REVIEW - Clinical efficacy and side effects of antimalarials in SLE

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Ann Rheum Dis 2010;69:20-28 doi:10.1136/ard.2008.101766

Clinical and epidemiological research

Extended report

Clinical efficacy and side effects of antimalarials in systemic lupus

erythematosus: a systematic review

G Ruiz-Irastorza1, M Ramos-Casals2, P Brito-Zeron2, M A Khamashta3

+ Author Affiliations

1Service of Internal Medicine, Hospital De Cruces, University Of The

Basque Country, Bizkaia, Spain

2Laboratory Of Autoimmune Diseases “p Font”, IDIBAPS, Hospital

Clinic, Barcelona, Spain

3Lupus Research Unit, The Rayne Institute, St. ’ Hospital,

King’s College, London, UK

Abstract

Background: Antimalarial drugs (AMs), chloroquine (CQ) and

hydroxychloroquine (HCQ), are frequently withdrawn in patients with

lupus with either severe or remitting disease. However, additional

effects beyond immunomodulation have been recently described. The aim

of the present work was to analyse all the published evidence of the

beneficial and adverse effects of AM therapy in systemic lupus

erythematosus (SLE).

Methods: A systematic review of the English literature between 1982

and 2007 was conducted using the MEDLINE and EMBASE databases.

Randomised controlled trials (RCTs) and observational studies were

selected. Case reports were excluded except for toxicity reports. The

GRADE system was used to analyse the quality of the evidence.

Results: A total of 95 articles were included in the systematic

review. High levels of evidence were found that AMs prevent lupus

flares and increase long-term survival of patients with SLE; moderate

evidence of protection against irreversible organ damage, thrombosis

and bone mass loss. Toxicity related to AMs is infrequent, mild and

usually reversible, with HCQ having a safer profile. In pregnant

women, high levels of evidence were found that AMs, particularly HCQ,

decrease lupus activity without harming the baby. By contrast,

evidence supporting an effect on severe lupus activity, lipid levels

and subclinical atherosclerosis was weak. Individual papers suggest

effects in preventing the evolution from SLE-like to full-blown SLE,

influencing vitamin D levels and protecting patients with lupus

against cancer.

Conclusions: Given the broad spectrum of beneficial effects and the

safety profile, HCQ should be given to most patients with SLE during

the whole course of the disease, irrespective of its severity, and be

continued during pregnancy.

http://ard.bmj.com/content/69/01/20.abstract?etoc

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