Anti-malarials are particularly effective in treating skin and joint symptoms that may occur in lupus. they have been demonstrated to improve muscle and joint pain, inflammation of the lining of the heart and lung, and other symptoms of lupus such as fatigue and fever. However, anti-malarials alone are not appropriate treatment for more severe manisfestations of lupus such as kidney disease.

Anti-malarials are very effective in the treatment of discoid lupus: 60-90% of patients with DLE went into remission or showed major improvement after being trated witha nti-lalarials. Skin lesion of DLE which have not responded to treatment with topical therapy may improve with the use of anti-malarial drugs.

Anti-malarials are useful in subacute cutaneous lupus, and in overlaop syndromes in which patients have acute symptoms of lupus and other auto-immune disorders.

The anti-malarials which are utilized in North America for the management of lupus include hydroxychloroquine (Plaquenil) and chloroquine (Aralen). These medications are not equivalent in their side effects. In the US, hydroxychloroquine (Plaquenil) is the most popular because it is felt to be less ikely to casue eye side effects. Quinacrine (Atabrine) is available from compounding pharmacists and became available again in 1994.

HOW DO ANTI-MALERIAL'S CONTROL SYSTEMIC LUPS?

The specific mechanisms by which anti-malarials control systemic lupus is unclear. It is known that anti-malarials protect against the damaging effect of ultraviolet light and improve skin lesions. Some researchers suggest that they combine with certain chemicals or groups of proteins and interfere with enzyme groups that play a role in inflammation. Other researchers believe that more complex mechanisms are involved, such as the inhibition of antibody response or the direct inhibition of the lupus erythematosus cell reaction.

CAN ANTI-MALARIAL'S BE TAKEN WITH OTHER MEDICATIONS?

Anti-malarials can be taken with other medications used for the treatment of systemic lupus such as corticosteroids, cytotoxics and anti-inflammatory medications including aspirin. In fact, anti-malarials are sometimes given in combination with prednisone to reduce the amount of steroid that is needed to improve symptoms. Obviously, any combination of medications should always be prescribed by a physician.

IS IT SAFE TO TAKE ANTI-MALARIAL'S DURING PREGNANCY?

The manufacturer recommends that anti-malarial not be given during pregnancy because of the potential for congenital malformations in the baby. However, anti-malarials are apparently safe when used to prevent malaria in pregnant women. Dr. Ann Parke of the University of Connecticut has treated 11 lupus patients who were pregnant with anti-malarials without adverse effects on the fetus. Clearly, more research is needed on this topic. Patients should discuss the pros and cons of continuing treatment with anti-malarials during pregnancy if they are planning to become pregnant.

WHAT ARE THE SIDE EFFECTS OF ANTI-MALARIAL'S?

The sie effects of anti-malarials include skin rashes and pigmentary changes. Ababrine specifically, can cause yellow pigmentation of the skin. Hair loss and dryness of the skin have also been described. Stomach upset, loss of appetite, abdominal bloating, cramps, nausea, vomiting, and diarrhea may also occur with the use of anti-malarials. These side effects usually go away after the patient adjusts to the medication. However, if they continue, a physician should be consulted.

Some patients may experience headaches, muscle aching, weakness as a result of taking anti-malarials. Nervousness, irritability or dizziness can occur, but these side effects are uncommon. Major neurological side effects such as confusion or seizures are quite rare. However, if any of these side effects occur, they should be reported immediately to a physician.

A major potential side effect of anti-malarial use is the possible damage to the retina that these medications can produce. It is important to note that retinal damage ue to the use of anti-malarials is dose related, and that the low doses currently used in the treatment of lupus are rarely associated with retinal damage. Most cses of eye disease occur in patients receiving more than 400 mg of plaquenil or more than 250mg of Aralen daily. Atabrine is not known to cause retinal damage.

Retinal damage due to the use of plaquenil is sometimes reversible, if it is treated early. However, chloroquine (Aralen) is irreversible. Thus, it is necessary to have the patient see the eye doctor or ophthalmologist prior to beginning treatment with anti-malarials for a baseline exam and to receive follow-up eye exams every three to six months thereafter. On many occasions, an ophthalmologist can see mild changes in the retinaal pigment that indicate early damage due to the use of anti-malarials. In addition to the regular eye check-ups which test visual acuity and eye pressure, tests of color vision and visual fild might be necessary. New computer assisted machines for testing the visual field for anti-malarial effects are very sensitive to small changes. Patients can also monitor themselves between visits by the use of a Amsler grid, which can be requested from an ophthalmologist. If visual symptoms do occur, these should be reported immediately to a doctor.

In summary, anti-malarials can contribute substantially to the relief of some of the symptoms associated with lupus, especially those of the skin and joint. Other potential benefits of plaquenil have included decreased levels of cholesterol in some patients who are steroid dependent and decreased thrombosis in some patients with positive cardiolipin antibodies. Plaquenil has also been used by some physicians for the management of sjogren's syndrome. All of these side effects mentioned are not common and anti-malarials are generally regarded as safe to use in the treatment of lupus.







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