SNOWMASS, COLO. — Antimalarials may not only treat active lupus, but also benefit the heart, W. Joseph McCune, M.D., said at a symposium sponsored by the American College of Rheumatology.
Lupus patients have an elevated risk of heart disease, and antimalarials have been shown to have a number of cardioprotective properties, said Dr. McCune, professor of internal medicine at the University of Michigan, Ann Arbor.
Such benefits may help offset the deleterious effects of prednisone, which has been shown to increase cholesterol levels. Each 10-mg titration in prednisone dosage is estimated to increase serum cholesterol by 7.5 mg/dL.
Several studies have shown that antimalarials are associated with lipid profile improvements in lupus patients. Each of those studies has treated patients somewhat differently and has shown slightly different results. “But the body of the studies clearly show that when a benefit is looked for, it is found mostly in lowering LDL cholesterol,” Dr. McCune said.
In one study involving lupus patients not on corticosteroids, antimalarial therapy was associated with a 4% drop in total cholesterol at 3 months and a 1% drop at 6 months, compared with baseline levels. In patients on a corticosteroid, antimalarial therapy was associated with an 11% drop in total cholesterol at 3 months and a 9% drop at 6 months (J. Rheumatol. 1999;26:325-30).
Among diabetes patients, antimalarials have been shown to lower glucose levels in non-insulin-dependent patients. They also reduce insulin requirements in insulin-dependent patients. The dosages used have tended to be much higher than those typically used to treat lupus. However, even at the lower dosages used for treating lupus, it's believed that there is some positive effect on glucose tolerance, Dr. McCune said.
Other drugs have been shown to have beneficial secondary effects in lupus patients, but the supporting evidence is generally less robust, he said.
Dehydroepiandrosterone, which can be steroid sparing when it is added to lupus treatment, may produce increases in bone density that could offset steroid-induced osteopenia. But this has not been shown in patients with lupus, and the evidence is not definitive.
Statins clearly have immunomodulatory effects and have been shown to help prevent transplant rejection and to improve rheumatoid arthritis symptoms. They obviously primarily lower cholesterol, and they may have positive effects on bone formation. But at present there are no trials of statins used in patients with lupus, Dr. McCune said.