SCOTTSDALE, ARIZ. – Thalidomide, methotrexate, dapsone, and belimumab may be the best treatment alternatives for cutaneous lupus erythematosus that is refractory to antimalarials, based on reviews of 15 years of medical records from three large tertiary care centers.
The study is the largest so far to take a comprehensive look at treatments and outcomes in hydroxychloroquine-refractory cutaneous lupus erythematosus (CLE), said Renee Fruchter, a medical student at New York University, who presented the findings at the annual meeting of the Society for Investigative Dermatology.
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CLE has no approved treatments in the United States. For affected patients, quality of life is so poor that it resembles that reported by survivors of recent myocardial infarction, according to Ms. Fruchter. Patients with localized CLE can do reasonably well with sun protection and topical and intralesional treatments, but patients with more extensive disease typically need systemic treatment, most often with antimalarials, she noted. However, up to half of CLE patients are refractory to the first-line therapy, hydroxychloroquine (Plaquenil), and treatment options for this CLE subgroup are understudied.
Therefore, Ms. Fruchter and her associates reviewed medical records from patients with CLE treated between 2000 and 2015 at NYU Langone Medical Center, Brigham and Women’s Hospital, and Massachusetts General Hospital. Although the study was retrospective, they used clinical documents and medical photos, when available, to assess treatment response via the validated CLE Disease Area and Severity Index (CLASI).
Among 46 CLE patients who were refractory to hydroxychloroquine, 87% were female and 30% were African American, with an average age of 36 years, Ms. Fruchter said. Nearly three-quarters of patients (73%) had generalized CLE, while the rest had disease localized to the head and neck. As in prior studies, patients exhibited a wide range of CLE subtypes, but most commonly generalized discoid variant, Ms. Fruchter said. Nearly 30% of patients currently smoked, which also resembled prior studies of this risk factor.
Refractory patients received a wide range of systemic agents – most commonly chloroquine (Aralen) and mycophenolate mofetil (Cellcept), followed by quinacrine, dapsone, methotrexate, belimumab (Benlysta), azathioprine, thalidomide (Thalomid), lenalidomide (Revlimid), prednisone, and rituximab (Rituxan), Ms. Fruchter and her associates reported. Although treatment subgroups were small, thalidomide was most effective by far, improving disease by at least 50% in four of five treated patients. In contrast, 5 of 11 patients on methotrexate achieved at least a 50% improvement, as did 4 of 11 patients on dapsone and 3 of 9 patients on belimumab. “Other medications had lower rates of success,” Ms. Fruchter noted. Notably, CLE that failed to respond to antimalarials was also refractory to immunomodulatory therapies, she said. For example, azathioprine failed to induce a substantial clinical response in any of the patients, and only 20% of patients responded to mycophenolate mofetil.
The study also showed that switching to another antimalarial may be effective if patients do not respond to hydroxychloroquine. Fully 53% of hydroxychloroquine nonresponders had a substantial response to quinacrine, while 40% had a substantial response to chloroquine, Ms. Fruchter said.
She had no disclosures.