified. A methotrexate (MTX) urinary dosage (METU) was recently developed. The aim of our study was to assess adherence to MTX in RA using METU in real-life conditions and to compare it with indirect adherence measurement technics. METHODS We performed a cross-sectional study at Reims University Hospital. We included over 18-year-old patients with RA treated by MTX for more than 6 months. Patients were invited to complete demographic, clinical and psychological questionnaires and adherence measurement technics (Compliance Questionnaire of Rheumatology (CQR) and Medication Possession Ratio (MPR)). A urinary sample was collected to measure MTX and information about tolerance was evaluated through Methotrexate Intolerance Severity Score. RESULTS 84 patients were included, 26 using oral MTX, 58 subcutaneous (SC) MTX. Among them, 73% were female, mean age was 61.5 years, MTX mean dose was 15 mg/week and 61.9% were treated by biological DMARDs (Disease Modifying Antirheumatic Drugs). 77 patients (91.7%) were adherent to treatment according to METU, whereas MPR and CQR reported less adherence (69.5% and 61.9%, respectively). MPR and METU were not significantly different in SC MTX users (p=0.059). Non-adherent patients had a higher number of tender joints and C reactive protein value (p<0.05). CONCLUSION This is the first largest study evaluating MTX adherence in patients with RA using a urinary dosage. We identified that indirect adherence measurements did not reflect real-life adherence. It would be appreciable to realise METU, in a new study, in patients with RA with unexplained response to treatment, to consider it before escalating therapeutic strategy.
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Affiliation(s)
- Noémie Théate
- Rhumatologie, Université de Reims Champagne-Ardenne, Reims, France
- Rhumatologie, Centre Hospitalier Universitaire de Reims, Reims, France
| | - Marion Geoffroy
- Rhumatologie, Centre Hospitalier Universitaire de Reims, Reims, France
| | - Lukshe Kanagaratnam
- UR 3797 VieFra, Université de Reims Champagne-Ardenne, Reims, France
- Unité d'Aide Méthodologique, Centre Hospitalier Universitaire de Reims, Reims, France
| | - Claire Gozalo
- UR 3801 PPF, Université de Reims Champagne-Ardenne, Reims, France
- Pharmacologie-Toxicologie, Pôle de Biologie Territoriale, Centre Hospitalier Universitaire de Reims, Reims, France
| | - Isabelle Charlot
- Rhumatologie, Centre Hospitalier Universitaire de Reims, Reims, France
| | - Lois Bolko
- Rhumatologie, Centre Hospitalier Universitaire de Reims, Reims, France
| | | | - Zoubir Djerada
- UR 3801 PPF, Université de Reims Champagne-Ardenne, Reims, France
- Pharmacologie-Toxicologie, Pôle de Biologie Territoriale, Centre Hospitalier Universitaire de Reims, Reims, France
| | - Jean-Hugues Salmon
- Rhumatologie, Université de Reims Champagne-Ardenne, Reims, France
- Rhumatologie, Centre Hospitalier Universitaire de Reims, Reims, France
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Peng-Cheng L, Meng-Na L, Jian-Bin L, Shu-Jiao Y, Wu R. Advancements on the impact of hydroxychloroquine in systemic lupus erythematosus. Heliyon 2024; 10:e30393. [PMID: 38711668 PMCID: PMC11070867 DOI: 10.1016/j.heliyon.2024.e30393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 04/24/2024] [Accepted: 04/25/2024] [Indexed: 05/08/2024] Open
Abstract
Hydroxychloroquine (HCQ) has gained significant attention as a therapeutic option for systemic lupus erythematosus (SLE) because of its multifaceted mechanism of action. It is a lipophilic, lysosomotropic drug, that easily traverses cell membranes and accumulates in lysosomes. Once accumulated, HCQ alkalizes lysosomes within the cytoplasm, thereby disrupting their function and interfering with processes like antigen presentation. Additionally, HCQ has shown potential in modulating T-cell responses, inhibiting cytokine production, and influencing Toll-like receptor signaling. Its immunomodulatory effects have generated interest in its application for autoimmune disorders. Despite its established efficacy, uncertainties persist regarding the optimal therapeutic concentrations and their correlation with adverse effects such as retinal toxicity. Therefore, standardized dosing and monitoring guidelines are crucial. In this study, we provide a comprehensive review of the mechanisms, efficacy, dosing variations, and retinal toxicity profiles of HCQ, which are essential to optimize SLE treatment protocols and ensure patient safety.
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Affiliation(s)
- Liu Peng-Cheng
- Department of Rheumatology, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China
| | - Lv Meng-Na
- The First Clinical Medical College of Nanchang University, Nanchang, China
| | - Li Jian-Bin
- Department of Rheumatology, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China
| | - Yu Shu-Jiao
- Department of Rheumatology, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China
| | - Rui Wu
- Department of Rheumatology, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China
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Balevic S, Sun K, Rogers JL, Eudy A, Sadun RE, Maheswaranathan M, Doss J, Criscione-Schreiber L, O'Malley T, Clowse M, Weiner D. Interpreting hydroxychloroquine blood levels for medication non-adherence: a pharmacokinetic study. Lupus Sci Med 2024; 11:e001090. [PMID: 38688714 PMCID: PMC11086411 DOI: 10.1136/lupus-2023-001090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 04/20/2024] [Indexed: 05/02/2024]
Abstract
OBJECTIVE Characterise the relationship between hydroxychloroquine (HCQ) blood levels and the number of missed doses, accounting for dosage, dose timing and the large variability in pharmacokinetics (PK) between patients. METHODS We externally validated a published PK model and then conducted dosing simulations. We developed a virtual population of 1000 patients for each dosage across a range of body weights and PK variability. Using the model, 10 Monte Carlo simulations for each patient were conducted to derive predicted whole blood concentrations every hour over 24 hours (240 000 HCQ levels at steady state). To determine the impact of missed doses on levels, we randomly deleted a fixed proportion of doses. RESULTS For patients receiving HCQ 400 mg daily, simulated random blood levels <200 ng/mL were exceedingly uncommon in fully adherent patients (<0.1%). In comparison, with 80% of doses missed, approximately 60% of concentrations were <200 ng/mL. However, this cut-off was highly insensitive and would miss many instances of severe non-adherence. Average levels quickly dropped to <200 ng/mL after 2-4 days of missed doses. Additionally, mean levels decreased by 29.9% between peak and trough measurements. CONCLUSIONS We propose an algorithm to optimally interpret HCQ blood levels and approximate the number of missed doses, incorporating the impact of dosage, dose timing and pharmacokinetic variability. No single cut-off has adequate combinations of both sensitivity and specificity, and cut-offs are dependent on the degree of targeted non-adherence. Future studies should measure trough concentrations to better identify target HCQ levels for non-adherence and efficacy.
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Affiliation(s)
- Stephen Balevic
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Kai Sun
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jennifer L Rogers
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Amanda Eudy
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Rebecca Eli Sadun
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Mithu Maheswaranathan
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jayanth Doss
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | | | | | - Megan Clowse
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Daniel Weiner
- UNC Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA
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Manabe A, Sada RM, Miyake H, Akebo H, Tsugihashi Y, Hatta K. An observational study to identify causative factors for not using hydroxychloroquine in systemic lupus erythematosus. Sci Rep 2024; 14:7750. [PMID: 38565930 PMCID: PMC10987587 DOI: 10.1038/s41598-024-58463-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 03/29/2024] [Indexed: 04/04/2024] Open
Abstract
Hydroxychloroquine (HCQ) use is indicated for patients with systemic lupus erythematosus (SLE). Nevertheless, reports discussing the reasons for not prescribing HCQ are limited. We identified the factors that interfere with HCQ use in patients with SLE. This observational, single-center study included data from 265 patients with SLE in 2019. The patients were categorized into groups with and without a history of HCQ use. Between these groups, clinical characteristics were compared using univariate analysis and logistic regression models. Among the 265 patients, 133 (50.2%) had a history of HCQ use. Univariate analysis identified older age; longer disease duration; lower prednisolone dose, clinical SLE disease activity index 2000, and estimated glomerular filtration rate; higher C3 level; and lower anti-double-stranded DNA antibody concentration as HCQ non-use-related variables. Logistic regression models identified a positive association between HCQ non-use and longer disease duration (odds ratio [OR] 1.08), prednisolone dose ≤ 7.5 mg/day (OR 4.03), C3 level ≥ 73 mg/dL (OR 2.15), and attending physician having graduated > 10 years prior (OR 3.19). In conclusion, a longer disease duration, lower prednisolone dose, higher C3 level, and longer time since attending physicians' graduation correlated with HCQ non-use. Physicians and patients should be educated to facilitate HCQ use despite these factors.
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Affiliation(s)
- Atsushi Manabe
- Department of General Internal Medicine, Tenri Hospital, Tenri, Japan
- Department of Rheumatology and Clinical Immunology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Ryuichi Minoda Sada
- Department of General Internal Medicine, Tenri Hospital, Tenri, Japan.
- Department of Infection Control, Graduate School of Medicine, Osaka University, Suita, Japan.
- Department of Transformative Protection to Infectious Disease, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan.
| | - Hirofumi Miyake
- Department of General Internal Medicine, Tenri Hospital, Tenri, Japan
| | - Hiroyuki Akebo
- Department of General Internal Medicine, Tenri Hospital, Tenri, Japan
| | - Yukio Tsugihashi
- Medical Home Care Centre, Tenri Hospital, Shirakawa Branch, Tenri, Japan
| | - Kazuhiro Hatta
- Department of General Internal Medicine, Tenri Hospital, Tenri, Japan
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Ambler WG, Kaplan MJ. Vascular damage in systemic lupus erythematosus. Nat Rev Nephrol 2024; 20:251-265. [PMID: 38172627 DOI: 10.1038/s41581-023-00797-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2023] [Indexed: 01/05/2024]
Abstract
Vascular disease is a major cause of morbidity and mortality in patients with systemic autoimmune diseases, particularly systemic lupus erythematosus (SLE). Although comorbid cardiovascular risk factors are frequently present in patients with SLE, they do not explain the high burden of premature vascular disease. Profound innate and adaptive immune dysregulation seems to be the primary driver of accelerated vascular damage in SLE. In particular, evidence suggests that dysregulation of type 1 interferon (IFN-I) and aberrant neutrophils have key roles in the pathogenesis of vascular damage. IFN-I promotes endothelial dysfunction directly via effects on endothelial cells and indirectly via priming of immune cells that contribute to vascular damage. SLE neutrophils are vasculopathic in part because of their increased ability to form immunostimulatory neutrophil extracellular traps. Despite improvements in clinical care, cardiovascular disease remains the leading cause of mortality among patients with SLE, and treatments that improve vascular outcomes are urgently needed. Improved understanding of the mechanisms of vascular injury in inflammatory conditions such as SLE could also have implications for common cardiovascular diseases, such as atherosclerosis and hypertension, and may ultimately lead to personalized therapeutic approaches to the prevention and treatment of this potentially fatal complication.
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Affiliation(s)
- William G Ambler
- Systemic Autoimmunity Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Mariana J Kaplan
- Systemic Autoimmunity Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland, USA.
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11
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Liu PC, Luo SL, Lv MN, Wang Y, Li JB, Yu SJ, Wu R. Effect of hydroxychloroquine blood concentration on the efficacy and ocular toxicity of systemic lupus erythematosus. Sci Rep 2024; 14:7674. [PMID: 38561370 PMCID: PMC10984965 DOI: 10.1038/s41598-024-58391-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 03/28/2024] [Indexed: 04/04/2024] Open
Abstract
In the absence of evidence-based guidance on the impact of hydroxychloroquine (HCQ) blood concentration on efficacy and ocular toxicity in systemic lupus erythematosus (SLE), the clinical monitoring of HCQ blood concentration is not yet widely performed, which raised concerns about the necessity of conducting HCQ blood concentration monitoring. In this retrospective study, we consecutively enrolled 135 patients with SLE who received HCQ treatment for more than 6 months from July 2022 to December 2022. Ocular toxicity was evaluated by collecting relevant retinal parameters using optical coherence tomography angiography (OCTA). Therapeutic efficacy was evaluated using the SLE disease activity index (SLEDAI) and relevant clinical parameters. HCQ blood concentration was determined by high-performance liquid chromatography-tandem mass spectrometry (HPLC-MS/MS). Spearman correlation analysis revealed that the cumulative dose of HCQ was positively correlated with the foveal avascular zone (FAZ) perimeter and FAZ area (r = 0.734, P < 0.001; r = 0.784, P < 0.001). Meanwhile, the treatment duration of HCQ was positively correlated with FAZ perimeter and FAZ area (r = 0.761, P < 0.001; r = 0.882, P < 0.001). The univariate and multivariate logistic regression analyses indicated that HCQ blood concentration was associated with the disease activity of patients with SLE (odds ratio 0.994, 95% CI 0.990-0.999). HCQ blood concentration may be an important factor in assessing the therapeutic effectiveness of SLE patients. The HCQ-related ocular toxicity was a long-term effect related to long term exposure, rather than the blood concentration of HCQ at the time of testing. More importantly, when addressing HCQ-related ocular toxicity, it may be crucial to pay attention to the cumulative dose and treatment duration of HCQ.
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Affiliation(s)
- Peng-Cheng Liu
- Department of Rheumatology, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China
| | - Shui-Lin Luo
- Department of Rheumatology, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China
| | - Meng-Na Lv
- The First Clinical Medical College of Nanchang University, Nanchang, China
| | - Yan Wang
- Department of Rheumatology, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China
| | - Jian-Bin Li
- Department of Rheumatology, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China
| | - Shu-Jiao Yu
- Department of Rheumatology, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China
| | - Rui Wu
- Department of Rheumatology, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China.
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Pan Y, Le J, Lan L, Wang Y, Liu G, Shen X, Ren P, Chen J, Han F. Hydroxychloroquine Induces Remission for IgA Nephropathy With Mild to Moderate Proteinuria: A Single-Centered Retrospective Analysis. Cureus 2024; 16:e53395. [PMID: 38314382 PMCID: PMC10833060 DOI: 10.7759/cureus.53395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2024] [Indexed: 02/06/2024] Open
Abstract
BACKGROUND Hydroxychloroquine (HCQ) influences both toll-like receptor (TLR) signaling and leukocyte activation, which are speculated to play a role in the pathogenesis of IgA nephropathy (IgAN). METHODS This is a single-centered retrospective study involving 426 IgAN patients diagnosed from May 2016 to August 2020. All patients were matched according to a propensity score matching (PSM) to produce three groups: renin-angiotensin-aldosterone system inhibitors (RAASi) group (RAASi only), corticosteroids group (corticosteroids only or combined with RAASi), and HCQ group (HCQ only or combined with RAASi), consisting of 63 patients for each group. RESULTS After PSM, the median urine protein/creatinine ratio (UPCR) of overall patients was 0.91 g/g, while their median serum creatinine was 87.00 μmol/L. After the median follow-up period of 11.03 months, the total remission rates of the RAASi group, corticosteroids group, and HCQ groups were 49.21% (n = 31), 74.60% (n = 47), and 52.38% (n = 33), respectively (p = 0.017). Thirteen (6.88%) patients experienced a decline in estimated glomerular filtration rate (eGFR) of more than 25% from baseline, including six (9.52%) patients in the RAASi group, three (4.76%) patients in the corticosteroids group, and four (6.35%) patients in HCQ group (p = 0.677). One (1.59%) patient in the HCQ group had blurred vision and continued to use HCQ after ruling out retinal lesions by ophthalmic examination. CONCLUSION HCQ is effective in inducing remission and well-tolerated in IgAN patients with mild to moderate proteinuria.
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Affiliation(s)
- Yixuan Pan
- Nephrology, Kidney Disease Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, CHN
| | - Jingyun Le
- Nephrology, Kidney Disease Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, CHN
| | - Lan Lan
- Nephrology, Kidney Disease Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, CHN
| | - Yaomin Wang
- Nephrology, Kidney Disease Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, CHN
| | - Guangjun Liu
- Nephrology, Kidney Disease Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, CHN
| | - Xiaoqi Shen
- Nephrology, Kidney Disease Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, CHN
| | - Pingping Ren
- Nephrology, Kidney Disease Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, CHN
| | - Jianghua Chen
- Nephrology, Kidney Disease Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, CHN
| | - Fei Han
- Nephrology, Kidney Disease Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, CHN
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Garg S, Chewning B, Hutson P, Astor BC, Bartels CM. Reference Range of Hydroxychloroquine Blood Levels That Can Reduce Odds of Active Lupus and Prevent Flares. Arthritis Care Res (Hoboken) 2024; 76:241-250. [PMID: 37667434 DOI: 10.1002/acr.25228] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 08/04/2023] [Accepted: 08/31/2023] [Indexed: 09/06/2023]
Abstract
OBJECTIVE Recent data show that lower hydroxychloroquine (HCQ) doses are associated with a two- to six-fold higher risk of lupus flares. Thus, establishing an effective reference range of HCQ blood levels with upper and lower bounds for efficacy may support individualizing HCQ dosing to prevent flares. METHODS HCQ levels in whole blood and Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) were measured during the baseline visit and again during a standard of care routine follow-up visit. Active cross-sectional lupus at baseline was defined as SLEDAI ≥6; a within subject flare was defined as a subsequent three-point increase in SLEDAI with clinical symptoms requiring therapy change. We examined associations between active lupus and HCQ blood levels at baseline and flares and HCQ levels during 6 to 12-month routine lupus follow-up visits using mixed regression analysis. RESULTS Among 158 baseline patient visits, 19% had active lupus. Odds of active lupus were 71% lower in patients with levels within a 750 to 1,200 ng/mL range (adjusted odds ratio 0.29, 95% confidence interval 0.08-0.96). Using convenience sampling strategy during a pandemic, we longitudinally followed 42 patients. Among those patients, 17% flared during their follow-up visit. Maintaining HCQ levels within 750 to 1,200 ng/mL reduced the odds of a flare by 26% over a nine-month median follow-up. CONCLUSION An effective reference range of HCQ blood levels, 750 to 1,200 ng/mL, was associated with 71% lower odds of active lupus, and maintaining levels within this range reduced odds of flares by 26%. These findings could guide clinicians to individualize HCQ doses to maintain HCQ levels within this range to maximize efficacy.
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Affiliation(s)
- Shivani Garg
- University of Wisconsin School of Medicine and Public Health, Madison
| | | | - Paul Hutson
- University of Wisconsin School of Pharmacy, Madison
| | - Brad C Astor
- University of Wisconsin School of Medicine and Public Health, Madison
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14
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Zhao H, Pan M, Liu Y, Cheng F, Shuai Z. Evaluation of early retinal changes in patients on long-term hydroxychloroquine using optical coherence tomography angiography. Ther Adv Drug Saf 2024; 15:20420986231225851. [PMID: 38300766 PMCID: PMC10823852 DOI: 10.1177/20420986231225851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 12/21/2023] [Indexed: 02/03/2024] Open
Abstract
Background Connective tissue diseases (CTD), including systemic lupus erythematosus and rheumatoid arthritis (RA), have long been treated with hydroxychloroquine (HCQ). However, prolonged HCQ use poses a risk of adverse effects, particularly retinopathy. Objective To detect early retinal changes assessed by optical coherence tomography angiography (OCTA) in CTD patients with long-term HCQ treatment and to explore the relationship between OCTA parameters and the concentrations of HCQ and its metabolites. Design A cross-sectional study conducted from March 2020 to October 2021 at the First Affiliated Hospital of Anhui Medical University. Methods The area and perimeter of the foveal avascular zone (FAZ), the thickness of the fovea and parafovea, and the vascular density of the superficial capillary plexus (SCP) and deep capillary plexus (DCP) in each area of the macula were measured by OCTA in 43 CTD patients treated with HCQ for over 6 months. Meantime, blood concentrations of HCQ and its metabolites were determined by high-performance liquid chromatography-tandem mass spectrometry, and the clinical documents of all 43 involved patients were collected. Results There is no significant correlation between OCTA outcomes and the patient's age, disease duration, and weight-dependent dose. HCQ cumulative duration positively correlated with FAZ area and perimeter (r = 0.419, p = 0.005 and r = 0.407, p = 0.007, respectively) and negatively correlated with the foveal vessel density in DCP (r = -0.378, p = 0.012). HCQ cumulative dose had a positive correlation with FAZ area and perimeter (r = 0.445, p = 0.003 and r = 0.434, p = 0.004, respectively) and had a negative correlation with foveal vessel density in SCP and DCP (r = -0.383, p = 0.011 and r = -0.424, p = 0.005, respectively). OCTA outcomes did not correlate with HCQ and its metabolite concentrations. Conclusion OCTA could be used to detect microvascular changes in the macula of CTD patients with long-term HCQ therapy. It was not found the concentrations of HCQ and its metabolites were associated with retinal vascular changes.
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Affiliation(s)
- Huanhuan Zhao
- Department of Rheumatology, First Affiliated Hospital of Anhui Medical University, Hefei, China
- Anhui Public Health Clinical Center, Hefei, China
| | - Menglu Pan
- Department of Rheumatology, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Yaping Liu
- Department of Clinical Medicine, Anhui Medical University, Hefei, China
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Fangyue Cheng
- Department of Rheumatology, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Zongwen Shuai
- Department of Rheumatology, First Affiliated Hospital of Anhui Medical University, No. 218, Jixi Road, Hefei 230022, China
- Anhui Public Health Clinical Center, Hefei 230022, China
- Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, Hefei 230032, China
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15
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Chong KM, Jiang H, Lo EAG, Hong WZ, Wong ETY, Chan GC, Cho J. Therapeutic Drug Monitoring in Patients with Systemic Lupus Erythematosus: Utility and Gaps. J Clin Med 2024; 13:451. [PMID: 38256585 PMCID: PMC10816431 DOI: 10.3390/jcm13020451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 01/09/2024] [Accepted: 01/12/2024] [Indexed: 01/24/2024] Open
Abstract
Despite advances in the treatment of patients with systemic lupus erythematous (SLE), outcomes have remained suboptimal. Persistent disease activity, patient comorbidities and drug toxicities contribute to the accrual of progressive irreversible damage and high rates of morbidity and mortality. Currently, similar drug doses and regimens are promulgated in the treatment guidelines for all SLE patients, despite the vast differences in patient and environmental factors that affect the drugs' metabolism and blood concentrations. This causes a disconnect between drug dosing and drug blood concentrations, which can then result in unpredictability in drug toxicities and therapeutic effects. In this review, we discuss commonly used oral immunosuppressive medications in SLE, their pharmacogenomics, and factors affecting their metabolism and blood concentrations. Further, we highlight the role of therapeutic drug monitoring in SLE, which is the first accessible step to individualising therapy.
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Affiliation(s)
- Kar Mun Chong
- Division of Rheumatology, Department of Medicine, National University Hospital, Singapore 119074, Singapore;
| | - He Jiang
- Department of Pharmacy, National University Hospital, Singapore 119074, Singapore; (H.J.); (E.A.G.L.)
| | - Elaine Ah Gi Lo
- Department of Pharmacy, National University Hospital, Singapore 119074, Singapore; (H.J.); (E.A.G.L.)
| | - Wei-Zhen Hong
- Division of Nephrology, Department of Medicine, National University Hospital, Singapore 119074, Singapore; (W.-Z.H.); (E.T.-Y.W.); (G.C.C.)
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
| | - Emmett Tsz-Yeung Wong
- Division of Nephrology, Department of Medicine, National University Hospital, Singapore 119074, Singapore; (W.-Z.H.); (E.T.-Y.W.); (G.C.C.)
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
- National University Centre for Organ Transplantation, National University Hospital, Singapore 119074, Singapore
| | - Gek Cher Chan
- Division of Nephrology, Department of Medicine, National University Hospital, Singapore 119074, Singapore; (W.-Z.H.); (E.T.-Y.W.); (G.C.C.)
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
| | - Jiacai Cho
- Division of Rheumatology, Department of Medicine, National University Hospital, Singapore 119074, Singapore;
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
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16
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Pan M, Jin R, Dai Y, Gao B, Liu Y, Peng X, Qiao J, Shuai Z. The presumable effects of hydroxychloroquine and its metabolites in the treatment of systemic lupus erythematosus. Int Immunopharmacol 2024; 126:111269. [PMID: 38006753 DOI: 10.1016/j.intimp.2023.111269] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 11/10/2023] [Accepted: 11/17/2023] [Indexed: 11/27/2023]
Abstract
OBJECTIVE Hydroxychloroquine (HCQ) is an essential drug in the treatment of systemic lupus erythematosus (SLE). This study aimed to detect the concentrations of HCQ and its metabolites from peripheral blood of SLE patients and to investigate the relationship between those concentrations and SLE disease activity. METHODS 176 SLE patients treated with HCQ were enrolled in this study. The concentrations of HCQ and its metabolites in their peripheral blood were measured by high-performance liquid chromatography tandem mass spectrometry (HPLC-MS/MS). Patients' disease activity was evaluated with the systemic lupus erythematosus disease activity index (SLEDAI). The variables between different concentrations or treatments were statistically analyzed. Linear regression was employed to explore relationships between the concentrations of HCQ and its metabolites with the disease activity. RESULTS The SLEDAI was lower in patients with higher concentrations of HCQ, desethylhydroxychloroquine (DHCQ), and desethylchloroquine (DCQ) (P = 0.024, P = 0.018, and P = 0.003, respectively). There were no significant differences in SLEDAI and the concentrations of HCQ and its metabolites among groups with different treatments (P > 0.05). After adjusting age, gender, disease duration, HCQ dose adjusted to actual body weight, and glucocorticoid (GC) dose, the SLEDAI was negatively correlated with the concentrations of HCQ, DHCQ, DCQ and bisdesethylchloroquine (BDCQ) (P = 0.007, P = 0.011, P = 0.029, and P = 0.008, respectively). After grouping analysis, in patients treated with HCQ and GC, the SLEDAI was negatively correlated with concentrations of HCQ, DHCQ and BDCQ (P = 0.011, P = 0.035, and P = 0.036, respectively). CONCLUSIONS The concentrations of HCQ and metabolites were correlated with the SLE disease activity after adjusting possible confounding factors, indicating that HCQ and its metabolites might play certain immunoregulatory roles in SLE treatment. Moreover, GC might have a synergistic effect with HCQ. It is helpful in clinical management and follow-up to monitor the concentrations of HCQ and its metabolites in SLE patients.
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Affiliation(s)
- Menglu Pan
- Department of Rheumatology and Immunology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui Province 230022, China
| | - Ruimin Jin
- Department of Rheumatology and Immunology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui Province 230022, China
| | - Yaqian Dai
- Department of Clinical Laboratory, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui Province 230022, China
| | - Beibei Gao
- Department of Pharmacy, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui Province 230022, China
| | - Yue Liu
- Department of Rheumatology and Immunology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui Province 230022, China
| | - Xinchen Peng
- Department of Rheumatology and Immunology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui Province 230022, China
| | - Jinping Qiao
- Department of Clinical Laboratory, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui Province 230022, China.
| | - Zongwen Shuai
- Department of Rheumatology and Immunology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui Province 230022, China; Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, Hefei, Anhui Province 230032, China.
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17
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Jatta N, Stanslas J, Yong ACH, Ho WC, Wan Ahmad Kammal WSL, Chua EW, How KN. Whole blood hydroxychloroquine: Does genetic polymorphism of cytochrome P450 enzymes have a role? Clin Exp Med 2023; 23:4141-4152. [PMID: 37480404 DOI: 10.1007/s10238-023-01142-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 07/12/2023] [Indexed: 07/24/2023]
Abstract
Systemic lupus erythematosus (SLE) is a chronic autoimmune disease with a wide range of clinical manifestations and multifactorial etiologies ranging from environmental to genetic. SLE is associated with dysregulated immunological reactions, with increased immune complex formation leading to end-organ damages such as lupus nephritis, cutaneous lupus, and musculoskeletal disorders. Lupus treatment aims to reduce disease activity, prevent organ damage, and improve long-term patient survival and quality of life. Antimalarial, hydroxychloroquine (HCQ) is used as a first-line systemic treatment for lupus. It has shown profound efficacy in lupus and its associated conditions. However, wide variation in terms of clinical response to this drug has been observed among this group of patients. This variability has limited the potential of HCQ to achieve absolute clinical benefits. Several factors, including genetic polymorphisms of cytochrome P450 enzymes, have been stipulated as key entities leading to this inter-individual variation. Thus, there is a need for more studies to understand the role of genetic polymorphisms in CYP450 enzymes in the clinical response to HCQ. Focusing on the role of genetic polymorphism on whole blood HCQ in lupus disorder, this review aims to highlight up-to-date pathophysiology of SLE, the mechanism of action of HCQ, and finally the role of genetic polymorphism of CYP450 enzymes on whole blood HCQ level as well as clinical response in lupus.
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Affiliation(s)
- Njundu Jatta
- Department of Medicine, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, 43400, Serdang, Selangor, Malaysia
| | - Johnson Stanslas
- Department of Medicine, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, 43400, Serdang, Selangor, Malaysia
| | - Audrey Chee Hui Yong
- School of Pharmacy, MAHSA University, Bandar Saujana Putra, Jenjarom, Selangor, Malaysia
| | - Wen Chung Ho
- Department of Medicine, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, 43400, Serdang, Selangor, Malaysia
- Dermatology Unit, Hospital Sultan Abdul Aziz Shah, Universiti Putra Malaysia, Serdang, Malaysia
| | - Wan Syazween Lyana Wan Ahmad Kammal
- Department of Medicine, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, 43400, Serdang, Selangor, Malaysia
- Dermatology Unit, Hospital Sultan Abdul Aziz Shah, Universiti Putra Malaysia, Serdang, Malaysia
| | - Eng Wee Chua
- Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, Kuala Lumpur, Malaysia
| | - Kang Nien How
- Department of Medicine, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, 43400, Serdang, Selangor, Malaysia.
- Dermatology Unit, Hospital Sultan Abdul Aziz Shah, Universiti Putra Malaysia, Serdang, Malaysia.
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18
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Nguyen Y, Blanchet B, Urowitz MB, Hanly JG, Gordon C, Bae S, Romero‐Diaz J, Sanchez‐Guerrero J, Clarke AE, Bernatsky S, Wallace DJ, Isenberg DA, Rahman A, Merrill JT, Fortin PR, Gladman DD, Bruce IN, Petri M, Ginzler EM, Dooley MA, Ramsey‐Goldman R, Manzi S, Jönsen A, Alarcón GS, Van Vollenhoven RF, Aranow C, Le Guern V, Mackay M, Ruiz‐Irastorza G, Lim SS, Inanc M, Kalunian KC, Jacobsen S, Peschken CA, Kamen DL, Askanase A, Buyon J, Costedoat‐Chalumeau N. Association Between Severe Nonadherence to Hydroxychloroquine and Systemic Lupus Erythematosus Flares, Damage, and Mortality in 660 Patients From the SLICC Inception Cohort. Arthritis Rheumatol 2023; 75:2195-2206. [PMID: 37459273 PMCID: PMC10792124 DOI: 10.1002/art.42645] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 06/05/2023] [Accepted: 06/29/2023] [Indexed: 11/15/2023]
Abstract
OBJECTIVE The goals of this study were to assess the associations of severe nonadherence to hydroxychloroquine (HCQ), objectively assessed by HCQ serum levels, and risks of systemic lupus erythematosus (SLE) flares, damage, and mortality rates over five years of follow-up. METHODS The Systemic Lupus International Collaborating Clinics (SLICC) Inception Cohort is an international multicenter initiative (33 centers throughout 11 countries). The serum of patients prescribed HCQ for at least three months at enrollment were analyzed. Severe nonadherence was defined by a serum HCQ level <106 ng/mL or <53 ng/mL for HCQ doses of 400 or 200 mg/day, respectively. Associations with the risk of a flare (defined as a Systemic Lupus Erythematosus Disease Activity Index 2000 increase ≥4 points, initiation of prednisone or immunosuppressive drugs, or new renal involvement) were studied with logistic regression, and associations with damage (first SLICC/American College of Rheumatology Damage Index [SDI] increase ≥1 point) and mortality with separate Cox proportional hazard models. RESULTS Of the 1,849 cohort participants, 660 patients (88% women) were included. Median (interquartile range) serum HCQ was 388 ng/mL (244-566); 48 patients (7.3%) had severe HCQ nonadherence. No covariates were clearly associated with severe nonadherence, which was, however, independently associated with both flare (odds ratio 3.38; 95% confidence interval [CI] 1.80-6.42) and an increase in the SDI within each of the first three years (hazard ratio [HR] 1.92 at three years; 95% CI 1.05-3.50). Eleven patients died within five years, including 3 with severe nonadherence (crude HR 5.41; 95% CI 1.43-20.39). CONCLUSION Severe nonadherence was independently associated with the risks of an SLE flare in the following year, early damage, and five-year mortality.
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Affiliation(s)
- Yann Nguyen
- National Referral Centre for Rare Autoimmune and Systemic Diseases, Hôpital Cochin, AP‐HP Centre and Université Paris Cité and Centre de Recherche en Epidémiologie et Statistiques (CRESS), Unité Inserm 1153, Université de Paris CitéParisFrance
| | - Benoît Blanchet
- Biologie du médicament‐Toxicologie, AP‐HP Centre–Hôpital Cochin, Université Paris Cité, and UMR8038 CNRS, U1268 INSERM, Université Paris Cité, PRES Sorbonne Paris Cité, CARPEMParisFrance
| | | | - John G. Hanly
- Queen Elizabeth II Health Sciences Centre and Dalhousie UniversityHalifaxNova ScotiaCanada
| | - Caroline Gordon
- Institute of Inflammation and Ageing, University of BirminghamBirminghamUnited Kingdom
| | - Sang‐Cheol Bae
- Hanyang University Hospital for Rheumatic Diseases, Hanyang University Institute for Rheumatology, and Hanyang University Institute of Bioscience and BiotechnologySeoulKorea
| | | | | | - Ann E. Clarke
- Cumming School of MedicineUniversity of CalgaryCalgaryAlbertaCanada
| | | | | | | | | | | | | | - Dafna D. Gladman
- Toronto Western Hospital, University of TorontoTorontoOntarioCanada
| | - Ian N. Bruce
- NIHR Manchester Biomedical Research Centre, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Center and Centre for Epidemiology Versus Arthritis, The University of ManchesterManchesterUK
| | - Michelle Petri
- Johns Hopkins University School of MedicineBaltimoreMaryland
| | | | - Mary Anne Dooley
- Thurston Arthritis Research Center, University of North CarolinaChapel Hill
| | | | - Susan Manzi
- Allegheny Health NetworkPittsburghPennsylvania
| | | | | | | | - Cynthia Aranow
- Feinstein Institute for Medical ResearchManhassetNew York
| | - Véronique Le Guern
- National Referral Centre for Rare Autoimmune and Systemic Diseases, Hôpital Cochin, AP‐HP Centre, Université Paris CitéParisFrance
| | - Meggan Mackay
- Feinstein Institute for Medical ResearchManhassetNew York
| | | | - S. Sam Lim
- Emory University School of MedicineAtlantaGeorgia
| | | | | | - Søren Jacobsen
- Rigshospitalet, Copenhagen University HospitalCopenhagenDenmark
| | | | | | - Anca Askanase
- Hospital for Joint Diseases and, Seligman Centre for Advanced Therapeutics, New York UniversityNew York City
| | - Jill Buyon
- New York University School of MedicineNew York City
| | - Nathalie Costedoat‐Chalumeau
- National Referral Centre for Rare Autoimmune and Systemic Diseases, Hôpital Cochin, AP‐HP Centre and Université Paris Cité and Centre de Recherche en Epidémiologie et Statistiques (CRESS), Unité Inserm 1153, Université de Paris CitéParisFrance
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19
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Huang X, Shu Q, Luo X, Ge W, Xie H, Zhou Y. Analysis of Factors Influencing Whole Blood Hydroxychloroquine Concentration in Patients with Systemic Lupus Erythematosus in China. Rheumatol Ther 2023; 10:1597-1607. [PMID: 37755649 PMCID: PMC10654291 DOI: 10.1007/s40744-023-00598-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 09/01/2023] [Indexed: 09/28/2023] Open
Abstract
INTRODUCTION The aim of this study was to determine the factors associated with the concentrations of hydroxychloroquine (HCQ) and its major metabolite, desethylhydroxychloroquine (DHCQ), in patients with systemic lupus erythematosus (SLE). METHODS Patients with SLE taking oral HCQ for at least 3 months were recruited from the Department of Rheumatology and Immunology of Nanjing Drum Tower Hospital. Clinical characteristics and laboratory values were examined. The concentrations of HCQ and DHCQ were measured by high-performance liquid chromatography, and the effects of various factors on the concentrations were investigated. RESULTS A total of 272 patients were included in this study. The average concentration of HCQ was 690.90 ng/ml and the average concentration of DHCQ was 431.84 ng/ml. Multivariate analysis indicated that gender (P = 0.015), age (year) (P < 0.001), weight (kg) (P = 0.013), duration of HCQ use (month) (P < 0.001), systemic lupus erythematosus disease activity index (SLEDAI) (P < 0.001), platelet count (× 109/l) (P < 0.001), immunoglobulin G levels (g/l) (P = 0.014) were associated with low HCQ concentrations. Gender (P = 0.006), duration of HCQ use (month) (P < 0.001), SLEDAI (P = 0.007), and platelet count (× 109/l) (P < 0.001) were associated with low DHCQ concentrations. CONCLUSIONS Patients with SLE require long-term administration of HCQ, but blood levels vary widely between individuals. Studying the factors influencing the blood HCQ and DHCQ concentrations and optimizing the dose according to individual characteristics might help to improve the efficacy of HCQ. TRIAL REGISTRATION ChiCTR2300070628.
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Affiliation(s)
- Xuan Huang
- Department of Pharmacy, China Pharmaceutical University Nanjing Drum Tower Hospital, Nanjing, Jiangsu Province, China
| | - Qing Shu
- Department of Pharmacy, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008, Jiangsu Province, China
| | - Xuemei Luo
- Department of Pharmacy, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008, Jiangsu Province, China
| | - Weihong Ge
- Department of Pharmacy, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008, Jiangsu Province, China.
| | - Han Xie
- Department of Pharmacy, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008, Jiangsu Province, China.
| | - Yujie Zhou
- Department of Respiratory and Critical Care Medicine, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008, Jiangsu Province, China.
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20
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Zhang X, Guo Q, Sun S, Tang X, Shen W, Liang J, Yao G, Geng L, Ding S, Chen H, Wang H, Hua B, Wang D, Zhang H, Feng X, Sun L, Jin Z. Factors associated with 25-hydroxyvitamin D level in Chinese hospitalized patients with systemic lupus erythematosus: a retrospective cohort study. Rheumatol Int 2023:10.1007/s00296-023-05465-5. [PMID: 37750894 DOI: 10.1007/s00296-023-05465-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 09/08/2023] [Indexed: 09/27/2023]
Abstract
We aimed to investigate the factors associated with vitamin D deficiency and changes in 25 (OH)D levels, as well as the impact of those changes on disease activity and renal function among SLE patients. This retrospective cohort study was based on the medical records of SLE patients hospitalized between 2010 and 2021. We collected relevant information from this patient population. Logistic regression analysis was employed to determine the factors associated with vitamin D deficiency and increased 25 (OH)D levels, and we calculated the odds ratios (ORs) and 95% confidence intervals (CIs) accordingly. At baseline, among the 1257 SLE patients, the median and interquartile range of 25 (OH)D levels were 14 (9, 20) ng/ml, with 953 (75.8%) patients exhibiting 25 (OH)D deficiency (< 20 ng/ml). The presence of 25 (OH)D deficiency was found to be associated with renal involvement and a high glucocorticoid (GC) maintenance dose. Among the 383 patients who were followed up for an average of 18 months, an increase of at least 100% in 25 (OH)D levels was positively associated with a decreased GC maintenance dose and vitamin D3 supplementation, with adjusted odds ratios(OR) (95% confidence interval [CI]) of 2.16 (1.02, 4.59) and 1300 (70, 22300), respectively. Furthermore, an increased level of 25 (OH)D was significantly associated with a decrease in the Disease Activity Index 2000 score and the urinary protein/creatinine ratio. Patients with SLE have low vitamin D levels, especially those with impaired kidney function. Increased 25 (OH)D levels can be achieved through supplementation with high doses of vitamin D3 and are associated with improvements in disease activity and the urinary protein/creatinine ratio.
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Affiliation(s)
- Xueyi Zhang
- Department of Rheumatology and Immunology, China Pharmaceutical University, Nanjing Drum Tower Hospital, Nanjing, China
| | - Qingqing Guo
- Department of Rheumatology and Immunology, China Pharmaceutical University, Nanjing Drum Tower Hospital, Nanjing, China
| | - Siqin Sun
- Department of Rheumatology and Immunology, China Pharmaceutical University, Nanjing Drum Tower Hospital, Nanjing, China
| | - Xiaojun Tang
- Department of Rheumatology and Immunology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, China
| | - Wei Shen
- Department of Rheumatology and Immunology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, China
| | - Jun Liang
- Department of Rheumatology and Immunology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, China
| | - Genhong Yao
- Department of Rheumatology and Immunology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, China
| | - Linyu Geng
- Department of Rheumatology and Immunology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, China
| | - Shuai Ding
- Department of Rheumatology and Immunology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, China
| | - Hongwei Chen
- Department of Rheumatology and Immunology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, China
| | - Hong Wang
- Department of Rheumatology and Immunology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, China
| | - Bingzhu Hua
- Department of Rheumatology and Immunology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, China
| | - Dandan Wang
- Department of Rheumatology and Immunology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, China
| | - Huayong Zhang
- Department of Rheumatology and Immunology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, China
| | - Xuebing Feng
- Department of Rheumatology and Immunology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, China
| | - Lingyun Sun
- Department of Rheumatology and Immunology, China Pharmaceutical University, Nanjing Drum Tower Hospital, Nanjing, China.
- Department of Rheumatology and Immunology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, China.
- Rheumatology Medical Center and Stem Cell Intervention Center, The Affiliated Drum Tower Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, People's Republic of China.
| | - Ziyi Jin
- Department of Rheumatology and Immunology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, China.
- Rheumatology Medical Center and Stem Cell Intervention Center, The Affiliated Drum Tower Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, People's Republic of China.
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21
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Shimizu M, Furudate S, Nagai Y, Shimada K, Ohshima M, Setoguchi K, Hashiguchi M, Yokogawa N. Pharmacokinetics of hydroxychloroquine in Japanese systemic lupus erythematosus patients with renal impairment. Mod Rheumatol 2023; 33:953-960. [PMID: 36112484 DOI: 10.1093/mr/roac113] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 08/26/2022] [Accepted: 09/06/2022] [Indexed: 08/27/2023]
Abstract
OBJECTIVES Reduction of the hydroxychloroquine (HCQ) dosage is recommended in systemic lupus erythematosus (SLE) patients with renal impairment, but a pharmacokinetics (PK) study of patients with renal impairment has not yet been performed. METHODS We investigated the PK of both single and multiple doses of HCQ and its metabolites in SLE patients with renal impairment who newly started HCQ at a daily dose of 300 mg based on an ideal body weight dosage of 6.5 mg/kg. Population PK analysis was performed using a non-linear mixed-effects model. RESULTS In total, 219 samples from 21 patients were analysed. The PK of HCQ in blood after single and multiple oral administrations followed the two-compartment model. At steady state, the concentration ratio of HCQ to each metabolite was HCQ:desethylhydroxychloroquine:desethylchloroquine:bisdesethylchloroquine = 1:0.28:0.1:0.06. The HCQ concentration correlated positively with that of each metabolite. The estimated values (relative standard error) of the population PK parameters were the total clearance at 110 l/h (31%) and a central volume of distribution of 398 l (19%). Co-administration of prednisolone and age, but not renal impairment, were factors affecting the total clearance of HCQ. CONCLUSIONS From the PK perspective, a dosage reduction is unnecessary in SLE patients with impaired renal function.
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Affiliation(s)
- Mikiko Shimizu
- Department of Pharmaceutics and Pharmacometrics, School of Pharmacy, Shujitsu University, Okayama, Japan
- Department of Drug Metabolism and Pharmacokinetics, Faculty of Pharmaceutical Sciences, Aomori University, Aomori, Japan
| | - Sumito Furudate
- Department of Drug Metabolism and Pharmacokinetics, Faculty of Pharmaceutical Sciences, Aomori University, Aomori, Japan
| | - Yoshiki Nagai
- Department of Rheumatic Diseases, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Kota Shimada
- Department of Rheumatic Diseases, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Miho Ohshima
- Department of Rheumatology, Mitsui Memorial Hospital, Tokyo, Japan
| | - Keigo Setoguchi
- Department of Systemic Immunological Diseases, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Masayuki Hashiguchi
- Department of Clinical Pharmacology and Therapeutics, The Jikei University School of Medicine, Tokyo, Japan
| | - Naoto Yokogawa
- Department of Rheumatic Diseases, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
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Hawtin S, André C, Collignon-Zipfel G, Appenzeller S, Bannert B, Baumgartner L, Beck D, Betschart C, Boulay T, Brunner HI, Ceci M, Deane J, Feifel R, Ferrero E, Kyburz D, Lafossas F, Loetscher P, Merz-Stoeckle C, Michellys P, Nuesslein-Hildesheim B, Raulf F, Rush JS, Ruzzante G, Stein T, Zaharevitz S, Wieczorek G, Siegel R, Gergely P, Shisha T, Junt T. Preclinical characterization of the Toll-like receptor 7/8 antagonist MHV370 for lupus therapy. Cell Rep Med 2023; 4:101036. [PMID: 37196635 DOI: 10.1016/j.xcrm.2023.101036] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 11/17/2022] [Accepted: 04/12/2023] [Indexed: 05/19/2023]
Abstract
Genetic and in vivo evidence suggests that aberrant recognition of RNA-containing autoantigens by Toll-like receptors (TLRs) 7 and 8 drives autoimmune diseases. Here we report on the preclinical characterization of MHV370, a selective oral TLR7/8 inhibitor. In vitro, MHV370 inhibits TLR7/8-dependent production of cytokines in human and mouse cells, notably interferon-α, a clinically validated driver of autoimmune diseases. Moreover, MHV370 abrogates B cell, plasmacytoid dendritic cell, monocyte, and neutrophil responses downstream of TLR7/8. In vivo, prophylactic or therapeutic administration of MHV370 blocks secretion of TLR7 responses, including cytokine secretion, B cell activation, and gene expression of, e.g., interferon-stimulated genes. In the NZB/W F1 mouse model of lupus, MHV370 halts disease. Unlike hydroxychloroquine, MHV370 potently blocks interferon responses triggered by specific immune complexes from systemic lupus erythematosus patient sera, suggesting differentiation from clinical standard of care. These data support advancement of MHV370 to an ongoing phase 2 clinical trial.
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Affiliation(s)
- Stuart Hawtin
- Novartis Institutes for BioMedical Research, Novartis Pharma AG, 4056 Basel, Switzerland
| | - Cédric André
- Novartis Institutes for BioMedical Research, Novartis Pharma AG, 4056 Basel, Switzerland
| | | | - Simone Appenzeller
- Department of Orthopedics, Rheumatology, and Traumatology, School of Medical Science, University of Campinas (UNICAMP), Campinas, 13083-887 São Paulo, Brazil
| | - Bettina Bannert
- Department of Rheumatology, University Hospital Basel and University of Basel, 4031 Basel, Switzerland
| | - Lea Baumgartner
- Novartis Institutes for BioMedical Research, Novartis Pharma AG, 4056 Basel, Switzerland
| | - Damian Beck
- Novartis Institutes for BioMedical Research, Novartis Pharma AG, 4056 Basel, Switzerland
| | - Claudia Betschart
- Novartis Institutes for BioMedical Research, Novartis Pharma AG, 4056 Basel, Switzerland
| | - Thomas Boulay
- Novartis Institutes for BioMedical Research, Novartis Pharma AG, 4056 Basel, Switzerland
| | - Hermine I Brunner
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Melanie Ceci
- Novartis Institutes for BioMedical Research, Novartis Pharma AG, 4056 Basel, Switzerland
| | - Jonathan Deane
- Novartis Institutes for BioMedical Research, Novartis Pharma AG, La Jolla, CA 92121, USA
| | - Roland Feifel
- Novartis Institutes for BioMedical Research, Novartis Pharma AG, 4056 Basel, Switzerland
| | - Enrico Ferrero
- Novartis Institutes for BioMedical Research, Novartis Pharma AG, 4056 Basel, Switzerland
| | - Diego Kyburz
- Department of Rheumatology, University Hospital Basel and University of Basel, 4031 Basel, Switzerland
| | - Frederique Lafossas
- Novartis Institutes for BioMedical Research, Novartis Pharma AG, 4056 Basel, Switzerland
| | - Pius Loetscher
- Novartis Institutes for BioMedical Research, Novartis Pharma AG, 4056 Basel, Switzerland
| | | | - Pierre Michellys
- Novartis Institutes for BioMedical Research, Novartis Pharma AG, La Jolla, CA 92121, USA
| | | | - Friedrich Raulf
- Novartis Institutes for BioMedical Research, Novartis Pharma AG, 4056 Basel, Switzerland
| | - James S Rush
- Novartis Institutes for BioMedical Research, Novartis Pharma AG, 4056 Basel, Switzerland
| | - Giulia Ruzzante
- Novartis Institutes for BioMedical Research, Novartis Pharma AG, 4056 Basel, Switzerland
| | - Thomas Stein
- Novartis Institutes for BioMedical Research, Novartis Pharma AG, 4056 Basel, Switzerland
| | - Samantha Zaharevitz
- Novartis Institutes for BioMedical Research, Novartis Pharma AG, La Jolla, CA 92121, USA
| | - Grazyna Wieczorek
- Novartis Institutes for BioMedical Research, Novartis Pharma AG, 4056 Basel, Switzerland
| | - Richard Siegel
- Novartis Institutes for BioMedical Research, Novartis Pharma AG, 4056 Basel, Switzerland
| | - Peter Gergely
- Novartis Institutes for BioMedical Research, Novartis Pharma AG, 4056 Basel, Switzerland
| | - Tamas Shisha
- Novartis Institutes for BioMedical Research, Novartis Pharma AG, 4056 Basel, Switzerland
| | - Tobias Junt
- Novartis Institutes for BioMedical Research, Novartis Pharma AG, 4056 Basel, Switzerland.
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Katarzyna PB, Wiktor S, Ewa D, Piotr L. Current treatment of systemic lupus erythematosus: a clinician's perspective. Rheumatol Int 2023:10.1007/s00296-023-05306-5. [PMID: 37171669 DOI: 10.1007/s00296-023-05306-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 03/04/2023] [Indexed: 05/13/2023]
Abstract
Systemic lupus erythematosus (SLE) is a chronic autoimmune disease. Its variable course makes it difficult to standardize patient treatment. This article aims at a literature review on available drugs for treating SLE and on drugs that have shown therapeutic effects in this disease. The PubMed/MEDLINE electronic search engine was used to identify relevant studies. This review presents the current therapeutic options, new biological therapies, and combination therapies of biologics with standard immunosuppressive and immunomodulating drugs. We have also underlined the importance to implement the treat-to-target strategy aimed at reducing or discontinuing therapy with glucocorticosteroids (GCs). The awareness of the benefits and risks of using GCs helps in refining their dosage and thereby obtaining a better safety profile. The advent of biological targeted therapies, and more recently, low-molecular-weight compounds such as kinase inhibitors, initiated numerous clinical trials in SLE patients and led to the approval of two biological drugs, belimumab, and anifrolumab, for SLE treatment. Progress in the treatment of SLE was reflected in the 2019 and 2021 recommendations of the European Alliance of Associations for Rheumatology (EULAR). However, a mass of recent clinical research data requires continuous consolidation to optimize patient outcomes.
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Affiliation(s)
- Pawlak-Buś Katarzyna
- Department of Internal Medicine, Poznań University of Medical Sciences, Poznań, Poland.
- Department of Rheumatology, Systemic Connective Tissue Diseases and Immunotherapy of Rheumatic Diseases, J. Struś Municipal Hospital, Poznań, Poland.
| | - Schmidt Wiktor
- Department of Rheumatology, Systemic Connective Tissue Diseases and Immunotherapy of Rheumatic Diseases, J. Struś Municipal Hospital, Poznań, Poland
- Doctoral School, Poznań University of Medical Sciences, Poznań, Poland
| | - Dudziec Ewa
- Department of Internal Medicine, Poznań University of Medical Sciences, Poznań, Poland
| | - Leszczyński Piotr
- Department of Internal Medicine, Poznań University of Medical Sciences, Poznań, Poland
- Department of Rheumatology, Systemic Connective Tissue Diseases and Immunotherapy of Rheumatic Diseases, J. Struś Municipal Hospital, Poznań, Poland
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24
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Zhong X, Jin YB, Zhang Q, Liu SL, He J. Low estimated glomerular filtration rate is an independent risk factor for higher hydroxychloroquine concentration. Clin Rheumatol 2023:10.1007/s10067-023-06576-x. [PMID: 36939974 DOI: 10.1007/s10067-023-06576-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 03/07/2023] [Accepted: 03/09/2023] [Indexed: 03/21/2023]
Abstract
BACKGROUND The aim of this study was to analyze the relationship of the estimated glomerular filtration rate (eGFR) to hydroxychloroquine (HCQ) blood concentrations in systemic lupus erythematosus (SLE) patients. METHOD Patients with SLE who had been taking HCQ for more than 12 months were recruited. All subjects gave written informed consent. Various clinical characteristics and laboratory values were examined. The blood concentration of HCQ was measured by high-performance liquid chromatography, and the relationship of eGFR to HCQ blood concentration was mainly investigated. RESULT In total, 115 patients with SLE receiving long-term HCQ therapy were included in the study. The median concentration of HCQ was 1096 ng/ml (range 116-8240 ng/ml). The eGFR was strongly associated with blood concentration of HCQ (P = 0.011, P < 0.05), when adjusted for age, sex, body mass index (BMI), weight-adjusted dose, prednisone use and immunosuppressive drug use. No statistically significant association were found between age, duration, BMI, weight-adjusted HCQ dose, corticosteroid use, immunosuppressant use and blood concentrations of HCQ. CONCLUSION We provided novel evidence that impaired renal function influenced the blood concentration of HCQ. Patients with low eGFR need to adjust the HCQ dosage according to the monitoring results of HCQ blood concentrations.
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Affiliation(s)
- Xue Zhong
- Department of Pharmacy, Peking University People's Hospital, Beijing, China
| | - Yue-Bo Jin
- Department of Rheumatology & Immunology, Peking University People's Hospital, No. 11 South Avenue, Xi Zhi Men, Xicheng District, Beijing, China
| | - Qin Zhang
- Ophthalmology Optometry Centre, Peking University People's Hospital, Beijing, China
- Key Laboratory of Diagnosis and Therapy of Retinal and Choroid Diseases, Beijing, China
| | - Si-Lu Liu
- Department of Pharmacy, Peking University People's Hospital, Beijing, China
| | - Jing He
- Department of Rheumatology & Immunology, Peking University People's Hospital, No. 11 South Avenue, Xi Zhi Men, Xicheng District, Beijing, China.
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25
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Sun K, Eudy AM, Rogers JL, Criscione-Schreiber LG, Sadun RE, Doss J, Maheswaranathan M, Barr AC, Eder L, Corneli AL, Bosworth HB, Clowse ME. Pilot Intervention to Improve Medication Adherence Among Patients With Systemic Lupus Erythematosus Using Pharmacy Refill Data. Arthritis Care Res (Hoboken) 2023; 75:550-558. [PMID: 34739191 PMCID: PMC9068832 DOI: 10.1002/acr.24806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 09/07/2021] [Accepted: 10/12/2021] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Despite high rates of medication nonadherence among patients with systemic lupus erythematosus (SLE), effective interventions to improve adherence in SLE are limited. We aimed to assess the feasibility of a pilot intervention and explore its effect on adherence. METHODS The intervention used pharmacy refill data to monitor nonadherence and prompt discussions surrounding SLE medications during clinic encounters. Over 12 weeks, the intervention was delivered through routine clinic visits by providers to patients with SLE who take SLE-specific medications. We measured acceptability, appropriateness, and feasibility using provider surveys. We also measured acceptability by patient surveys and feasibility by medical record documentation. We explored change in adherence by comparing percent of patients with medication possession ratio (MPR) ≥80% 3 months before and after the intervention visit using the McNemar's test. RESULTS Six rheumatologists participated; 130 patients were included in the analysis (median age 43, 95% female, and 59% racial and ethnic minorities). Implementation of the intervention was documented in 89% of clinic notes. Provider surveys showed high scores for feasibility (4.7/5), acceptability (4.4/5), and appropriateness (4.6/5). Among patient surveys, the most common reactions to the intervention visit were feeling determined (32%), empowered (32%), and proud (19%). Proportion of patients with MPR ≥80% increased from 48% to 58% (P = 0.03) after the intervention visit. CONCLUSION Our intervention showed feasibility, acceptability, and appropriateness and led to a statistically significant improvement in adherence. Future work should refine the intervention, assess its efficacy in a controlled setting, and adapt its use among other clinic settings.
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Affiliation(s)
- Kai Sun
- Division of Rheumatology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Amanda M. Eudy
- Division of Rheumatology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Jennifer L. Rogers
- Division of Rheumatology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | | | - Rebecca E. Sadun
- Division of Rheumatology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Jayanth Doss
- Division of Rheumatology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Mithu Maheswaranathan
- Division of Rheumatology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Ann Cameron Barr
- Division of Rheumatology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Lena Eder
- Division of Rheumatology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Amy L. Corneli
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Hayden B. Bosworth
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Megan E.B. Clowse
- Division of Rheumatology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
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26
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Anders HJ, Loutan J, Bruchfeld A, Fernández-Juárez GM, Floege J, Goumenos D, Turkmen K, van Kooten C, Frangou E, Stevens KI, Kronbichler A, Segelmark M, Tesar V. The management of lupus nephritis as proposed by EULAR/ERA 2019 versus KDIGO 2021. Nephrol Dial Transplant 2023; 38:551-561. [PMID: 34888694 DOI: 10.1093/ndt/gfab351] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Indexed: 11/12/2022] Open
Abstract
In 2019 and 2021, the European League for Rheumatism (EULAR) jointly with the European Renal Association (ERA) and the Kidney Disease: Improving Global Outcomes (KDIGO), respectively, released updated guidelines on the management of lupus nephritis (LN). The Immunology Working Group of the ERA reviewed and compared both updates. Recommendations were either consistent or differences were of negligible clinical relevance for: indication for kidney biopsy, kidney biopsy interpretation, treatment targets, hydroxychloroquine dosing, first-line initial immunosuppressive therapy for active class III, IV (±V) LN, pregnancy in LN, LN in paediatric patients and LN patients with kidney failure. Relevant differences in the recommended management relate to the recognition of lupus podocytopathies, uncertainties in steroid dosing, drug preferences in specific populations and maintenance therapy, treatment of pure class V LN, therapy of recurrent LN, evolving alternative drug options and diagnostic work-up of thrombotic microangiopathy. Altogether, both documents provide an excellent guidance to the growing complexity of LN management. This article endeavours to prevent confusion by identifying differences and clarifying discrepancies.
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Affiliation(s)
- Hans-Joachim Anders
- Division of Nephrology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Munich, Germany
| | - Jerome Loutan
- Division of Nephrology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Munich, Germany
| | - Annette Bruchfeld
- Department of Health, Medicine and Caring Sciences, Division of Diagnostics and Specialist Medicine, Linköping University, Linköping, Sweden.,Department of Clinical Science, Intervention and Technology, Division of Renal Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Gema M Fernández-Juárez
- Department of Nephrology, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, Spain
| | - Jürgen Floege
- Division of Nephrology, RWTH Aachen University Hospital, Aachen, Germany
| | - Dimitrios Goumenos
- Department of Nephrology and Renal Transplantation, Patras University Hospital, Patras, Greece
| | - Kultigin Turkmen
- Department of Internal Medicine, Division of Nephrology, Necmettin Erbakan University, Konya, Turkey
| | - Cees van Kooten
- Division of Nephrology and Transplant Medicine, Department of Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Eleni Frangou
- Department of Nephrology, Limassol General Hospital, Limassol, Cyprus
| | - Kate I Stevens
- The Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | | | - Mårten Segelmark
- Department of Clinical Science, Intervention and Technology, Division of Renal Medicine, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Sciences Lund, Division of Nephrology, Lund University and Skåne University Hospital, Lund, Sweden
| | - Vladimir Tesar
- Department of Nephrology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czechia
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Fasano S, Messiniti V, Iudici M, Coscia MA, Ciccia F. Hydroxychloroquine daily dose, hydroxychloroquine blood levels and the risk of flares in patients with systemic lupus erythematosus. Lupus Sci Med 2023; 10:10/1/e000841. [PMID: 36631164 PMCID: PMC9835942 DOI: 10.1136/lupus-2022-000841] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 01/04/2023] [Indexed: 01/13/2023]
Abstract
BACKGROUND Recent guidelines for SLE recommend using a hydroxychloroquine (HCQ) dose less than 5.0 mg/kg/day to reduce the risk of retinopathy. To determine if this dose reduction would have an impact on the clinical course of SLE, we compared flare incidence in a cohort of patients with SLE treated with two different oral HCQ dosages (≤5 mg/kg/day or >5 mg/kg/day). As a secondary analysis, we compared HCQ blood levels between the two different oral dosages, and evaluated the frequency of non-adherence in patients with SLE treated with HCQ. METHODS We identified a cohort of patients with SLE taking HCQ for at least 6 months and followed for 24 months. At study entry and 6 months later, a blood venous sample was taken to measure HCQ blood levels by liquid chromatography. Incidence of new SLE flares after recruitment was put in relation to daily HCQ dose and mean HCQ blood levels. Cox regression analysis served to identify factors associated with SLE flares. RESULTS 83 patients were enrolled. We observed 11 (16%) flares that developed in mean 14.8 months of follow-up. The difference in terms of flare rate and mean HCQ blood levels between the two oral dosages was not statistically significant. There was a trend (p=0.08) for high HCQ dose being associated with a lower flare rate. At Cox analysis, higher HCQ blood levels and older age at baseline were protective against flare occurrence, while concomitant immunosuppressant therapy showed significant positive association. HCQ blood levels did not correlate with prescribed HCQ dose. CONCLUSION Patients with low oral HCQ dosage tend to have more flares, although the difference was not statistically significant. Higher HCQ blood levels were protective against flare occurrence. The risks and benefits must be balanced in choosing HCQ dose.
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Affiliation(s)
- Serena Fasano
- Rheumatology Unit, Department of Precision Medicine, University of Campania, "Luigi Vanvitelli", Naples, Italy
| | - Valentina Messiniti
- Rheumatology Unit, Department of Precision Medicine, University of Campania, "Luigi Vanvitelli", Naples, Italy
| | - Michele Iudici
- Department of Internal Medicine Specialties, Geneva University Hospitals, Geneva, Switzerland
| | - Melania Alessia Coscia
- Rheumatology Unit, Department of Precision Medicine, University of Campania, "Luigi Vanvitelli", Naples, Italy
| | - Francesco Ciccia
- Rheumatology Unit, Department of Precision Medicine, University of Campania, "Luigi Vanvitelli", Naples, Italy
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Sun K, Coles TM, Voils CI, Anderson DR, Eudy AM, Sadun RE, Rogers JL, Criscione-Schreiber LG, Doss J, Maheswaranathan M, Clowse MEB. Development and Initial Validation of a Systemic Lupus Erythematosus-Specific Measure of the Extent of and Reasons for Medication Nonadherence. J Rheumatol 2022; 49:1341-1348. [PMID: 36243406 PMCID: PMC9722566 DOI: 10.3899/jrheum.220399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Medication nonadherence is common in patients with systemic lupus erythematosus (SLE) and negatively affects outcomes. To better recognize and address nonadherence in this population, there is a need for an easily implementable tool with interpretable scores. Domains of Subjective Extent of Nonadherence (DOSE-Nonadherence) is a measure that captures both extent of and reasons for nonadherence. We refined and evaluated DOSE-Nonadherence for patients with SLE. METHODS We refined the reasons for the nonadherence domain of DOSE-Nonadherence through rheumatologist feedback and patient cognitive interviewing. We then administered the refined instrument to patients prescribed oral SLE medications and compared the results to the Beliefs About Medicines Questionnaire (BMQ), the Medication Adherence Self-Report Inventory (MASRI), medication possession ratios (MPRs), and hydroxychloroquine (HCQ) blood levels using Pearson correlations. RESULTS Five rheumatologists provided feedback; 16 patients (median age 43 yrs, 100% female, 50% Black) participated in cognitive interviews and 128 (median age 49 yrs, 95% female, 49% Black, 88% on antimalarials, and 59% on immunosuppressants) completed the refined instrument. Items assessing extent of nonadherence produced reliable scores (α 0.89) and identified 47% as nonadherent. They showed convergent validity with MASRI (r = -0.57), HCQ blood levels (r = -0.55), to a lesser extent MPRs (r = -0.34 to -0.40), and discriminant validity with BMQ domains (r = -0.27 to 0.32). Nonadherent patients reported on average 3.5 adherence barriers, the most common being busyness/forgetting (62%), physical fatigue (38%), and pill fatigue (33%). CONCLUSION Our results support the reliability and validity of DOSE-Nonadherence for SLE medications. This refined instrument, DOSE-Nonadherence-SLE, can be used to identify, rigorously study, and guide adherence intervention development in SLE.
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Affiliation(s)
- Kai Sun
- K. Sun, MD, D.R. Anderson, MD, PhD, A.M. Eudy, PhD, J.L. Rogers, MD, L.G. Criscione-Schreiber, MD, MEd, J. Doss, MD, MPH, M. Maheswaranathan, MD, M.E.B. Clowse, MD, MPH, Division of Rheumatology and Immunology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina;
| | - Theresa M Coles
- T.M. Coles, PhD, Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Corrine I Voils
- C.I. Voils, PhD, William S Middleton Memorial Veterans Hospital and Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin
| | - D Ryan Anderson
- K. Sun, MD, D.R. Anderson, MD, PhD, A.M. Eudy, PhD, J.L. Rogers, MD, L.G. Criscione-Schreiber, MD, MEd, J. Doss, MD, MPH, M. Maheswaranathan, MD, M.E.B. Clowse, MD, MPH, Division of Rheumatology and Immunology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Amanda M Eudy
- K. Sun, MD, D.R. Anderson, MD, PhD, A.M. Eudy, PhD, J.L. Rogers, MD, L.G. Criscione-Schreiber, MD, MEd, J. Doss, MD, MPH, M. Maheswaranathan, MD, M.E.B. Clowse, MD, MPH, Division of Rheumatology and Immunology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Rebecca E Sadun
- R.E. Sadun, MD, PhD, Division of Rheumatology and Immunology, Department of Medicine, and Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jennifer L Rogers
- K. Sun, MD, D.R. Anderson, MD, PhD, A.M. Eudy, PhD, J.L. Rogers, MD, L.G. Criscione-Schreiber, MD, MEd, J. Doss, MD, MPH, M. Maheswaranathan, MD, M.E.B. Clowse, MD, MPH, Division of Rheumatology and Immunology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Lisa G Criscione-Schreiber
- K. Sun, MD, D.R. Anderson, MD, PhD, A.M. Eudy, PhD, J.L. Rogers, MD, L.G. Criscione-Schreiber, MD, MEd, J. Doss, MD, MPH, M. Maheswaranathan, MD, M.E.B. Clowse, MD, MPH, Division of Rheumatology and Immunology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Jayanth Doss
- K. Sun, MD, D.R. Anderson, MD, PhD, A.M. Eudy, PhD, J.L. Rogers, MD, L.G. Criscione-Schreiber, MD, MEd, J. Doss, MD, MPH, M. Maheswaranathan, MD, M.E.B. Clowse, MD, MPH, Division of Rheumatology and Immunology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Mithu Maheswaranathan
- K. Sun, MD, D.R. Anderson, MD, PhD, A.M. Eudy, PhD, J.L. Rogers, MD, L.G. Criscione-Schreiber, MD, MEd, J. Doss, MD, MPH, M. Maheswaranathan, MD, M.E.B. Clowse, MD, MPH, Division of Rheumatology and Immunology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Megan E B Clowse
- K. Sun, MD, D.R. Anderson, MD, PhD, A.M. Eudy, PhD, J.L. Rogers, MD, L.G. Criscione-Schreiber, MD, MEd, J. Doss, MD, MPH, M. Maheswaranathan, MD, M.E.B. Clowse, MD, MPH, Division of Rheumatology and Immunology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
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Balevic SJ, Randell R, Weiner D, Beard C, Schanberg LE, Hornik CP, Cohen-Wolkowiez M, Gonzalez D. Pharmacokinetics of hydroxychloroquine in paediatric lupus: data from a novel, direct-to-family clinical trial. Lupus Sci Med 2022; 9:9/1/e000811. [PMID: 36328395 PMCID: PMC9639143 DOI: 10.1136/lupus-2022-000811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 10/14/2022] [Indexed: 11/06/2022]
Abstract
Objective Determine the pharmacokinetics (PK) and exposure–response of hydroxychloroquine (HCQ) and desethylhydroxychloroquine (DHCQ) in paediatric SLE (pSLE). Methods We conducted an exploratory phase 2, direct-to-family trial. Children enrolled in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry with a diagnosis of pSLE were eligible if they were receiving HCQ as standard of care for ≥3 months. Biological samples were collected at up to four visits over a 6-month period. At each visit, plasma was obtained to measure the concentrations of HCQ and DHCQ, as well as cytokines. HCQ and DHCQ plasma PK data were analysed using a population PK modelling approach. Results Twenty-five subjects provided a total of 88 plasma concentrations for PK analysis. There was a poor linear fit between HCQ concentrations and total body weight (R2=0.03). There was a decline in both interferon (IFN)-alpha and IFN-gamma with higher concentrations of HCQ and DHCQ. Volume of distribution for HCQ in plasma was higher in children compared with published values in adults (73 000 L vs 44 000 L), but clearance values in children were similar to adults. Conclusions We report the first population PK model for HCQ and DHCQ in children using data from a novel direct-to-family clinical trial. We observed high interindividual variability in HCQ PK and found that weight-based dosing for HCQ is poorly correlated with drug concentrations, suggesting the need to use therapeutic drug monitoring to individualise dosing. Furthermore, our results suggest that the current weight-based dosing paradigm for HCQ may result in suboptimal drug exposures, particularly for children with obesity. Accordingly, additional studies of HCQ are needed in pSLE to determine the optimal drug concentration and dosing to reduce disease activity and improve outcomes. Trial registration number NCT04358302.
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Affiliation(s)
- Stephen J Balevic
- Pediatric Rheumatology, Duke University, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Rachel Randell
- Pediatric Rheumatology, Duke University, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Daniel Weiner
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Claire Beard
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Laura Eve Schanberg
- Pediatric Rheumatology, Duke University, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Christoph P Hornik
- Duke Clinical Research Institute, Durham, North Carolina, USA
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Michael Cohen-Wolkowiez
- Duke Clinical Research Institute, Durham, North Carolina, USA
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Luo M, Xie D, Lin Z, Sun H, Liu Y. Toxicology evaluation of overdose hydroxychloroquine on zebrafish (Danio rerio) embryos. Sci Rep 2022; 12:18259. [PMID: 36309536 PMCID: PMC9617536 DOI: 10.1038/s41598-022-23187-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 10/26/2022] [Indexed: 12/31/2022] Open
Abstract
Potential risks of treatment with hydroxychloroquine (HCQ) include QT interval prolongation, hypoglycemia, a wide range of neuropsychiatric manifestations, hematotoxicity, and potential genetic defects. HCQ is extremely toxic when used in overdose and can lead to tachycardia, hypotension, known central nervous system, transmission defects, hypokalemia and other manifestations in individuals. The mechanism of excessive HCQ leading to these manifestations is still unclear. In this paper, overdose HCQ at different concentrations was used to treat zebrafish embryos, and the phenomena like human beings were obtained, such as increased heart rate and nervous system inhibition. With the increase of concentration to 100 μM, embryo mortality and malformation rate increased and hatching rate decreased, in situ hybridization showed abnormal differentiation of embryo germ layers and formation of vital organs. We selected embryos treated with 50 μM HCQ, in which concentration the mortality rate, hatching rate and malformation rate of the embryos were like those of the control group, for transcriptome analysis. Although the above indexes did not change significantly, the molecular changes related to the development of the heart, eye, nerve and other important organs were significant. This study provides useful information for further research on the toxicity mechanism of HCQ overdose, and provides some insight that can guide future studies in humans.
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Affiliation(s)
- Min Luo
- grid.13291.380000 0001 0807 1581Prenatal Diagnosis Center, Department of Obstetrics & Gynecologic, Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, 610041 People’s Republic of China
| | - Dan Xie
- grid.13291.380000 0001 0807 1581Prenatal Diagnosis Center, Department of Obstetrics & Gynecologic, Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, 610041 People’s Republic of China
| | - Ziyuan Lin
- grid.13291.380000 0001 0807 1581SCU-CUHK Joint Laboratory for Reproductive Medicine, Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, 610041 People’s Republic of China
| | - Huaqin Sun
- grid.13291.380000 0001 0807 1581SCU-CUHK Joint Laboratory for Reproductive Medicine, Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, 610041 People’s Republic of China
| | - Yanyan Liu
- grid.13291.380000 0001 0807 1581Prenatal Diagnosis Center, Department of Obstetrics & Gynecologic, Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, 610041 People’s Republic of China
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Garg S, Chewning B, Gazeley D, Gomez S, Kaitz N, Weber AC, Rosenthal A, Bartels C. Patient and healthcare team recommended medication adherence strategies for hydroxychloroquine: results of a qualitative study informing intervention development. Lupus Sci Med 2022; 9:9/1/e000720. [PMID: 35914839 PMCID: PMC9345084 DOI: 10.1136/lupus-2022-000720] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 07/19/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Patients identified as black and from disadvantaged backgrounds have a twofold higher hydroxychloroquine (HCQ) non-adherence, which contributes to worse lupus outcomes and disparities. Yet, most adherence interventions lack tailored strategies for racially and socioeconomically diverse patients who face unique challenges with HCQ. We aimed to examine a broadly representative group of patients with SLE and physician perspectives on HCQ adherence and adherence strategies to redesign an adherence intervention. METHODS We conducted four virtual focus groups (90 min each) with 11 racially and socioeconomically diverse patients with SLE recruited from two health systems. Additionally, we hosted two focus group meetings with nine healthcare advisors. In focus groups, patients: (1) shared their perspectives on using HCQ; (2) shared concerns leading to non-adherence; (3) discussed strategies to overcome concerns; (4) prioritised strategies from the most to least valuable to inform an adherence intervention. In two separate focus groups, healthcare advisors gave feedback to optimise an adherence intervention. Using content analysis, we analysed transcripts to redesign our adherence intervention. RESULTS Worry about side effects was the most common barrier phrase mentioned by patients. Key themes among patients' concerns about HCQ included: information gaps, logistical barriers, misbeliefs and medication burden. Finally, patients suggested adherence strategies and ranked those most valuable including co-pay assistance, personal reminders, etc. Patient and healthcare advisors informed designing a laminate version of an adherence intervention to link each barrier category with four to six patient-recommended adherence strategies. CONCLUSION We developed a patient stakeholder-informed and healthcare stakeholder-informed tailored intervention that will target non-adherence at the individual patient level.
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Affiliation(s)
- Shivani Garg
- Department of Medicine, Division of Rheumatology, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Betty Chewning
- Department of Pharmacy, University of Wisconsin-Madison School of Pharmacy, Madison, Wisconsin, USA
| | - David Gazeley
- Department of Medicine, Rheumatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Shelby Gomez
- Department of Pharmacy, University of Wisconsin-Madison School of Pharmacy, Madison, Wisconsin, USA
| | - Noah Kaitz
- Department of Pharmacy, University of Wisconsin-Madison School of Pharmacy, Madison, Wisconsin, USA
| | - Amanda C Weber
- Department of Medicine, Division of Rheumatology, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Ann Rosenthal
- Department of Medicine, Division of Rheumatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Christie Bartels
- Department of Medicine, Division of Rheumatology, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
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De Gregori S, Falaschi F, Ballesio A, Fusco A, Cremonte E, Canta R, Sabatini U, Molinaro M, Soffiantini C, Nardone A, Vicentini A, De Silvestri A, Di Sabatino A. Hydroxychloroquine Blood Concentrations Can Be Clinically Relevant Also After Drug Discontinuation. Drugs R D 2022; 22:155-163. [PMID: 35553396 PMCID: PMC9103606 DOI: 10.1007/s40268-022-00387-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2022] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Hydroxychloroquine was widely used during the severe acute respiratory syndrome coronavirus 2 pandemic as an antiviral drug. Most previous pharmacokinetic/pharmacodynamic studies on hydroxychloroquine were conducted on healthy volunteers or patients receiving long-term therapy. There are no studies on the elimination of hydroxychloroquine after short-term treatments. Hydroxychloroquine is known to have a pro-arrhythmic effect through QT interval prolongation, but data in this setting are not conclusive. Our aims were to estimate the time needed for hydroxychloroquine concentrations (CHCQ) to drop to a safe concentration (500 ng/mL) after a short-term therapeutic cycle and to correlate the corrected QT interval with CHCQ. METHODS We collected blood samples and electrocardiograms of patients who underwent short-term therapy with hydroxychloroquine during drug intake and after discontinuation. Hydroxychloroquine concentrations were determined by high-performance liquid chromatography-tandem mass spectrometry and analysed with a linear regression model to estimate the elimination time of the drug after its discontinuation. We conducted a multivariate analysis of the corrected QT interval correlation with CHCQ. RESULTS Our data suggest that short-term hydroxychloroquine courses can generate significant CHCQ persisting above 500 ng/mL up to 16 days after discontinuation of treatment. Corrected QT interval prolongation significantly correlates with CHCQ. CONCLUSIONS The study confirms the long half-life of hydroxychloroquine and its effect on the corrected QT interval even after short-term courses of the drug. This can inform the clinician using hydroxychloroquine treatments that it would be safer to start or re-initiate treatments with corrected QT interval-prolonging potential 16 days after hydroxychloroquine discontinuation.
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Affiliation(s)
- Simona De Gregori
- Clinical and Experimental Pharmacokinetics Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Francesco Falaschi
- Internal Medicine 2, Fondazione I.R.C.C.S. Policlinico San Matteo, Pavia, Italy.
| | - Alessia Ballesio
- Department of Internal Medicine, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Alessandra Fusco
- Department of Internal Medicine, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Elisa Cremonte
- Department of Internal Medicine, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Roberta Canta
- Department of Internal Medicine, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Umberto Sabatini
- Department of Internal Medicine, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Mariadelfina Molinaro
- Clinical and Experimental Pharmacokinetics Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Carlo Soffiantini
- Department of Internal Medicine, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Alba Nardone
- Department of Internal Medicine, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Alessandro Vicentini
- Cardiac Intensive Care Unit, Arrhythmia and Electrophysiology and Laboratory of Clinical and Experimental Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Annalisa De Silvestri
- Clinical Epidemiology and Biometry Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Antonio Di Sabatino
- Internal Medicine 2, Fondazione I.R.C.C.S. Policlinico San Matteo, Pavia, Italy
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Arora S, Rovin BH. Expert Perspective: An Approach to Refractory Lupus Nephritis. Arthritis Rheumatol 2022; 74:915-926. [PMID: 35166048 PMCID: PMC9156543 DOI: 10.1002/art.42092] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 01/24/2022] [Accepted: 02/09/2022] [Indexed: 11/06/2022]
Abstract
Systemic lupus erythematosus affects the kidneys in ~50% of all patients, and lupus nephritis (LN) is the most common manifestation of kidney involvement. Despite prompt diagnosis and treatment with aggressive immunosuppression, a significant proportion of LN patients do not respond to treatment and are considered to have refractory LN. Several factors other than drug resistance, such as nonadherence to treatment, undertreatment with conventional drugs, the effects of accumulated chronic damage, and genetic factors, may contribute to a poor response to treatment and should be considered. We define refractory LN as no change in (or worsening of) proteinuria and/or estimated glomerular filtration rate in response to 2 different standard-of-care induction regimens after 4-6 months in patients who are adherent to treatment. For patients who have LN that is truly refractory to standard of care, B cell-targeted therapy, specifically rituximab (RTX), is the most common next step. There is limited evidence available on alternative rescue therapies that may be used when there is no response to RTX. These include anti-CD38, leflunomide, intravenous immunoglobulin, plasma exchange, autologous stem cell transplantation, chimeric antigen receptor T cell therapy, anticomplement therapy, and interleukin-2 therapy.
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Affiliation(s)
| | - Brad H. Rovin
- The Ohio State University Wexner Medical Center, Columbus OH
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34
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Chen RI, Kuo BL, Kalur A, Muste JC, Deal C, Singh RP. Impact of an Electronic Decision Support Tool to Improve Ophthalmic Safety in Hydroxychloroquine Prescribing Practices. Ophthalmic Surg Lasers Imaging Retina 2022; 53:310-316. [PMID: 35724373 DOI: 10.3928/23258160-20220601-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND OBJECTIVE The purpose of this study was to implement a clinical decision support tool (CDS) and assess its impact on adherence to 2016 American Academy of Ophthalmology (AAO) hydroxychloroquine dosing recommendations. PATIENTS AND METHODS This retrospective, interventional study implemented an automated alert to calculate maximum daily hydroxychloroquine dose based on 2016 AAO recommendations and flag noncompliant orders. Prevalence of excessive dosing after CDS implementation was assessed. RESULTS A total of 7,417 patients met inclusion criteria. After intervention, prevalence of excessive dosing decreased from 27.4% to 21.1% (P < .001) among all prescriptions and from 26.8% to 16.2% (P < .001) among new prescriptions. Daily doses exceeding 400 mg decreased from 0.8% to 0.02% (P < .001). Risk factors for excessive dosing included low weight (odds ratio, 75.6 [95% CI, 54.0 to 105.8]) and nonrheumatologist prescriber (odds ratio, 1.60 to 3.63; all P < .005). CONCLUSIONS This study highlights the efficacy of a CDS in reducing excessive hydroxychloroquine dosing and improving adherence to AAO ophthalmic safety guidelines. [Ophthalmic Surg Lasers Imaging 2022;53:310-316.].
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Abstract
PURPOSE OF REVIEW This review summarizes the recent literature exploring hydroxychloroquine levels and their relationship with disease activity and risk of toxicity. RECENT FINDINGS There is no clear correlation between weight-based dosing of hydroxychloroquine and the resulting blood levels of the medication. Recent studies have shown that increased hydroxychloroquine levels are associated with lower lupus disease activity and likely also increased risk of medication toxicity. SUMMARY Mounting evidence supports use of hydroxychloroquine levels in clinical practice to document adherence and ensure safety.
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Affiliation(s)
- Katherine Chakrabarti
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
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Petri M. Drug monitoring in systemic lupus erythematosus. Curr Opin Pharmacol 2022; 64:102225. [PMID: 35490454 DOI: 10.1016/j.coph.2022.102225] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 03/21/2022] [Indexed: 11/16/2022]
Abstract
Therapeutic drug monitoring (TDM) is not yet accepted by systemic lupus erythematosus (SLE) treatment guidelines. Studies in SLE, however, have proven benefit in three areas: identification of non-adherence or poor adherence; targets for clinical benefit; and ranges of toxicity. This review covers the data on three medications commonly used for SLE, drawing on studies from both the SLE and non-SLE literature.
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Affiliation(s)
- Michelle Petri
- Johns Hopkins University School of Medicine, Department of Medicine, Division of Rheumatology, 1830 E. Monument Street, Suite 7500, Baltimore, MD, 21205, USA.
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37
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Belmont HM, Haj-Ali M. Whole blood drug levels do not correlate with QTc intervals in hydroxychloroquine-treated systemic lupus erythematosus patients. Rheumatology (Oxford) 2022; 62:450-456. [PMID: 35426919 PMCID: PMC9383788 DOI: 10.1093/rheumatology/keac245] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 03/31/2022] [Accepted: 04/03/2022] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVES HCQ is recommended for all patients with SLE, but reports of cardiac toxicity in severe acute respiratory syndrome coronavirus 2 patients raised concerns. We aimed to study the relationship between HCQ blood levels and QTc intervals. METHODS A retrospective review of 90 SLE patients (cohort 1) was conducted with data collected regarding demographics, QTc interval and chronic kidney disease (CKD). A prospective study of 84 SLE patients (cohort 2) was conducted with data collected regarding demographics, dose of HCQ, duration of HCQ treatment, presence of echocardiographic abnormalities and CKD simultaneous with whole blood HCQ levels measured by HPLC. Statistical analysis utilized one-way analysis of variance, Pearson's correlation coefficient and t tests. RESULTS In cohort 1 there was no significant difference in mean QTc based on 75 HCQ-treated [437.91 msec (s.d. 20.02)] as compared with 15 untreated patients [434.6 msec (s.d. 27.49)]. In patients with CKD, the mean QTc in HCQ users [448 (s.d. 23.37)] as compared with non-users [444.5 msec (s.d. 24.61)] also had no significant difference. In cohort 2, HCQ levels did not correlate with QTc interval (r = 0.017) and this applied regardless of the dose prescribed (r = 0.113 for 400 mg and r = 0.06 for 200 mg), duration of exposure (P = 0.36 for 0-5, >5-10 or >10 years), CKD (r = 0.482) or underlying cardiac abnormalities (r = 0.430). CONCLUSIONS This is the first study relying on measured blood levels demonstrating the absence of a clinically consequential increase in QTc levels in HCQ-treated SLE patients.
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Affiliation(s)
- H Michael Belmont
- Correspondence to: H. Michael Belmont, Department of Medicine, NYU Grossman School of Medicine, 333 East 38th Street, New York, NY 10016, USA. E-mail:
| | - Mayce Haj-Ali
- Department of Medicine, Division of Rheumatology, Atlantic Medical Group, Institute for Rheumatic Diseases, Summit, New Jersey, USA
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Pejčić AV. Acute Hydroxychloroquine Overdose: A Review of Published Pediatric Cases With Confirmed Hydroxychloroquine Exposure. Pediatr Emerg Care 2022; 38:174-182. [PMID: 34570079 DOI: 10.1097/pec.0000000000002547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVES This review aimed to explore and summarize information from available cases of pediatric acute hydroxychloroquine overdose with confirmed hydroxychloroquine exposure to give the clinicians a helpful perspective for its better recognition and management. METHODS Electronic searches were conducted in PubMed/MEDLINE, Web of Science, Scopus, EBSCO and Serbian Citation Index. The abstracts from 2 toxicology conferences were manually checked for additional relevant publications, as well as reference lists of the retrieved publications. Descriptive statistics, narrative summation, and tabulation of the extracted data were made. RESULTS Nine publications and a total of 9 patients were included in the review. Reported age of the patients varied from 2.5 to 16 years (median, 16 years). There were more female patients (77.8%). Estimated total ingested hydroxychloroquine dose was reported in 7 cases (77.8%), and it ranged from 4.0 to 20.0 g (median: 12.0 g). Four patients (44.4%) ingested hydroxychloroquine with a coingestant. Altered mental status (100.0%), cardiotoxicity (88.9%), hypotension (77.8%), and hypokalemia (55.6%) were the most commonly reported clinical manifestations. The majority of the patients were hospitalized (88.9%). More than half of the patients (55.6%) were reported to be treated in the intensive care unit. Most frequently reported therapeutic measures were the following: administration of intravenous fluids/infusions (77.8%), vasopressors (77.8%), bicarbonate therapy-sodium bicarbonate (66.7%), potassium replacement (55.6%), and intubation/ventilation (55.6%). Three patients (33.3%) died. CONCLUSIONS Management of acute hydroxychloroquine overdose in children should be symptomatic and tailored to observed clinical manifestations. There is a need for additional investigations to better understand the impact and effectiveness of various treatment options.
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Affiliation(s)
- Ana V Pejčić
- From the Department of Pharmacology and Toxicology, Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
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Emamikia S, Gentline C, Enman Y, Parodis I. How Can We Enhance Adherence to Medications in Patients with Systemic Lupus Erythematosus? Results from a Qualitative Study. J Clin Med 2022; 11:jcm11071857. [PMID: 35407466 PMCID: PMC8999748 DOI: 10.3390/jcm11071857] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 03/16/2022] [Accepted: 03/22/2022] [Indexed: 12/12/2022] Open
Abstract
Medication non-adherence is common among patients with systemic lupus erythematosus (SLE) and may lead to poor clinical outcomes. Our aim was to identify influenceable contributors to medication non-adherence and suggest interventions that could increase adherence. Patients with SLE from two Swedish tertiary referral centres (n = 205) participated in a survey assessing self-reported adherence to medications. Responses were used to select patients for qualitative interviews (n = 15). Verbatim interview transcripts were analysed by two researchers using content analysis methodology. The median age of the interviewees was 32 years, 87% were women, and their median SLE duration was nine years. Reasons for non-adherence were complex and multifaceted; we categorised them thematically into (i) patient-related (e.g., unintentional non-adherence due to forgetfulness or intentional non-adherence due to disbelief in medications); (ii) healthcare-related (e.g., untrustworthy relationship with the treating physician, authority fear, and poor information about the prescribed medications or the disease); (iii) medication-related (e.g., fear of side-effects); and (iv) disease-related reasons (e.g., lacking acceptance of a chronic illness or perceived disease quiescence). Interventions identified that healthcare could implement to improve patient adherence to medications included (i) increased communication between healthcare professionals and patients; (ii) patient education; (iii) accessible healthcare, preferably with the same personnel; (iv) well-coordinated transition from paediatric to adult care; (v) regularity in addressing adherence to medications; (vi) psychological support; and (vii) involvement of family members or people who are close to the patient.
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Affiliation(s)
- Sharzad Emamikia
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet and Karolinska University Hospital, 17176 Stockholm, Sweden; (C.G.); (Y.E.)
- Correspondence: (S.E.); (I.P.)
| | - Cidem Gentline
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet and Karolinska University Hospital, 17176 Stockholm, Sweden; (C.G.); (Y.E.)
| | - Yvonne Enman
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet and Karolinska University Hospital, 17176 Stockholm, Sweden; (C.G.); (Y.E.)
| | - Ioannis Parodis
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet and Karolinska University Hospital, 17176 Stockholm, Sweden; (C.G.); (Y.E.)
- Department of Rheumatology, Faculty of Medicine and Health, Örebro University, 70182 Örebro, Sweden
- Correspondence: (S.E.); (I.P.)
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40
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Srihari P, Minns AB, Gao HT, Kreshak AA. Massive Nonfatal Hydroxychloroquine Ingestion in a Pediatric Patient. J Emerg Med 2022; 62:332-336. [PMID: 35065861 DOI: 10.1016/j.jemermed.2021.10.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 09/24/2021] [Accepted: 10/12/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Hydroxychloroquine overdose is rare but potentially lethal. Hydroxychloroquine overdose symptoms are characterized by central nervous system toxicity, cardiac toxicity, and hypokalemia. Recommended treatment consists of epinephrine, high-dose diazepam, and careful potassium repletion. Few pediatric hydroxychloroquine overdoses have been reported. CASE REPORT We describe a 14-year-old girl who ingested 10 g (172 mg/kg) of hydroxychloroquine. She developed tachycardia, hypotension, and hypokalemia. She was intubated and treated with diazepam and epinephrine infusions and potassium supplementation. Her serum hydroxychloroquine concentration obtained 10 h after ingestion was 13,000 ng/mL (reference range 500-2000 ng/mL). The patient made a full medical recovery. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Pediatric hydroxychloroquine overdoses are reported rarely, and the toxic and lethal doses of hydroxychloroquine ingestion have not been established. This case of a teenaged patient who ingested 10 g of hydroxychloroquine and survived provides additional information that may be used to help establish toxic and lethal doses of ingestion.
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Affiliation(s)
- Priya Srihari
- Department of Emergency Medicine, Keck School of Medicine of University of Southern California, Los Angeles, California
| | - Alicia B Minns
- Division of Medical Toxicology, Department of Emergency Medicine, University of California-San Diego, San Diego, California
| | - Han T Gao
- South Texas Poison Center, Texas Poison Center Network, Department of Emergency Medicine, University of Texas Health San Antonio, San Antonio, Texas
| | - Allyson A Kreshak
- Division of Medical Toxicology, Department of Emergency Medicine, University of California-San Diego, San Diego, California
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Fasano S, Iudici M, Coscia MA, Messiniti V, Borgia A, Tirri R, Ciccia F. Influence of hydroxychloroquine blood levels on adhesion molecules associated with endothelial dysfunction in patients with systemic lupus erythematosus. Lupus Sci Med 2022; 9:9/1/e000681. [PMID: 35332100 PMCID: PMC8948388 DOI: 10.1136/lupus-2022-000681] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 03/14/2022] [Indexed: 11/22/2022]
Abstract
Background Patients with SLE have an endothelial dysfunction (ED), which is considered the earliest marker of cardiovascular (CV) disease. Endothelial cell activation induced by proinflammatory cytokines is defined by the endothelial expression of cell-surface adhesion molecules, such as vascular cell adhesion molecule-1 (VCAM-1), intercellular adhesion molecule-1 (ICAM-1) and E-selectin. The aim of this study was to investigate whether serum endothelial adhesion molecule levels are influenced by blood hydroxychloroquine (HCQ) levels in SLE. Methods Consecutive patients with SLE taking a stable dose of HCQ were investigated. At study entry and 6 months later HCQ blood levels were quantified by tandem mass spectrometry. Serum levels of P-selectin, E-selectin, ICAM-1 and VCAM-1 were also measured using a Luminex 200 instrument. Comparison of endothelial soluble adhesion molecules in groups with different HCQ blood levels was performed by t-test. Results 83 patients with SLE were enrolled. Correlation were demonstrated between mean blood HCQ concentrations and endothelial soluble adhesion molecules (E-selectin, ICAM-1 and VCAM-1). Moreover, serum levels of ICAM-1 and VCAM-1 were significantly lower in the patients with SLE with HCQ blood levels >500 ng/mL (83.67±52.8 ng/mL vs 158.81±125.1 ng/mL and 8.9±2.2 ng/mL vs 10.4±2.3 ng/mL). Serum levels of E-selectin were nearly significantly lower in the patients with SLE with HCQ blood levels >500 ng/mL (64.7±30.2 ng/mL vs 71.6±42.2 ng/mL, p=0.06). No significant difference in concentration of P-selectin was detected. Conclusions In the present study, there was a trend towards higher adhesion molecules levels with lower HCQ blood levels in patients with SLE. Further longitudinal studies will determine whether changes in endothelial biomarkers reflect decreased clinical CV events.
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Affiliation(s)
- Serena Fasano
- Rheumatology Unit, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Michele Iudici
- Department of Internal Medicine Specialties, Geneva University Hospitals, Geneve, Switzerland
| | | | | | - Alessia Borgia
- Rheumatology Unit, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Rosella Tirri
- Rheumatology Unit, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Francesco Ciccia
- Rheumatology Unit, University of Campania "Luigi Vanvitelli", Naples, Italy
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42
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Clowse MEB, Eudy AM, Balevic S, Sanders-Schmidler G, Kosinski A, Fischer-Betz R, Gladman DD, Molad Y, Nalli C, Mokbel A, Tincani A, Urowitz M, Bay C, van Noord M, Petri M. Hydroxychloroquine in the pregnancies of women with lupus: a meta-analysis of individual participant data. Lupus Sci Med 2022; 9:9/1/e000651. [PMID: 35318256 PMCID: PMC8935175 DOI: 10.1136/lupus-2021-000651] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 02/26/2022] [Indexed: 11/21/2022]
Abstract
Objective Multiple guidelines recommend continuing hydroxychloroquine (HCQ) for SLE during pregnancy based on observational data. The goal of this individual patient data meta-analysis was to identify the potential benefits and harms of HCQ use within lupus pregnancies. Methods Eligible studies included prospectively collected pregnancies in women with lupus. After a systematic literature search, seven datasets meeting inclusion criteria were obtained. Pregnancy outcomes and lupus activity were compared for pregnancies with a visit in the first trimester in women who did or did not take HCQ throughout pregnancy. Birth defects were not systematically collected. This analysis was conducted in each dataset, and results were aggregated to provide a pooled OR. Results Seven cohorts provided 938 pregnancies in 804 women. After selecting one pregnancy per patient with a first trimester visit, 668 pregnancies were included; 63% took HCQ throughout pregnancy. Compared with pregnancies without HCQ, those with HCQ had lower odds of highly active lupus, but did not have different odds of fetal loss, preterm delivery or pre-eclampsia. Among women with low lupus activity, HCQ reduced the odds of preterm delivery. Conclusions This large study of prospectively-collected lupus pregnancies demonstrates a decrease in lupus activity among woman who continue HCQ through pregnancy and no harm to pregnancy outcomes. Like all studies of HCQ in lupus pregnancy, this study is confounded by indication and non-adherence. As this study confirms the safety of HCQ and diminished SLE activity with use, it is consistent with current recommendations to continue HCQ throughout pregnancy.
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Affiliation(s)
| | - Amanda M Eudy
- Medicine, Duke University, Durham, North Carolina, USA
| | - Stephen Balevic
- Rheumatology and Clinical Immunology, Duke University, Durham, North Carolina, USA.,The Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Gillian Sanders-Schmidler
- Duke-Margolis Center for Health Policy, Duke Clinical Research Institute and Department of Population Health Sciences, Duke University, Durham, North Carolina, USA
| | - Andrzej Kosinski
- Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
| | | | - Dafna D Gladman
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Yair Molad
- Rheumtology, Beilinson Hospital, Rabin Medical Center, Petach Tikva, Israel
| | - Cecilia Nalli
- Rheumatology and Clinical Immunology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | | | - Angela Tincani
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Murray Urowitz
- Center for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital, University of Toronto, Lupus Clinic, Toronto, Ontario, Canada
| | | | - Megan van Noord
- Library, University of California Davis, Davis, California, USA
| | - Michelle Petri
- Rheumatology, Johns Hopkins University, Baltimore, Maryland, USA
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43
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Wallace DJ. Suggested additions to future directions: comment on the ACR white paper on antimalarials and cardiac toxicity by Desmarais et al. Arthritis Rheumatol 2022; 74:1300-1301. [PMID: 35212181 DOI: 10.1002/art.42100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 02/15/2022] [Indexed: 11/06/2022]
Affiliation(s)
- Daniel J Wallace
- Cedars-Sinai Medical Center and David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA
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44
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Zhao F, Wang J, Wang Q, Hou Z, Zhang Y, Li X, Wu Q, Chen H. Organoid technology and lung injury mouse models evaluating effects of hydroxychloroquine on lung epithelial regeneration. Exp Anim 2022; 71:316-328. [PMID: 35197405 PMCID: PMC9388344 DOI: 10.1538/expanim.21-0168] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) damages lung epithelial stem/progenitor cells. Ideal anti-SARS-CoV-2 drug candidates should be screened to prevent secondary injury to the lungs. Here, we propose that in vitro three-dimensional organoid and lung injury repair mouse models are powerful models for the screening antiviral drugs. Lung epithelial progenitor cells, including airway club cells and alveolar type 2 (AT2) cells, were co-cultured with supportive fibroblast cells in transwell inserts. The organoid model was used to evaluate the possible effects of hydroxychloroquine, which is administered as a symptomatic therapy to COVID-19 patients, on the function of mouse lung stem/progenitor cells. Hydroxychloroquine was observed to promote the self-renewal of club cells and differentiation of ciliated and goblet cells in vitro. Additionally, it inhibited the self-renewal ability of AT2 cells in vitro. Naphthalene- or bleomycin-induced lung injury repair mouse models were used to investigate the in vivo effects of hydroxychloroquine on the regeneration of club and AT2 cells, respectively. The naphthalene model indicated that the proliferative ability and differentiation potential of club cells were unaffected in the presence of hydroxychloroquine. The bleomycin model suggested that hydroxychloroquine had a limited effect on the proliferation and differentiation abilities of AT2 cells. These findings suggest that hydroxychloroquine has limited effects on the regenerative ability of epithelial stem/progenitor cells. Thus, stem/progenitor cell-derived organoid technology and lung epithelial injury repair mouse models provide a powerful platform for drug screening, which could possibly help end the pandemic.
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Affiliation(s)
- Fuxiaonan Zhao
- Department of Basic Medicine, Haihe Clinical College of Tianjin Medical University
| | - Jianhai Wang
- Department of Basic Medicine, Haihe Clinical College of Tianjin Medical University.,Department of Basic Medicine, Haihe Hospital, Tianjin University
| | - Qi Wang
- Key Research Laboratory for Infectious Disease Prevention for State Administration of Traditional Chinese Medicine, Tianjin Institute of Respiratory Diseases
| | - Zhilli Hou
- Department of Basic Medicine, Haihe Clinical College of Tianjin Medical University.,Key Research Laboratory for Infectious Disease Prevention for State Administration of Traditional Chinese Medicine, Tianjin Institute of Respiratory Diseases
| | - Yingchao Zhang
- Department of Pulmonary and Critical Care Medicine, Tianjin Baodi Hospital, Baodi Clinical College of Tianjin Medical University
| | - Xue Li
- Department of Basic Medicine, Haihe Clinical College of Tianjin Medical University.,Department of Basic Medicine, Haihe Hospital, Tianjin University.,Tianjin Key Laboratory of Lung Regenerative Medicine
| | - Qi Wu
- Department of Basic Medicine, Haihe Clinical College of Tianjin Medical University
| | - Huaiyong Chen
- Department of Basic Medicine, Haihe Clinical College of Tianjin Medical University.,Department of Basic Medicine, Haihe Hospital, Tianjin University.,Key Research Laboratory for Infectious Disease Prevention for State Administration of Traditional Chinese Medicine, Tianjin Institute of Respiratory Diseases.,Tianjin Key Laboratory of Lung Regenerative Medicine
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45
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Alvarez JC, Davido B, Moine P, Etting I, Annane D, Larabi IA, Simon N. Population Pharmacokinetics of Hydroxychloroquine and 3 Metabolites in COVID-19 Patients and Pharmacokinetic/Pharmacodynamic Application. Pharmaceuticals (Basel) 2022; 15:ph15020256. [PMID: 35215368 PMCID: PMC8877570 DOI: 10.3390/ph15020256] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 02/16/2022] [Accepted: 02/17/2022] [Indexed: 02/04/2023] Open
Abstract
We develop a population pharmacokinetic model for hydroxychloroquine (HCQ) and three of its metabolites (desethylhydroxychloroquine, Des HCQ; desethylchloroquine, DesCQ; and didesethylchloroquine, didesCQ) in COVID-19 patients in order to determine whether a pharmacokinetic (PK)/pharmacodynamic (PD) relationship was present. The population PK of HCQ was described using non-linear mixed effects modelling. The duration of hospitalization, the number of deaths, and poor clinical outcomes (death, transfer to ICU, or hospitalization ≥ 10 d) were evaluated as PD parameters. From 100 hospitalized patients (age = 60.7 ± 16 y), 333 BHCQ and M were available for analysis. The data for BHCQ were best described by a four-compartment model with a first-order input (KA) and a first-order output. For M, the better model of the data used one compartment for each metabolite with a first-order input from HCQ and a first-order output. The fraction of HCQ converted to the metabolites was 75%. A significant relationship was observed between the duration of hospitalization and BHCQ at 48 h (r2 = 0.12; p = 0.0052) or 72 h (r2 = 0.16; p = 0.0012). At 48 h or 72 h, 87% or 91% of patients vs. 63% or 62% had a duration < 25 d with a BHCQ higher or below 200 μg/L, respectively. Clinical outcome was significantly related to BHCQ at 48 h (good outcome 369 +/- 181 μg/L vs. poor 285 +/- 144 μg/L; p = 0.0441) but not at 72 h (407 +/- 207 μg/L vs. 311 +/- 174 μg/L; p = 0.0502). The number of deaths was not significantly different according to the trough concentration (p = 0.972 and 0.836 for 48 h and 72 h, respectively).
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Affiliation(s)
- Jean Claude Alvarez
- Department of Pharmacology and Toxicology, Paris-Saclay University (Versailles Saint-Quentin-en-Yvelines), Inserm U-1173, FHU Sepsis, Raymond Poincaré hospital, AP-HP, 104 Boulevard Raymond Poincaré, 92380 Garches, France; (I.E.); (I.A.L.)
- Correspondence: ; Tel.: +33-1-4710-7946; Fax: +33-147-1079-23
| | - Benjamin Davido
- Infectious Unit, Paris-Saclay University (Versailles Saint-Quentin-en-Yvelines), Raymond Poincaré Hospital, AP-HP, 104 Boulevard Raymond Poincaré, 92380 Garches, France;
| | - Pierre Moine
- Intensive Care Unit, Paris-Saclay University (Versailles Saint-Quentin-en-Yvelines), Inserm U-1173, FHU Sepsis, Raymond Poincaré Hospital, AP-HP, 104 Boulevard Raymond Poincaré, 92380 Garches, France; (P.M.); (D.A.)
| | - Isabelle Etting
- Department of Pharmacology and Toxicology, Paris-Saclay University (Versailles Saint-Quentin-en-Yvelines), Inserm U-1173, FHU Sepsis, Raymond Poincaré hospital, AP-HP, 104 Boulevard Raymond Poincaré, 92380 Garches, France; (I.E.); (I.A.L.)
| | - Djillali Annane
- Intensive Care Unit, Paris-Saclay University (Versailles Saint-Quentin-en-Yvelines), Inserm U-1173, FHU Sepsis, Raymond Poincaré Hospital, AP-HP, 104 Boulevard Raymond Poincaré, 92380 Garches, France; (P.M.); (D.A.)
| | - Islam Amine Larabi
- Department of Pharmacology and Toxicology, Paris-Saclay University (Versailles Saint-Quentin-en-Yvelines), Inserm U-1173, FHU Sepsis, Raymond Poincaré hospital, AP-HP, 104 Boulevard Raymond Poincaré, 92380 Garches, France; (I.E.); (I.A.L.)
| | - Nicolas Simon
- Department of clinical Pharmacology, CAP-TV Aix-Marseille University, APHM, INSERM, IRD, SESSTIM, Hop Sainte Marguerite, 13000 Marseille, France;
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46
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Synergistic Adverse Effects of Azithromycin and Hydroxychloroquine on Human Cardiomyocytes at a Clinically Relevant Treatment Duration. Pharmaceuticals (Basel) 2022; 15:ph15020220. [PMID: 35215332 PMCID: PMC8877825 DOI: 10.3390/ph15020220] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 02/07/2022] [Accepted: 02/10/2022] [Indexed: 02/07/2023] Open
Abstract
Adverse effects of drug combinations and their underlying mechanisms are highly relevant for safety evaluation, but often not fully studied. Hydroxychloroquine (HCQ) and azithromycin (AZM) were used as a combination therapy in the treatment of COVID-19 patients at the beginning of the pandemic, leading to higher complication rates in comparison to respective monotherapies. Here, we used human-induced pluripotent stem cell-derived cardiomyocytes (iPSC-CMs) to systematically investigate the effects of HCQ, AZM, and their combination on the structure and functionality of cardiomyocytes, and to better understand the underlying mechanisms. Our results demonstrate synergistic adverse effects of AZM and HCQ on electrophysiological and contractile function of iPSC-CMs. HCQ-induced prolongation of field potential duration (FPDc) was gradually increased during 7-day treatment period and was strongly enhanced by combination with AZM, although AZM alone slightly shortened FPDc in iPSC-CMs. Combined treatment with AZM and HCQ leads to higher cardiotoxicity, more severe structural disarrangement, more pronounced contractile dysfunctions, and more elevated conduction velocity, compared to respective monotreatments. Mechanistic insights underlying the synergistic effects of AZM and HCQ on iPSC-CM functionality are provided based on increased cellular accumulation of HCQ and AZM as well as increased Cx43- and Nav1.5-protein levels.
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47
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Gao B, Tan T, Cao X, Pan M, Yang C, Wang J, Shuai Z, Xia Q. Relationship of cytochrome P450 gene polymorphisms with blood concentrations of hydroxychloroquine and its metabolites and adverse drug reactions. BMC Med Genomics 2022; 15:23. [PMID: 35135554 PMCID: PMC8822703 DOI: 10.1186/s12920-022-01171-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 02/01/2022] [Indexed: 12/27/2022] Open
Abstract
Background Hydroxychloroquine (HCQ) is a cornerstone therapy for systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA). This study aimed to investigate the relationship of cytochrome P450 (CYP450) gene polymorphisms with blood concentrations of HCQ and its metabolites and adverse drug reactions (ADRs) in patients with SLE and RA. Methods A cohort of 146 patients with SLE and RA treated with HCQ was reviewed. The ADRs of the patients were recorded. The blood concentrations of HCQ and its metabolites were measured by liquid chromatography-tandem mass spectrometry (LC-MS/MS) analysis. Genotyping of single nucleotide polymorphisms (SNPs) in CYP450, a metabolic enzyme involved in the HCQ metabolic pathway, was performed using a MassARRAY system. The chi-square test, T-test, and one-way analysis of variance were used to analyse data. Results Among 29 candidate SNPs, we found that CYP3A4 (rs3735451) was significantly associated with blood levels of HCQ and its metabolites in both the unadjusted model and adjusted model (patients taking HCQ for > 10 years) (P < 0.05). For CYP3A5 (rs776746), a greater risk of skin and mucous membrane ADRs was associated with the TT genotype than with the CT + CC genotypes (P = 0.033). For CYP2C8 (rs1058932), the AG genotype carried a greater risk of abnormal renal function than the AA + GG genotype (P = 0.017); for rs10882526, the GG genotype carried a greater risk of ophthalmic ADRs than the AA + AG genotypes (P = 0.026). Conclusions The CYP2C8 (rs1058932 and rs10882526) and CYP3A5 (rs776746) polymorphisms are likely involved in the ADRs of HCQ. Gene polymorphism analysis of CYP450 and therapeutic drug monitoring of HCQ and its metabolites might be useful to optimise HCQ administration and predict ADRs.
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Affiliation(s)
- Beibei Gao
- Department of Pharmacy, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Tingfei Tan
- Department of Pharmacy, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Xi Cao
- Department of Pharmacy, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Menglu Pan
- Department of Rheumatism and Immunity, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Chunlan Yang
- Department of Pharmacy, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Jianxiong Wang
- Department of Rheumatism and Immunity, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Zongwen Shuai
- Department of Rheumatism and Immunity, The First Affiliated Hospital of Anhui Medical University, Hefei, China.,Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, Hefei, China
| | - Quan Xia
- Department of Pharmacy, The First Affiliated Hospital of Anhui Medical University, Hefei, China. .,The Grade 3 Pharmaceutical Chemistry Laboratory of State Administration of Traditional Chinese Medicine, Hefei, China.
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48
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Balevic SJ, Weiner D, Clowse MEB, Eudy AM, Maharaj AR, Hornik CP, Cohen-Wolkowiez M, Gonzalez D. Hydroxychloroquine PK and exposure-response in pregnancies with lupus: the importance of adherence for neonatal outcomes. Lupus Sci Med 2022; 9:9/1/e000602. [PMID: 34996856 PMCID: PMC8744126 DOI: 10.1136/lupus-2021-000602] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 12/06/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Evaluate the impact of pregnancy physiology and medication non-adherence on serum hydroxychloroquine (HCQ) pharmacokinetics (PK) and exposure-response in SLE. METHODS We conducted a PK analysis using data from two observational pregnancy registries. We enrolled pregnant women with SLE taking HCQ at least 3 months prior to, and throughout pregnancy, and excluded those with multiple gestations. Using the PK model, we conducted dosing simulations and imputed 0%/20%/40%/60% non-adherence to evaluate the impact of adherence versus physiological changes on HCQ concentrations. We compared the effect of pregnancy-average non-adherent concentrations (≤100 ng/mL vs >100 ng/mL) on preterm birth using adjusted logistic regression. RESULTS We enrolled 56 women who had 61 pregnancies. By the third trimester, mean apparent HCQ clearance increased by 59.6%. At a dosage of 400 mg/day, fully adherent patients are expected to have HCQ concentrations ≤100 ng/mL only 0.3% of the time, compared with 24.2% when 60% of doses are missed. Persistently low HCQ concentrations throughout pregnancy were associated with a significantly higher odds of preterm birth, controlling for lupus nephritis and race (OR 11.2; 95% CI 2.3 to 54.2; p=0.003). CONCLUSIONS We observed significant changes in HCQ PK during pregnancy, resulting in a shortening in the drug's half-life by 10 days; however, medication non-adherence had a more pronounced effect on HCQ exposure compared with physiological changes alone. Moreover, pregnant women with non-adherent HCQ concentrations had significantly higher rates of preterm birth. Accordingly, optimising adherence in pregnancy may be more clinically meaningful than adjusting HCQ dosage to account for physiological changes. PK modelling indicates that serum HCQ concentrations ≤100 ng/mL are suggestive of non-adherence regardless of trimester and may help identify pregnancies at risk for poor outcomes.
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Affiliation(s)
- Stephen J Balevic
- Department of Pediatrics, Duke University, Durham, North Carolina, USA .,Duke Clinical Research Institute, Durham, North Carolina, USA.,Department of Internal Medicine, Duke University, Durham, North Carolina, USA
| | - Daniel Weiner
- Division of Pharmacotherapy and Experimental Therapeutics, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Megan E B Clowse
- Department of Internal Medicine, Duke University, Durham, North Carolina, USA
| | - Amanda M Eudy
- Department of Internal Medicine, Duke University, Durham, North Carolina, USA
| | - Anil R Maharaj
- Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Christoph P Hornik
- Department of Pediatrics, Duke University, Durham, North Carolina, USA.,Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Michael Cohen-Wolkowiez
- Department of Pediatrics, Duke University, Durham, North Carolina, USA.,Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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49
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Balevic SJ, Sagcal-Gironella ACP. Precision Medicine: Towards Individualized Dosing in Pediatric Rheumatology. Rheum Dis Clin North Am 2021; 48:305-330. [PMID: 34798954 DOI: 10.1016/j.rdc.2021.09.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Despite an increase in the number of available therapeutics, many children with rheumatic disease continue to experience active inflammatory disease and treatment failure. One reason for treatment failure is the lack of dosing paradigms to account for the wide between-patient variability in drug pharmacokinetics because of developmental changes or genetic polymorphisms that effect drug absorption, distribution, metabolism, and elimination. This review highlights several strategies to optimize dosing for biologic and nonbiologic disease-modifying antirheumatic drugs, including therapeutic drug monitoring, pharmacogenomics, and the use of pharmacokinetic/pharmacodynamic modeling.
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Affiliation(s)
- Stephen J Balevic
- Department of Pediatrics, Duke University, Durham, NC, USA; Duke Clinical Research Institute, Durham, NC, USA.
| | - Anna Carmela P Sagcal-Gironella
- Department of Pediatrics, Hackensack Meridian School of Medicine, Nutley, NJ, USA; Division of Pediatric Rheumatology, Joseph M. Sanzari Children's Hospital, 30 Prospect Avenue, WFAN 3rd Floor, Hackensack, NJ 07601, USA; K. HovnanianChildren's Hospital, Neptune, NJ, USA
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50
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Effects of hydroxychloroquine and its metabolites in patients with connective tissue diseases. Inflammopharmacology 2021; 29:1795-1805. [PMID: 34743268 PMCID: PMC8572531 DOI: 10.1007/s10787-021-00887-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 10/24/2021] [Indexed: 11/24/2022]
Abstract
Hydroxychloroquine has attracted attention in the treatment of COVID-19. Many conflicting findings have been reported regarding the efficacy and safety of this drug, which has been used safely in the rheumatological diseases for years. However, these studies lacked measurement methods that allow accurate assessment of hydroxychloroquine and its metabolite levels. The aim of this study was to measure hydroxychloroquine and its metabolite levels in whole blood samples of patients with rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), Sjogren’s syndrome (SS) and scleroderma (Scl) by a robust, simple and accurate validated tandem mass spectrometric method, and to investigate the relationship between these levels with drug-related adverse effects and disease activity scores. The validated LC–MS/MS method was applied to measure blood hydroxychloroquine and its metabolite levels of patients with RA, SLE, SS, Scl. Various haematological and biochemical parameters were measured with Beckman-Coulter AU 5800 and Beckman Coulter LH 780 analyzers, respectively. QTc intervals were calculated with Bazett’s formula, and the patients were followed up by clinicians in terms of clinical findings and adverse effects. Hydroxychloroquine levels of patients were similar to previous studies. There was a negative correlation between disease activity scores and hydroxychloroquine levels, while the highest correlation was between QTc interval, creatinine and GFR levels with desethylchloroquine. Bidetylchloroquine had the highest correlation with RBC count and liver function tests. Our findings showed that hydroxychloroquine and its metabolite levels were associated with disease activity scores, renal, hepatic function, QTc prolongation, and hematological parameters.
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