RESEARCH - Early use of Plaquenil prevents damage accrual in SLE

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Early use of hydroxychloroquine prevents damage accrual in systemic lupus

erythematosus

Rheumawire

May 23, 2005

Alison Palkhivala

Birmingham, AL - Starting the antimalarial drug hydroxychloroquine (HCQ)

(Plaquenil) early on in the disease process may help prevent damage accrual

in patients with systemic lupus erythematosus (SLE) [1]. A new study,

published in the May 2005 issue of Arthritis & Rheumatism, has demonstrated

that HCQ appears to reduce the risk of damage accrual, provided the drug is

initiated before damage has begun.

" This study suggests that patients with mild disease who are treated with

HCQ do better in the long run than patients who were not treated with HCQ, "

lead author of the study, Dr Barri Fessler (University of Alabama at

Birmingham Health System), tells rheumawire. The results suggest that it

might have a protective effect against certain lupus manifestations or

complications from medications used to treat lupus. " Therefore, it should be

more widely prescribed in lupus patients, [and] not only to those with the

manifestations [that currently define its typical use]. "

Fessler comments that hydroxychloroquine " is typically used for treatment of

joint pain and swelling, rashes, and fatigue associated with lupus. The dose

is typically 200 mg once or twice daily [up to] 6.5 mg/kg per day. " HCQ is

relatively safe, so patients can remain on this therapy as long as there is

no evidence of toxicity. " A very rare side effect of treatment with

hydroxychloroquine is retinopathy, and therefore it is recommended that

patients have a baseline examination followed by regular exams by an

ophthalmologist. "

Previous studies have demonstrated that, in patients with SLE, HCQ is

beneficial for the management of mucocutaneous manifestations, arthritis,

and mild constitutional symptoms. Added benefits include reductions in serum

cholesterol levels, protection against osteoporosis in patients taking

corticosteroids, and a decrease in the frequency of lupus flares. What

remained to be seen was whether HCQ could also reduce the risk of damage

accrual in SLE patients.

Follow-up in 518 patients

To help answer this question, Fessler and colleagues conducted annual

follow-ups of 518 patients who met at least four components of the American

College of Rheumatology (ACR) criteria for SLE but had had the disease for

only five years or less. Follow-up included measurements of clinical and

serological manifestations of SLE as well as measurement of disease activity

using the Systemic Lupus Activity Measure (SLAM) and measurement of damage

using the Systemic Lupus International Collaborating Clinics damage index

(SDI). Mean follow-up was nearly three years.

At the time of enrollment, 56% of the 518 patients followed were being

treated with HCQ. These patients had lower SLAM and SDI scores at the outset

of the study than patients not taking HCQ. In addition, patients taking HCQ

were significantly less likely to have major organ involvement, including

renal disease (p<0.0001) and central nervous system disease (p<0.0025) at

the study outset.

Unadjusted analysis using a proportional hazards model revealed that

patients taking HCQ were less likely than those not receiving HCQ to accrue

damage, with a hazard ratio (HR) of 0.68. After adjusting for differences at

study enrollment between patients who received HCQ and those who did not,

the HR for accruing damage among those taking HCQ, compared with those who

were not, rose to 0.73 but remained significant at p=0.05.

HCQ appeared to protect against damage accrual only in patients who did not

have damage when they were initiated on the medication, however. Among

patients taking HCQ who had no damage at the study outset, the HR for the

risk of damage accrual was 0.55 (p=0.0111). Among those receiving HCQ who

already had damage at the study outset, the HR was not statistically

significant, at 1.106, p=0.6630.

" Hydroxychloroquine should be started as treatment as soon as a diagnosis of

lupus is established, regardless of its manifestations or severity, as it

may help to prevent development of organ damage in the future, " Fessler

comments.

Source

a. Fessler BJ, Alarcon GS, McGwin G, et al. Systemic lupus

erythematosus in three ethnic groups. XVI. Association of hydroxychloroquine

use with reduced risk of damage accrual. Arthritis Rheum. 2005;

52:1473-1480.

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