Clinical efficacy and side effects of antimalarials in systemic lupus erythematosus: a systematic review
Abstract
Background Antimalarial drugs (AMs), chloroquine (CQ) and hydroxychloroquine (HCQ), are frequently withdrawn in patients with lupus with either severe or remitting disease. However, additional effects beyond immunomodulation have been recently described. The aim of the present work was to analyse all the published evidence of the beneficial and adverse effects of AM therapy in systemic lupus erythematosus (SLE).Methods A systematic review of the English literature between 1982 and 2007 was conducted using the MEDLINE and EMBASE databases. Randomised controlled trials (RCTs) and observational studies were selected. Case reports were excluded except for toxicity reports. The GRADE system was used to analyse the quality of the evidence.Results A total of 95 articles were included in the systematic review. High levels of evidence were found that AMs prevent lupus flares and increase long-term survival of patients with SLE; moderate evidence of protection against irreversible organ damage, thrombosis and bone mass loss. Toxicity related to AMs is infrequent, mild and usually reversible, with HCQ having a safer profile. In pregnant women, high levels of evidence were found that AMs, particularly HCQ, decrease lupus activity without harming the baby. By contrast, evidence supporting an effect on severe lupus activity, lipid levels and subclinical atherosclerosis was weak. Individual papers suggest effects in preventing the evolution from SLE-like to full-blown SLE, influencing vitamin D levels and protecting patients with lupus against cancer.Conclusions Given the broad spectrum of beneficial effects and the safety profile, HCQ should be given to most patients with SLE during the whole course of the disease, irrespective of its severity, and be continued during pregnancy.
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Current recommendations advise hydroxychloroquine for SLE patients with persistent moderate-to-high antiphospholipid antibodies or positive lupus anticoagulant for primary prevention (grade 1B to 2B), based on its other benefits in SLE and thrombosis.
“HCQ treatment is currently recommended for SLE patients with persistent moderate-high aPL Ab or LAC+ for primary prevention (grade 1B to 2B recommendation) based on the other beneficial effects of HCQ in SLE (12, 13) and thrombosis (14).”
Hydroxychloroquine use is linked to improved survival.
“and is associated with increased survival [10].”
From Antithrombotic effects of hydroxychloroquine in primary antiphospholipid syndrome patients (2013) · cites this paper as [10]
Hydroxychloroquine may be beneficial as an antithrombotic in patients with systemic lupus erythematosus and/or antiphospholipid syndrome.
“HCQ could be useful as an antithrombotic both in the general population [9] and in systemic lupus erythematosus and/or APS patients [10]”
From Antithrombotic effects of hydroxychloroquine in primary antiphospholipid syndrome patients (2013) · cites this paper as [10]
There is evidence for multiple beneficial effects of hydroxychloroquine in SLE.
“There is evidence for multiple beneficial effects of HCQ in SLE”
From 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus (2019) · cites this paper as [32]
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- Authors
- Ruiz-Irastorza, G., Ramos-Casals, M., Brito-Zeron, P., & Khamashta, M. A.
- Affiliations
- St Thomas' Hospital (GB)
- ORCID
- Khamashta, M A
- Venue
- Annals of the Rheumatic Diseases
- Publisher
- Elsevier BV
- Published
- 2010-01
- Volume
- 69
- Issue
- 1
- Pages
- 20-28
- ISSN
- 0003-4967 (ISSN-L)
- OpenAlex
- W2004135257
- Cited by
- 978
- References
- 106
- Citations by year
- 2026: 34 · 2025: 37 · 2024: 50 · 2023: 47 · 2022: 58 · 2021: 77 · 2020: 123 · 2019: 61 · 2018: 59 · 2017: 50 · 2016: 52 · 2015: 43 · 2014: 67 · 2013: 60 · 2012: 59
- FWCI
- 4.80
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Annals of the Rheumatic Diseases (publishedVersion)
- PubMed (publishedVersion)
- Research Portal (King's College London) (submittedVersion)
- HighWire Press Open Archive (submittedVersion)
- Topics
- Health Sciences › Medicine › Rheumatology › Systemic Lupus Erythematosus Research
- Health Sciences › Medicine › Radiology, Nuclear Medicine and Imaging › Monoclonal and Polyclonal Antibodies Research
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Malaria Research and Control
- Keywords
- systemic lupus erythematosus, antimalarial drugs, chloroquine, hydroxychloroquine, clinical efficacy, adverse effects, monoclonal antibodies, scFv, pre-trained language models, convolutional neural networks
- MeSH terms
- Antimalarials, Humans, Lipids, Lupus Erythematosus, Systemic, Osteoporosis, Research Design, Thrombosis, Bone Density, Survival Analysis, Evidence-Based Medicine, Atherosclerosis
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
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