According to Dr. Petri, ideal levels of hydroxychloroquine in whole blood should range from 750–1,000 mg/dL, and it is very reasonable for clinicians to monitor blood levels to ensure adherence and to confirm appropriate dosing.
Hydroxychloroquine, a medication with myriad positive effects in lupus, is not used optimally by providers or patients.
Overuse of Glucocorticoids
A second issue facing patients with lupus is that, as a whole, rheumatologists are still using too much prednisone for treatment, leading to poor outcomes for many patients. Evidence suggests that glucocorticoid use is an independent risk factor for damage accrual in SLE, and that development of irreversible organ damage associated with glucocorticoid treatment occurs in a dose-dependent fashion.5
For this reason, Dr. Petri explains, the “P” in prednisone stands for poison.
This helps explain why the EULAR recommendations for the management of SLE state that, in the chronic maintenance of lupus disease, glucocorticoid dose should be kept to less than 7.5 mg/day (prednisone equivalent) and, when possible, glucocorticoids should be withdrawn entirely.6
Morbidity & Mortality
Dr. Petri went on to explain that several other issues continue to impact morbidity and mortality in patients with lupus, including infections, thrombosis and cardiovascular disease. During the past several years, COVID-19 infection has been a particular concern in patients with lupus, both because of the potential for increased risk associated with the underlying disease and treatment and the impact that certain medications may have on dampening antibody production after COVID-19 vaccination.
Thrombosis is a particular problem in patients with antiphospholipid syndrome. In addition to anticoagulation with warfarin or a heparin product, Dr. Petri noted that evidence indicates potential benefits associated with hydroxychloroquine, aspirin, statins and vitamin D in these patients.
With regard to cardiovascular disease, it has been known for some time that lupus is an accelerant of atherosclerotic disease and that cardiac symptoms must be taken seriously in patients with lupus, irrespective of age. Dr. Petri and colleagues have developed a data-driven equation for cardiovascular risk in SLE, and this equation has been able to estimate the 10-year cardiovascular risk in patients with lupus better than traditional predictive models, such as the Framingham equation.7
Concluding Thoughts
Dr. Petri concluded her presentation by describing a few other roadblocks on the path to progress in treating lupus effectively. These include the threats to health posed by renal disease, malignancy and type 2 non-inflammatory symptoms.
