ORIGINAL INVESTIGATION Minocycline and Lupuslike Syndrome in Acne Patients Miriam C. J. M. Sturkenboom, PhD, PharmD, MSc; Christoph R. Meier, PhD, MSc; Hershel Jick, MD; Bruno H. C. Stricker, PhD, MB Background: Recently several case reports described the Results: We identified 29 cases and selected 152 controls. association between minocycline and lupuslike syn- Current single use of minocycline was associated with an drome. Minocycline, one of the tetracyclines, is widely 8.5-fold (95% confidence interval [CI], 2.1-35) increased used to treat acne. We aimed to examine the association risk of developing lupuslike syndrome compared with non- of exposure to minocycline and other tetracyclines with users and past users of tetracyclines combined. The risk of the development of lupuslike syndrome. past exposure to any of the tetracyclines was closely simi- lar to nonuse (relative risk, 1.3; 95% CI, 0.5-3.3). Current Methods: We conducted a nested case-control study in use of doxycycline, oxytetracycline, or tetracycline com- a cohort of 27 688 acne patients aged 15 to 29 years, us- bined was associated with a 1.7-fold (95% CI, 0.4-8.1) in- ing data automatically recorded on general practitioners’ crease of risk. The risk increased with longer use. office computers in the United Kingdom. Controls were matched to cases on age, sex, and practice. The main out- Conclusion: Current use of minocycline increased the come was lupuslike syndrome defined as the occurrence risk of developing lupuslike syndrome 8.5-fold in the co- of polyarthritis or polyarthralgia of unknown origin, with hort of young acne patients. The effect was stronger in negative rheumatoid factor or latex agglutination test, posi- longer-term users. However, the absolute risk of devel- tive or unmeasured antinuclear factor, elevated or unmea- oping lupuslike syndrome seems to be relatively low. sured erythrocyte sedimentation rate, and absence of or unmeasured antinative DNA antibody levels. Arch Intern Med. 1999;159:493-497 INOCYCLINE IS a semi- In 1959, 3 patients were described synthetic tetracycline who developed a systemic lupus antibiotic that is used erythematosus–like clinical syndrome to treat infections while being treated with tetracycline.6 caused by several types However, this association was likely Mof gram-positive and gram-negative bac- based on a misperception, and no other terias, Rickettsia, Chlamydia, and Myco- cases of tetracycline-induced lupus have plasma species. It became available in been published since then.7 Minocycline, 1972 and has been widely used since however, was related to lupus in num- then. Its long half-life, allowing for erous case reports, the first of which once- or twice-daily dosing, and the appeared in 1992.8 Through the begin- suggestion that minocyline rarely causes ning of 1998, 64 minocycline users who resistance makes it popular with both developed lupuslike syndrome have been patients and physicians.1-4 Tetracyclines described in the literature.7-19 The mean are used orally in the treatment of mod- age of patients was 21 years and 85% erate to severe inflammatory acne vul- were female. In most patients, the onset From the garis and other infections sensitive to of arthralgia or arthritis accompanied by Pharmacoepidemiology Unit, the actions of tetracylines. Because of its myalgia or malaise developed after pro- Erasmus University Medical favorable dosing characteristics and the longed periods of exposure to minocy- School, Rotterdam, the low rate of resistance, minocycline is cline (mean duration, 24 months; range, Netherlands (Dr Sturkenboom now the most widely prescribed antibi- 1.5-72 months). All were asymptomatic and Stricker); and Boston 1 Collaborative Drug otic for acne. An estimated 800 000 before treatment. Typical were the pres- Surveillance Program, Boston prescriptions were written in 1993 in ence of antinuclear antibodies and 1 University Medical Center, the United Kingdom, and 65% of oral elevated erythrocyte sedimentation rate Lexington, Mass (Drs Meier minocycline use in the United States but negative levels of antihistone anti- and Jick). was for treatment of acne.5 bodies and antinative DNA antibodies. ARCH INTERN MED/ VOL 159, MAR 8, 1999 493 ©1999 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/30/2021 METHODS CASES AND CONTROLS From the cohort of acne patients, we identified (blinded We conducted a case-control study with data from the Gen- to any tetracycline exposure) all patients who had a first- eral Practice Research Database (GPRD). More than 4 mil- time diagnosis of systemic lupus erythematosus or poly- lion people in the United Kingdom are enrolled with se- arthralgia/polyarthritis. We then asked general practition- lected general practitioners who use office computers ers to send us patient records of these potential cases and provided by Value Added Medical Products (currently assessed all available information. These hospital records owned by Reuters Information Services, Toronto, Ontario) and referral letters as well as laboratory reports were re- and who have agreed to provide data for research pur- viewed independently by 2 of us (C.R.M. and M.C.J.M.S.), poses to the GPRD, which is currently owned by the United again while blinded to exposure. Cases were included if they Kingdom Department of Health. General practitioners have had negative rheumatoid factor or latex agglutination test, been trained to record medical information in a standard positive or unmeasured antinuclear antibody levels, el- manner and to supply it anonymously. The information re- evated or unmeasured erythrocyte sedimentation rate, and corded includes demographics, medical diagnoses, and all absence of or unmeasured anti-DNA antibody levels. drug prescriptions, since the physicians generate prescrip- To each case, we matched 8 controls from among all tions directly with the computer. It contains the name of noncases in the base population of patients with acne on the preparation, route of administration, dose, and num- practice, age (same year), and sex. The same exclusion cri- ber of tablets for each prescription. Hospital discharge and teria and index date were applied to controls as to cases. referral letters are available for review to validate the di- Exposure to minocycline, tetracycline, oxytetracycline, agnoses recorded in the computer record. A modification and doxycycline, as well as to other drugs that have been im- of the Oxford Medical Information System (OXMIS) is used plicated as causing drug-induced lupus, was assessed from to enter medical diagnoses. For the purpose of this study, the computer record.20 Drug use was classified as either “cur- OXMIS codes have been mapped onto International Clas- rent use” (legend duration of prescription includes the index sification of Diseases, Ninth Revision, Clinical Modification date or stops at a maximum of 14 days before) and “past use” (ICD) codes. The recorded information on drug exposure (theoretical stop date .2 weeks prior to index date). The to- and on diagnoses in the GPRD is of high quality and is sat- tal cumulative exposure was assessed using defined daily doses isfactory for drug safety studies.21,22 and categorized “#100 defined daily doses” and “.100 de- For this study, 319 practices contributed informa- fined daily doses.”23 If study subjects used more than 1 tet- tion recorded on computer from January 1, 1991, through racycline within the study period, we classified them as “mul- February 1996. From this population we identified all per- tiple users,” but their defined daily doses were summed. sons with acne (ICD codes 706.0 and 706.1), aged 15 to 29 years, without a history of lupus, arthralgia, rheuma- ANALYSIS toid arthritis, or chronic active hepatitis. Persons were ex- cluded if they had any preexisting cancer of the blood or Based on the number of cases occurring during current use immune system (leukemia, lymphoma) or acquired im- of one of the tetracyclines and the number of prescriptions munodeficiency syndrome prior to the index date, if they for the different tetracyclines, we assessed crude incidence used anticonvulsants (associated with lupuslike syn- rates and 95% confidence intervals (CIs) for exposure to the drome), or if the first diagnosis of acne occurred after the various study drugs, stratified by sex. For the case-control diagnosis of lupuslike syndrome (subsequently, the date analysis, we obtained relative risk (RR) estimates (odds ra- of first-time diagnosis of the lupuslike syndrome will be tios) through conditional logistic regression analysis with referred to as the index date). the software program SAS (SAS Institute Inc, Cary, NC). All patients recovered rapidly after drug removal, and an- approximately 60% of the use occurred in males and tibody levels became normal. In several cases, rechal- about 70% of the prescriptions of the various tetracy- lenge was positive, indicating a causal relationship.7-19 clines were written for persons in the age range of 15 to There is no consensus on the diagnostic criteria for 19 years. drug-induced lupus, but it should be expected in pa- We identified by computer 78 potential cases with tients who do not have a history of idiopathic lupus, who a diagnosis of systemic lupus erythematosus or multiple develop antinuclear antibodies, and who have at least 1 joint pain. After manual review of the computerized pa- clinical feature of lupus after an appropriate duration of tient profiles, we retained 44 patients for whom