Antimalarials Recommended for All Lupus Patients

Anthony J. Brown, MD

January 22, 2010

January 22, 2010 — Use of antimalarial agents can improve survival with systemic lupus erythematosus and should be given to all patients with the disease, according to a report in the January 7th issue of Arthritis & Rheumatism.

During a median follow-up period of 55 months, the mortality rate for non-users of antimalarial drugs was 11.5%, while that of users was just 4.4% (p < 0.001). Further analysis showed that patients who used the drugs for more than 2 years had the lowest mortality per 1000 person-years of follow-up — 0.54 deaths, compared to 3.07 in non-users.

Prior research has suggested that antimalarial therapy can help prevent flare-ups of lupus and reduce overall damage from the disease, Dr. Bernardo A. Pons-Estel, from Hospital Provincial de Rosario, Argentina and co-researchers note.

"The beneficial effects of antimalarials in lupus, however, go beyond disease activity and damage accrual," the authors state. As an example, they cite a study in Caucasian patients in which antimalarials seemed "to have a protective effect on survival" with "a reduction in mortality." Of note, none of the subjects in the study died from cardiovascular causes, the most common cause of death in untreated patients, they add.

Data from the LUMINA study, reported in 2007, confirmed a survival benefit with antimalarials in a multiethnic cohort, the investigators state. "However, the minimal time of drug exposure required to exert this effect could not be derived from their data."

To identify any time-dependent effects of antimalarials on lupus survival, the researchers examined socio-demographic characteristics, clinical manifestations, classification criteria, laboratory tests, and treatment variables in 1480 patients in the GLADEL cohort (Grupo Latino Americano De Estudio de Lupus). This large multiethnic cohort was started in 1997 and drawn from 34 centers in 9 countries.

Antimalarial users were defined as patients who used antimalarial agents for at least 6 months, while non-users were defined as those who used such drugs for less than 6 months or not at all. Deaths were classified as lupus activity, infection, cardiovascular, thrombosis, malignancy, other, or unknown.

Overall, 1141 (77%) of the patients were antimalarial users, and the average exposure time was 48.5 months (range 6 to 98 months). Seventy patients used antimalarials for 6 to 11 months, 146 used them for 1 to 2 years, and 925 used them for more than 2 years.

Eighty-nine patients (6.0%) died during follow-up and, as noted, mortality was higher in non-users of antimalarial drugs.

As the duration of antimalarial drug use climbed from 6 to 11 months to more than 2 years, mortality fell from 3.85 to 0.54 deaths per 1000 person-years of follow-up. The mortality rate in non-users was 3.07 per 1000 person-years. After accounting for possible confounders, antimalarial use appeared to reduce mortality by 38%.

No differences in the causes of death were seen between users and non-users, indicating that in contrast to previous research, antimalarial use had no apparent protective effect against deaths from cardiovascular causes.

"The data presented, taken in conjunction with the data from the published literature, suggest that antimalarials should be used in all lupus patients regardless of their disease manifestation or disease duration," the authors conclude.

Arthritis Rheum. Published online January 7, 2010.

Reuters Health Information 2010. © 2010 Reuters Ltd.

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