SFGH 11.23 pearls: SLE and anti-malarials!

  • While there is no strict definition, a lupus flare is generally characterized by a measurable increase in disease activity based on serologies and clinical manifestations that is severe enough to warrant a change in therapy.
  • An elevated ESR without a significant CRP elevation may be consistent with a lupus flare (though unreliable in those with ESRD).
    • An exception to this is serositis, which may have an associated CRP increase. Without serositis, an high CRP in SLE should raise suspicion for infection.
  • In patients with atypical lupus presentation, remember to evaluate for other possible causes (such as malignancy) before beginning treatment if they are clinically stable.
  • Antimalarial drugs can cause visual impairment through corneal deposits (which are reversible) and retinopathy, which is the most feared complication of these medications and irreversible.
    • Antimalarials can bind to melanin in the retinal epithelial layer and damage the rods and cods, leading to permanent vision loss
    • This affects ~3-4% of patients on hydroxychloroquine over 10 years, and 10% of those on chloroquine, and the effect is related to cumulative dosing.
  • Quinacrine is another antimalarial used for rheumatic diseases much less frequently because it has to be compounded and can cause skin yellowing over time. However, the skin changes are usually reversible and this drug does not cause ocular toxicity.
  • There is a tendency for decreased clinical and serological SLE activity after onset of ESRD and initiation of HD among lupus patients, for reasons that are not yet known.
    • Survival on HD for SLE patients is the same as for the general HD population and SLE patients do better with renal transplant that patients with several other rheumatic disease

Evernote link: https://www.evernote.com/shard/s300/sh/032b88bf-b777-4786-bace-760cd9aa63ce/d34f2f375fe857884dadd732eff5113d

Mosak J, Furie R. Comparative safety of therapies in systemic lupus erythematosus. Rheum Dis Clin North Am 2012; 38:795.

Rynes RI, Bernstein HN. Ophthalmologic safety profile of antimalarial drugs. Lupus 1993; 2 Suppl 1:S17.

Ruperto N, Hanrahan LM, Alarcón GS, et al. International consensus for a definition of disease flare in lupus. Lupus 2011; 20:453.

Firooz N, Albert DA, Wallace DJ, et al. High-sensitivity C-reactive protein and erythrocyte sedimentation rate in systemic lupus erythematosus. Lupus 2011; 20:588.

Mojcik CF, Klippel JH, End-stage renal disease and systemic lupus erythematosus. Am J Med. 199 Jul;10(1):100-7.


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