Clinical efficacy and side effects of antimalarials in systemic lupus erythematosus: a systematic review

Guillermo Ruiz-Irastorza ^1*, Manuel Ramos-Casals ², Pilar Brito-Zeron ² and Munther A Khamashta ³

¹ Hospital de Cruces, Spain
² Hospital Clinic, Spain
³ Lupus Research Unit, United Kingdom

^* To whom correspondence should be addressed. E-mail: r.irastorza{at}euskalnet.net.

Accepted 14 December 2008

Abstract

Background: Antimalarial drugs (AM), chloroquine (CQ) and hydroxychloroquine (HCQ), are frequently withdrawn in lupus patients with either severe or remitting disease. However, additional effects beyond immunomodulation have been recently described. Our aim was to analyse all the published evidence of the beneficial and adverse effects of AM therapy in SLE.

Methods: Systematic review of the English literature between 1982-2007 using MEDLINE and EMBASE. 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: 95 articles were included in the systematic review. We have found high evidence that AM prevent lupus flares and increase long-term survival of SLE patients; moderate evidence of protection against irreversible organ damage, thrombosis and bone mass loss .Toxicity related to AM is infrequent, mild and usually reversible, with HCQ having a safer profile. In pregnant women, we have found high evidence that AM, particularly HCQ, decrease lupus activity without harming the baby. On the other hand, 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 lupus patients against cancer.

Conclusion: 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.