Effect of hydroxychloroquine on the survival of patients with systemic lupus erythematosus: data from LUMINA, a multiethnic US cohort (LUMINA L)

Abstract

Objective: In patients with systemic lupus erythematosus (SLE), hydroxychloroquine prevents disease flares and damage accrual and facilitates the response to mycophenolate mofetil in those with renal involvement. A study was undertaken to determine whether hydroxychloroquine also exerts a protective effect on survival. Methods: Patients with SLE from the multiethnic LUMINA (LUpus in MInorities: NAture vs nurture) cohort were studied. A case-control study was performed within the context of this cohort in which deceased patients (cases) were matched for disease duration (within 6 months) with alive patients (controls) in a proportion of 3:1. Survival was the outcome of interest. Propensity scores were derived by logistic regression to adjust for confounding by indication as patients with SLE with milder disease manifestations are more likely to be prescribed hydroxychloroquine. A conditional logistic regression model was used to estimate the risk of death and hydroxychloroquine use with and without the propensity score as the adjustment variable. Results: There were 608 patients, of whom 61 had died (cases). Hydroxychloroquine had a protective effect on survival (OR 0.128 (95% CI 0.054 to 0.301 for hydroxychloroquine alone and OR 0.319 (95% CI 0.118 to 0.864) after adding the propensity score). As expected, the propensity score itself was also protective. Conclusions: Hydroxychloroquine, which overall is well tolerated by patients with SLE, has a protective effect on survival which is evident even after taking into consideration the factors associated with treatment decisions. This information is of importance to all clinicians involved in the care of patients with SLE.

Analysis of Complete Remission in Systemic Lupus Erythematosus Patients Over a 32‐Year Period

“…There is evidence that supports the use of antimalarials for the prevention of flares or recurrences (13,14). Sixtytwo percent of our patients who achieved remission were taking antimalarials.…”

Hydroxychloroquine in Systemic Lupus Erythematosus: Comment on the Article by Muangchan et al

“…In multivariate analysis, use of HCQ was associated with a reduced risk of developing new damage. The LUMINA Study Group showed that use of HCQ was associated with a greater survival rate in 608 SLE patients in a case-control study (6). The effect of HCQ on survival was also observed in the observational, prospective cohort study by Ruiz-Irastorza et al (7).…”

“…However, finding improved survival in SLE patients who used antimalarials versus those who did not could be confounding by indication, where perhaps only those patients with mild SLE were prescribed antimalarials (i.e., those with skin and joint involvement, mucositis, and mild constitutional symptoms) compared to those presenting with major organ involvement who received strong immunosuppressives and high doses of steroids. We agree that clinicians should use knowledge from the literature and their clinical experience when treating SLE and recognize the benefits of antimalarial treatment, such as a steroid-sparing effect in a randomized trial (6).…”

Dr. Durcan, et al reply

“…This is an issue of critical importance in SLE because HCQ therapy associates with a myriad of benefits in a serious, potentially fatal condition 4,5 .…”