Sep 05: Systemic Lupus Erythematosus, commonly known as lupus, is an autoimmune disease that causes inflammation across the body, including in the kidneys, lungs, and other organs. People with lupus are at a much higher risk of cardiovascular disease compared to the general population, and young women with lupus are up to 50 times more likely to have a heart attack than young women without lupus.
The most common treatment for lupus is hydroxychloroquine, a daily and potentially lifelong medication that may help prevent organ damage and relieve other symptoms of the disease. A new Yale-led paper published in Arthritis Care and Research found that maintaining stable HCQ levels could also help reduce the risk of atherosclerosis, a common cardiovascular disease, as well as other cardiovascular outcomes.
“We have always thought of HCQ as a foundational therapy, but we didn’t have clear data showing if maintaining levels within the therapeutic range, defined by our team and others, has a real-world effect on lowering the risk of having a heart attack or stroke,” says Shivani Garg, MD, PhD, associate professor of medicine (rheumatology, allergy & immunology), first author of the study, and director of the Yale Lupus Program. “We wanted to see if the target therapeutic range identified in previous studies also had an effect on cardiovascular disease risk.”
To explore this question, Garg and her colleagues studied a longitudinal cohort of 248 patients with lupus and calculated their individual risk level for ASCVD, high cholesterol, high blood pressure, and other related cardiovascular outcomes using a tool developed by the American Heart Association called PREVENT. The researchers then followed the group and recalculated each patient’s risk score after one year.
They compared these risk scores to two metrics: each patient’s HCQ blood levels, which provided a snapshot of how much of the drug had been absorbed into the bloodstream, and the medication adherence pattern of each patient, including how consistently they refilled their prescriptions.
The study found that people with very low levels of HCQ in the blood and low adherence trends had an increased ASCVD risk after one to two years. Garg notes that although the risk level increased only slightly, the increase was especially meaningful because the study participants were young and had a low or intermediate cardiovascular disease risk. Garg hopes to validate these study results in a different, larger cohort of patients.
“This study underscores the need for targeted interventions that both improve long-term adherence to HCQ and help patients achieve the target HCQ blood levels,” Garg says. “It can be difficult for patients to commit to taking medication every single day for the rest of their lives. By giving patients clear data about their HCQ level and how it impacts their heart health and risk for flare-ups, we can help them make better-informed decisions about their medicines and care. Moreover, it gives an actionable next step for the clinicians and patients to optimize HCQ use and dosing to prevent a heart attack or stroke. These findings clearly give another reason for monitoring HCQ blood levels at the point of care instead of using the standard one-size-fits-all dosing.”
Rheumatology, Allergy & Immunology, one of 10 sections in the Yale Department of Internal Medicine, is dedicated to providing care for patients with rheumatic, allergic, and immunologic disorders; educating future generations of thought leaders in the field; and researching fundamental questions of autoimmunity and immunology. To learn more, visit Rheumatology, Allergy & Immunology.