Professional Documents
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1175-0561/05/0001-0001/$34.95/0
THERAPY IN PRACTICE
Contents
Abstract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1. Brief Review of Lupus Erythematosus (LE)-Specific Skin Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2. Delayed Onset of Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3. Antimalarial Treatment Regimens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.1 Inhibition of Antimalarial Efficacy by Cigarette Smoking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.2 Antimalarial Treatment of LE-Nonspecific Skin Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.3 Antimalarial Treatment in Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.4 Antimalarial Treatment in Pregnancy and in Breastfeeding Mothers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4. Antimalarial Adverse Effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.1 Overdose Precautions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5. Potential Drug Interactions of Hydroxychloroquine and Chloroquine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6. Disorders that May be Worsened by Antimalarial Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7. Mechanisms by which Antimalarial Agents Provide Benefit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8. Treatment Options When Standard Therapy Fails . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Abstract
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Antimalarials have been used to treat cutaneous and systemic lupus erythematosus (LE) for decades.
Although controlled studies comparing the efficacy of antimalarials versus placebo and other treatments are
generally lacking, many case reports and series support the therapeutic efficacy of these agents in treating both
LE-specific and -nonspecific skin lesions. Currently, the two most frequently used antimalarial agents are
chloroquine and hydroxychloroquine. There may be a delay of weeks to months in the onset of therapeutic
effects of antimalarials when treating LE. Smoking appears to inhibit the therapeutic efficacy of antimalarials
when treating cutaneous LE. Antimalarials have been associated with a number of potentially serious adverse
effects, including irreversible loss of vision. The aim of this review is to discuss the many facets of antimalarials
that will help clinicians optimally utilize these agents when treating cutaneous LE.
Fig. 1. (a) Patient with subacute cutaneous lupus erythematosus that failed to respond to hydroxychloroquine monotherapy for several months followed by
a combination of hydroxychloroquine and quinacrine. (b) Same patient 1 month after hydroxychloroquine was switched to chloroquine while quinacrine
therapy was maintained.
Cigarette Smoking
Although some authors have advocated the withdrawal of antimalarial treatment when a patient becomes pregnant, more recent
reports indicate that antimalarials not only have a good safety
profile but are helpful in suppressing LE flares that sometime
occur during pregnancy.[53-55] Levy et al.,[54] in the first randomized, placebo-controlled study of patients with lupus, not only
revealed the absence of teratogenic effects after a 3-year follow-up
of children but also observed a lower frequency of LE flares
during pregnancy. It is even suggested that hydroxychloroquine,
but not quinacrine, can be initiated during pregnancy for lupus
flares.[54]
Hydroxychloroquine and chloroquine bind avidly to various
tissues, so stopping these agents at the first sign of pregnancy
means that it will still take several months for them to be completely eliminated from the bound tissues.[10,56] Hydroxychloroquine
may be safer than chloroquine during pregnancy as it binds less
avidly to tissues, is less toxic and has a lesser ability to cross the
placenta than chloroquine.[54] Hydroxychloroquine may have an
2005 Adis Data Information BV. All rights reserved.
routine screening of all patients before starting antimalarial therapy is not considered necessary by some.[68] There is general
agreement that antimalarial compounds should be used with caution in patients with hepatic disease or alcoholism. Patients at risk
of hepatic disease should have routine liver function tests before
and periodically while receiving antimalarial agents. When antimalarials are used according to the treatment guidelines (hydroxychloroquine 6.5 mg/kg/day, chloroquine 4 mg/kg/day and
quinacrine 100 mg/day) they are unlikely to cause hepatic injury
in healthy individuals.[68] The data in the literature suggests that
hydroxychloroquine is even protective against elevated liver function test results in patients with rheumatoid arthritis receiving
aspirin or methotrexate.[96] As antimalarials can cause adverse
ocular effects, they are contraindicated in patients with pre-existing retinopathy, visual field defects, or maculopathy.[97]
There are conflicting opinions concerning the necessity for
periodic complete blood cell counts in patients during antimalarial
treatment. In the authors opinion periodic testing is still advisable
during treatment, particularly in patients who have or are at risk of
developing hematologic disease. Antimalarials should be discontinued if any severe blood disorder appears. It is worth mentioning
that many studies did not reveal hematologic abnormalities during
routine antimalarial treatment.[49,96,98] Although quinacrine produced serious hematologic adverse effects when taken in dosages
of >100 mg/day in the past, hematologic reactions are so unlikely
when current dosage guidelines are followed that it is not cost
effective to frequently check hematologic function during treatment.[81]
There are conflicting data in the literature concerning the use of
antimalarials in psoriatic patients. Some authors claim that in
contrast to lithium and -blockers, antimalarials do not induce
psoriasis de novo but only worsen already existing disease.[99]
As antimalarials can be neurotoxic and myotoxic, special care
is required when treating patients with neuromuscular disorders.
Caucasians and patients with concomitant renal failure may be at
increased risk of developing proximal myopathy, peripheral
neuropathy, and cardiac myotoxicity while taking hydroxychloroquine.[100]
Although the incidence of antimalarial psychosis is small, close
observation of patients during therapy is recommended, especially
when any behavioral changes are noted.[75] It is unlikely that
hydroxychloroquine could worsen schizophrenia. In fact, hydroxychloroquine was once considered as a useful adjunct therapy for
the treatment of schizophrenia, but the results of studies performed
on 61 randomized patients with schizophrenia did not show significant differences between general symptoms in patients treated
with standard antipsychotic drugs combined with hydroxychloroquine compared with antipsychotics combined with placebo.[101]
Am J Clin Dermatol 2005; 6 (1)
Fig. 2. Treatment algorithm for lupus erythematosus (LE)-specific cutaneous LE, based mostly on data from reports on subacute cutaneous LE and
discoid LE. 1 Use of tacrolimus, pimecrolimus and imiquimod based on
recent limited case reports.[111-115]
2005 Adis Data Information BV. All rights reserved.
Acknowledgments
No sources of funding were used to assist in the preparation of this
manuscript. The authors have no conflicts of interest that are directly relevant
to the content of this review.
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