Anti-malarials are particularly effective in treating skin and joint symptoms that may occur in SLE. They have been demonstrated to improve muscle and joint pain, inflammation of the lining of the heart (pericarditis) and lung (pleuritis), and other symptoms of lupus such as fatigue and fever. However, anti-malarials alone are not appropriate treatment for more severe manifestations of systemic lupus such as kidney disease.
Anti-malarials are very effective in the treatment of discoid lupus erythematosus (DLE): 60-90% of patients with DLE went into remission or showed major improvement after being treated with anti-malarials. Skin lesions of DLE which have not responded to treatment with topical therapy (e.g., creams, ointments) may improve with the use of anti-malarial drugs.
Anti-malarials are useful in subacute cutaneous lupus, and in overlap 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 systemic lupus include hydroxychloroquine (Plaquenil), and chloroquine (Aralen). These medications are not equivalent in their side effects. In the United States, hydroxychloroquine (Plaquenil) is the most popular because it is felt to be less likely to cause eye side effects. Quinacrine (Atabrine) is available from compounding pharmacists and will be available again in 1994.
Some patients may experience headaches, muscle aching, and 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 (back of the eye) that these medications can produce. It is important to note that retinal damage due 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 cases of eye disease occur in patients receiving more than 400 mg of Plaquenil or more than 250 mg 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 an eye doctor or ophthalmologist prior to beginning treatment with anti-malarials for a baseline examination and to receive follow-up eye examinations every three to six months thereafter. On many occasions, an ophthalmologist can see mild changes in the retinal 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 field 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 an Amsler grid, which can be requested from an ophthalmologist. If visual symptoms do occur (blurred vision or any other changes in vision), 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 joints. 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 the side effects mentioned are not common and anti-malarials are generally regarded as safe to use in the treatment of lupus.