For patients with systemic lupus erythematosus (SLE), maintaining low long-term hydroxychloroquine (HCQ) intake and very low HCQ blood levels is associated with an increased risk for atherosclerotic cardiovascular disease (ASCVD), according to a study published online Aug. 3 in Arthritis Care & Research.
Shivani Garg, M.D., Ph.D., from Yale University in New Haven, Connecticut, and colleagues conducted a prospective longitudinal study involving 248 adults with SLE taking HCQ. The proportion of days covered (PDC) was used to estimate long-term HCQ intake, and whole-blood HCQ levels were a marker for recent exposure. Ten-year ASCVD risk was calculated, and associations between HCQ exposure patterns and ASCVD risk were assessed.
The researchers found that the risk for ASCVD was significantly higher at baseline (+2.1 percent) for patients with very low HCQ blood levels (<200 ng/mL) and low long-term intake (PDC <80 percent), with a mean predicted risk of 6.6 percent. The highest ASCVD risk at follow-up (5.7 percent) was seen for those who remained in or transitioned into these low-exposure categories over one year.
“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 said in a statement. “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.”
Research shows that Black Americans, particularly Black women, are disproportionately affected by systemic lupus erythematosus (SLE). They are also more likely to develop the autoimmune disease at younger ages than white Americans. Disease severity, organ involvement, and mortality rates tend to be higher among Black patients.
Cardiovascular disease is already a leading cause of death in lupus, so any factor linked to increased ASCVD risk may have heightened importance in Black patients. With this in mind, clinicians caring for Black patients with lupus should consider heart health assessments during routine follow-ups.
Several factors could influence lower hydroxychloroquine intake, including:
For clinicians, it’s important to look beyond medication nonadherence to understand why patients may have lower hydroxychloroquine levels in their blood. This is especially important for Black patients with SLE, who may face multiple barriers that affect their ability to take their medication at the prescribed dosage and frequency.
Here’s what clinicians can consider when treating patients with SLE:
Future research should continue to examine HCQ exposure and cardiovascular outcomes across racial and ethnic groups. More data is needed to better understand whether medication blood-level monitoring can reduce disparities for patients disproportionately burdened by the autoimmune disease. Studies with a larger representation of Black participants could help determine whether targeted interventions could improve outcomes.
The link between low hydroxychloroquine blood levels and increased ASCVD risks adds to a growing body of evidence that consistent lupus control should extend beyond controlling disease activity. For Black patients, who already experience a disproportionate burden of severe SLE and cardiovascular complications, identifying and addressing barriers to medication adherence may represent an important opportunity to improve long-term outcomes.
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