SAT0208 INCIDENCES OF ADVERSE EFFECTS AND DISEASE FLARE DUE TO PNEUMOCYSTIS PNEUMONIA PROPHYLAXIS WITH TRIMETHOPRIM/SULFAMETHOXAZOLE IN SYSTEMIC LUPUS ERYTHEMATOSUS PATIENTS
Authors: M. Goto, N. Yokogawa, Y. Miyoshi, K. Shimada
Journal: Annals of the Rheumatic Diseases (2020)

Background: Methods of preventing pneumocystis pneumonia (PCP) in systemic lupus erythematosus (SLE) are controversial. Previous studies have verified the efficacy and safety of trimethoprim/sulfamethoxazole (TMP-SMX) in patients with rheumatic diseases 1 . However, as for SLE, some clinicians advise against prescribing TMP-SMX because sulfa allergy is reportedly more common in SLE than in other rheumatic diseases 2, 3 . Anecdotally, sulfonamides may also worsen SLE itself, but few data are available on lupus flares related to sulfonamides 3 . Objectives: This study aimed to assess the incidences of adverse effects and disease flare due to PCP prophylaxis with TMP-SMX in SLE patients. Methods: SLE patients seen at our hospital between September 2010 and April 2018 who received TMP-SMX as a PCP prophylaxis were enrolled. The clinical manifestations, treatment course, adverse drug reactions, and occurrence of lupus flares were retrospectively assessed from the medical records. The Naranjo adverse drug reaction probability scale4 was used to determine whether the reactions were induced by SMX-TMP. According to the British Isles Lupus Assessment Group (BILAG) 2004 index, a severe flare of lupus was defined as a development of a new grade A manifestation, and a moderate flare as a development of grade B manifestation following grade C, D or E. Two board-certificated rheumatologists reviewed the medical records in a blinded fashion to determine the reason for the flare, with disagreement resolved by consensus. Results: In total, 188 SLE patients were enrolled; of these, 117 (62.2%) had no adverse events and were able to continue taking SMX-TMP as needed. Seventy-one patients (37.8%) stopped SMX-TMP due to suspected adverse drug reactions, including fever, rash, liver function disorder, and cytopenia. The Naranjo scale indicated “definite” in 4, “probable” in 39, and “possible” in 28. Eighteen-patients restarted the SMX-TMP and 9 patients could continue the prophylaxis without adverse effects. Five patients were hospitalized to treat the adverse events: 3 with drug rash (concomitant use of hydroxychloroquine in 2), 1 with hypersensitivity (concomitant use of azathioprine) and 1 with hyponatremia, respectively. Lupus flares occurred in 10 patients (5.3%) within one month after the start of the the SMX-TMP prophylaxis. Macrophage activation syndrome (MAS) or neuropsychiatric SLE occurred in 9 of them. Of 188 cases, 2 patients (1.1%) developed a new onset of MAS during the stable clinical course as the flare, which was considered due to SMX-TMP. Confounding factors, including high disease activity and the reduction of glucocorticoids, were identified in other 8 flares. Conclusion: PCP prophylaxis with SMX-TMP was tolerable in most SLE patients. However, a small number of SLE patients developed severe adverse effects or disease flares due to the SMX-TMP. References: [1]Park JW, et al. Annals of the Rheumatic Diseases 2018;77:644-649. [2]Suyama Y, et al. Modern Rheumatology 2016;26:557-61 [3]Petri M, et al. Journal of Rheumatology 1992;19:265-9 [4]Naranjo CA, et al. Clinical Pharmacology and Therapeutics 1981;30:239-45 Disclosure of Interests: None declared