Page 35 - e-CPG-SLE-8_5_24
P. 35

Management of Systemic Lupus Erythematosus

           thrombosis and bone mass loss compared with control in SLE. 60, level I
           However, the quality assessment of primary studies was not reported.

           A prospective cohort study showed that the use of HCQ reduced the risk
           of death (HR=0.46, 95% CI 0.29 to 0.72) and renal damage (HR=0.30,
           95%  CI  0.13  to  0.68)  compared  with  non-HCQ  use  in  patients  with
           SLE. 61, level II-2

           In  a  retrospective  cohort  study  among  patients  in  the  maintenance
           phase of SLE, there were no significant difference between usual dose
           HCQ (5 mg/kg) and low dose HCQ (200 mg) in SLEDAI, Cutaneous
           Lupus  Erythematous  Disease Area  and  Severity  Index  (CLASI)  and
           serum levels of anti-dsDNA antibodies at 6-month. 62, level II-2

           A  systematic  review  of  mixed  study  designs  in  SLE  showed  higher
           odds of flare in patients with low HCQ levels (<1000 ng/mL) compared
           with  high  levels  (OR=5.89,  95%  CI  1.38  to  25.08).  The  overall  risk
           of bias assessment of primary studies in the review showed the
           eight  observational  studies  were  of  fair  to  good  quality  while  the
           three interventional studies were of unclear to low risk. 63, level II-2  HCQ
           adherence can be assessed using drug levels in the blood but it has not
           been recommended in routine clinical practice at present.

           Long-term  use  of  HCQ  treatment  is  safe. Toxicity  related  to  HCQ  is
           infrequent, mild and usually reversible. 60, level I

           Specifically, retinal toxicity related to HCQ is uncommon. A retrospective
           cohort study on newly diagnosed SLE patients showed an incidence of
           HCQ retinal toxicity at one in 1000 person-years. 64, level II-2  However, the
           incidence increased in SLE patients with risk factors (e.g. long duration
                                               65
           and high dose of HCQ) for toxic retinopathy.  In a case-control study
           on SLE, a small proportion (5.5%) of patients developed antimalarial-
           induced retinal complications over an average usage of 12.8 years. No
           retinal toxicity was reported in the first five years of exposure. 66, level II-2
           The American Academy of Ophthalmology recommends HCQ dose of
           no more than 5 mg/kg actual body weight to reduce the occurrence of
           retinopathy. 65

           Recommendation 6
           •  All patients with systemic lupus erythematosus (SLE) should be on
             hydroxychloroquine (HCQ) unless intolerant or contraindicated.
           •  Ophthalmologic assessment should be done for patients with SLE on
             HCQ at baseline, and then:
               yearly in the presence of known retinopathy risk factors*
               after five years and yearly thereafter in the absence of retinopathy
                risk factors*


                                      18
   30   31   32   33   34   35   36   37   38   39   40