Medical Center Baden-Baden and ViDia-Kliniken Karlsruhe, Practice for Rheumatology and Clinical Immunology, Beethovenstr. 2, 76530, Baden-Baden, Germany.
Klinik für Augenheilkunde, Universitätsklinik Freiburg, Freiburg, Germany.
Z Rheumatol. 2021 Feb;80(Suppl 1):1-9. doi: 10.1007/s00393-020-00785-4.
Antimalarial medication (AM) plays an important role in the treatment of rheumatic diseases.
Updated evidence-based recommendations on the safety management of rheumatological treatment with AM are presented.
A systematic literature search in the databases Medline (PubMed) and Cochrane identified 1160 studies on the safety of treatment with AM in rheumatology. In addition, a manual search was carried out and 67 publications considered to be particularly relevant by the authors were analyzed in more detail. These publications served as a basis for consensus-based recommendations.
Treatment with AM in rheumatology should be carried out with hydroxychloroquine (HCQ) with a dosage not exceeding 5 mg/kg body weight/day. Patients should undergo a basic ophthalmological examination within the first 6 months of AM treatment. Pre-existing maculopathy, renal insufficiency (glomerular filtration rate, GFR <60 ml/min), tamoxifen comedication, a daily dose of >5 mg/kg HCQ or treatment with chloroquine (CQ) show an increased risk for AM-induced retinopathy. These patients should undergo an annual ophthalmological check from the beginning of the treatment, whereas patients with no risk factors are recommended to start this only after 5 years of taking the medication. The ophthalmological examination should comprise at least both an appropriate subjective and an objective method and these are usually an automated visual field test and optical coherence tomography (OCT). A visual field test revealing a parafoveal sensitivity loss and an OCT showing a parafoveal circumscribed loss of the photoreceptor layer or focal interruptions of the structural line of the outer segment are signs of a possible AM retinopathy. Determination of creatine kinase (CK) and lactate dehydrogenase (LDH) in blood is appropriate to screen for cardiomyopathy and myopathy and should be checked before starting the treatment and then ca. every 3 months. The use of cardiac biomarkers, such as brain natriuretic peptide (BNP) or troponin in serum, electrocardiograph (ECG) or cardiac imaging should be considered depending on the situation. An intake of HCQ is safe during pregnancy and breastfeeding according to the current state of knowledge and is protective for mother and child in patients with systemic lupus erythematosus.
The updated recommendations on AM treatment in rheumatology in particular include a more rigorous measuring of doses, risk stratification in monitoring and defined ophthalmological examination methods to detect a possible retinopathy.
抗疟药物（AM）在治疗风湿性疾病中发挥着重要作用。
提出风湿性疾病中使用 AM 治疗的安全性管理的最新循证推荐。
在 Medline（PubMed）和 Cochrane 数据库中进行系统的文献检索，共检索到 1160 项关于风湿科使用 AM 治疗安全性的研究。此外，还进行了手动检索，并分析了作者认为特别相关的 67 篇出版物。这些出版物是基于共识推荐的基础。
风湿科使用 AM 治疗应采用羟氯喹（HCQ），剂量不超过 5mg/kg 体重/天。在 AM 治疗的前 6 个月内，患者应接受基本的眼科检查。预先存在的黄斑病变、肾功能不全（肾小球滤过率，GFR <60ml/min）、他莫昔芬合并用药、每日剂量>5mg/kg HCQ 或氯喹（CQ）治疗显示出 AM 诱导的视网膜病变的风险增加。这些患者应从治疗开始就每年进行眼科检查，而无风险因素的患者建议在服药 5 年后才开始进行该检查。眼科检查应至少包括适当的主观和客观方法，通常是自动视野测试和光学相干断层扫描（OCT）。视野测试显示旁中心敏感性丧失，OCT 显示光感受器层旁中心局限丧失或外节结构线的焦点中断是 AM 视网膜病变的可能迹象。血液中肌酸激酶（CK）和乳酸脱氢酶（LDH）的测定适用于筛查心肌病和肌病，应在开始治疗前检查，然后大约每 3 个月检查一次。应根据具体情况考虑使用心脏生物标志物，如血清中的脑钠肽（BNP）或肌钙蛋白、心电图（ECG）或心脏成像。根据目前的知识水平，HCQ 在怀孕期间和母乳喂养期间是安全的，并且对系统性红斑狼疮患者的母婴都有保护作用。
风湿科 AM 治疗的最新推荐特别包括更严格的剂量测量、监测中的风险分层以及确定眼科检查方法以检测可能的视网膜病变。
