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Hydroxychloroquine Treatment for Primary Sjogren's Syndrome

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Hydroxychloroquine Treatment for Primary Sjogren's Syndrome 360 Annals of the Rheumatic Diseases 1993; 52: 360-364 treatment Hydroxychloroquine for primary Ann Rheum Dis: first published as 10.1136/ard.52.5.360 on 1 May 1993. Downloaded from Sjogren's syndrome: a two year double blind crossover trial. AA Kruize, R J Hene, C G M Kallenberg, 0 P van Bijsterveld, A van der Heide, L Kater, J W J Bijlsma Abstract life threatening extraglandular manifestations. Objectives-In 1985 and 1988 a positive Cytotoxic drugs are contraindicated because of effect of treatment of primary Sj6gren's a possible enhancement of the already excess syndrome with hydroxychloroquine was risk of the development of lymphoma in reported in two small open studies. To primary Sjogren's syndrome.6 investigate further the clinical and In several rheumatic diseases, such as laboratory effects of hydroxychloroquine rheumatoid arthritis and systemic lupus in primary Sjogren's syndrome a two year erythematosus, hydroxychloroquine has a study was performed. therapeutically beneficial effect.7-'0The mech- Methods-The design of the study anism of action ofhydroxychloroquine in these included a prospective, placebo con- rheumatic diseases is not fully understood. It trolled, two year double blind crossover has been suggested that it is caused by trial in 19 patients interference with macrophage processing of Results-A significant decrease in IgG antigens, resulting in an interaction with T cell and IgM and a tendency for a decrease in activation." 12 As T cell derived lymphokines the erythrocyte sedimentation rate (ESR) are required for B cells to switch from IgM to during treatment with hydroxychloro- IgG synthesis, treatment with hydroxychloro- quine compared with treatment with quine in patients with Sjogren's syndrome placebo were found. No beneficial clinical could lead to a decrease in their IgG hyper- effect of the use of hydroxychloroquine as globulinaemia.'2 In 1985 a positive effect of expressed in preference for treatment treatment of primary Sjogren's syndrome with with hydroxychloroquine or placebo with hydroxychloroquine was found in a small open http://ard.bmj.com/ regard to symptoms and signs of primary study with three patients lasting for nine, 20, Section of Clinical Sjogren's syndrome could be shown, and 59 months, respectively.'3 All three Immunology, however, nor any relevant change in tear patients reported a subjective improvement in University Hospital gland activity and sequelae of peripheral disorders of the eyes and mouth. Laboratory Utrecht, tear function deficiency, nor salivary data showed a decrease of the erythrocyte The Netherlands AA Kruize gland scintigraphy. sedimentation rate (ESR) and the y globulin R J Hene Conclusions-The use of hydroxychloro- serum levels, in combination with an increase on October 1, 2021 by guest. Protected copyright. L Kater quine at a dose of 400 mg daily taken over of serum haemoglobin concentration. In 1988 W Bijlsma J J a 12 month period does not have a the potential benefit of hydroxychloroquine Department of worthwhile clinical benefit in patients with was evaluated in an open comparative study Rheumatology, University Hospital primary Sjogren's syndrome despite an including 20 patients with primary Sjogren's Utrecht, improvement of hyperglobulinaemia and syndrome, matched for age and sex. 12 The The Netherlands slight changes in the ESR and IgM. group of 10 patients treated with hydroxy- A A Kruize showed a significantly larger A van der Heide chloroquine J W J Bijlsma (Ann Rheum Dis 1993; 52: 360-364) decrease in total IgG and the ESR and an Department of increase in haemoglobin compared with the Nephrology, group of 10 patients treated with placebo. University Hospital Primary Sjogren's syndrome is a systemic Subjective clinical effects were not reported. In Utrecht, The Netherlands disease characterised by dryness ofthe eyes and 1987 we started a prospective, placebo con- R J Hene mouth due to lymphocytic infiltration of the trolled, crossover double blind trial to Department of lachrymal and salivary glands. 1-3 Extra- investigate further the clinical and laboratory Ophthalmology, glandular manifestations are not un- effects of hydroxychloroquine in patients with University Hospital common.' I The and primary Sjogren's syndrome. Utrecht, aetiology pathogenesis The Netherlands are not known. Because of the generally benign O P van Bijsterveld character of the disease primary Sjogren's Correspondence to: syndrome is preferably managed by Patients and methods Dr A A Kruize, measures If and Nineteen patients with primary Sjogren's Department of symptomatic only. myalgia Rheumatology, arthralgia are present, analgesics and non- syndrome defined according to the criteria F02.223, proposed by Daniels and Talal3 in 1987 University Hospital, steroidal anti-inflammatory drugs (NSAIDs) Box 85500, can be used. Low dose corticosteroids may be (table 1) were included in the study. Twelve 3508 GA Utrecht, features such as patients were seen at the University Hospital The Netherlands. beneficial when systemic weariness occur, but high dose Utrecht and seven at the University Hospital Accepted for publication invalidating 20 January 1993 corticosteroids are indicated only in cases of Groningen, The Netherlands. The mean (SD) Hydroxychloroquine treatment for Sjdgren's syndrome 361 Table 1 Diagnostic citeriaforpimary Sjdgren's syndrome proposed by Daniels and Talal technetium-99m, including a recording of the (1987)3 accumulation and secretion of radioactive 1 Keratoconjunctivitis sicca labelled pertechnetate by the salivary glands, a Characteristic comeal and conjunctival epithelial staining with rose bengal observed and gallium-67 citrate showing an increased Ann Rheum Dis: first published as 10.1136/ard.52.5.360 on 1 May 1993. Downloaded from through a slit lamp; and b reduced tear meniscus and breakup time; or uptake of gallium citrate if a cellular reactive c unanaesthetised Schirmer's test <5 mm/five minutes process was present, possibly through lacto- 2 Focal sialadenitis in an adequate labial salivary gland biopsy specimen with a focus score ferrin as a gallium citrate binding protein in greater than one focus/4 mm2 after exclusions polymorphonuclear leucocytes.'6 Technetium- 99m scintigraphy (Tc scan) therefore repre- sents the function of the major salivary glands, age was 51 9(15-5) years, the median (range) whereas gallium-67 citrate scintigraphy (Ga disease duration was 3X0(0@ 1-23-0) years; scan) indicates the activity of inflammation of disease duration was measured from the time the salivary glands. Quantification of salivary of confirmation of the clinical diagnosis by a scintigraphy is difficult because ofthe anatomi- salivary gland biopsy sample. Exclusion criteria cal site and shape of the glands, so all scans for the study included treatment with hydroxy- were scored blindly by an independent chloroquine, corticosteroids, or immuno- observer and two of the authors (AAK and suppressive drugs in the three months pre- RJH). ceding the start of the study; ophthalmological Safety and tolerability assessments included contraindications for the use ofhydroxychloro- whole blood count, serum creatinine, alkaline quine, such as retinitis pigmentosa; and other phosp'atase, and transaminases every three concurrent systemic rheumatic disease such as months; ophthalmological examination was rheumatoid arthritis, systemic lupus performed before the study, after one year, and erythematosus, systemic sclerosis, and mixed after two years; if retinal changes were present connective tissue disease. the examination was repeated every three The study was approved by the ethical months. committees of the two hospitals. After informed consent patients were randomised (in blocks of four) to one of two treatment groups. STATISTICS The first group was treated with hydroxy- The effects of treatment with hydroxychloro- chloroquine for one year and with placebo quine and placebo in the two groups were during the second year. In the second group analysed by comparing differences in outcome treatment was given in the reverse order. after the first and the second year between the Hydroxychloroquine dosage was 400 mg daily, two groups for continuous variables; only the given in two tablets of 200 mg each. Placebo results at the end of the two years were tablets, indistinguishable from hydroxychloro- analysed because of possible carryover effects quine tablets, were also given twice daily. at earlier phases in a year.'7 Differences were http://ard.bmj.com/ Previously applied symptomatic treatment was tested for statistical significance using continued in all patients. Student's t tests and the Wilcoxon rank sum Every three months parameters of efficacy tests because of the small size of the study. As were determined (by RJH, JWJB, and the results were similar, only the results of the CGMK). (a) In a standard questionnaire t tests are reported here. For binary variables patients were asked for the presence and obtained from the questionnaire on clinical with the visit of the symptoms, the overall preference of patients severity compared previous on October 1, 2021 by guest. Protected copyright. following symptoms: dryness or a sandy feeling for one of the two treatment periods was used of the eyes, infection of the eyes or the eyelids, to compare groups.'8 Fisher's exact test was dryness of the mouth, swelling of the salivary used to assess statistical significance. p Values glands, fatigue, myalgia, and arthralgia. (b) of less than 0 05 were considered significant in Patients were
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