Evaluating large language models as a supplementary patient information resource on antimalarial use in systemic lupus erythematosus

ObjectiveTo assess the accuracy, completeness, and reproducibility of Large Language Models (LLMs) (Copilot, GPT-3.5, and GPT-4) on antimalarial use in systemic lupus erythematosus (SLE).Materials and MethodsWe utilized 13 questions derived from patient surveys and common inquiries from the National Health Service. Two independent rheumatologists assessed responses from the LLMs using predefined Likert scales for accuracy, completeness, and reproducibility.ResultsThe GPT models and Copilot achieved high scores in accuracy. However, the completeness of outputs was rated at 38.5%, 55.9%, and 92.3% for Copilot, GPT-3.5, and GPT-4. When questions related to "mechanism of action" and "lifestyle", were analyzed for completeness (n = 8), ChatGPT-4 scored significantly higher (100%) compared to Copilot (37.5%). In contrast, questions related to "side-effects" (n = 5) scored higher for ChatGPT models than Copilot, and the differences were not statistically significant. All three LLMs demonstrated high reproducibility, with rates ranging from 84.6% to 92.3%.ConclusionsAdvanced LLMs like GPT -4 offer significant promise in enhancing patients' understanding of antimalarial therapy in SLE. Although chatbots' capability can potentially bridge the information gap patients face, the performance and limitations of such tools need further exploration to optimize their use in clinical settings.

Antimalarial Adherence and Risk of Cardiovascular Events in Patients With Rheumatoid Arthritis and Systemic Lupus Erythematosus: A Population-Based Study

OBJECTIVE

We aimed to assess the association between antimalarial adherence and cardiovascular events between incident rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE) population-based cohorts.

METHODS

All patients with incident RA/SLE and incident antimalarial use in British Columbia, Canada, between January 1997 and March 2015 were identified using provincial administrative databases. The outcomes were incident cardiovascular events, including myocardial infarction (MI), stroke, or venous thromboembolism (VTE). The exposure was antimalarial adherence with levels: discontinuation (proportion of days covered [PDC = 0]), nonadherence (0 < PDC < 0.90), and adherence (PDC ≥ 0.90). We used marginal structural models to estimate the effect of antimalarial adherence on the rate of cardiovascular events, accounting for potential confounders.

RESULTS

We identified 16,538 individuals with incident RA/SLE and incident antimalarial use without any cardiovascular event before the index date. Over nine years mean follow-up, 2,174 incident cardiovascular events (13.2%) were observed. The adjusted hazard ratio (aHR) for incident cardiovascular events for antimalarial adherence relative to discontinuation was 0.72 (95% confidence interval [CI] 0.64-0.81) and 1.01 (95% CI 0.90-1.14) for nonadherence. Additionally, the aHRs for all cardiovascular events, MI, stroke, and VTE for adherence relative to nonadherence was 0.71 (95% CI 0.61-0.82), 0.62 (95% CI 0.51-0.75), 0.45 (95% CI 0.36-0.58), and 0.65 (95% CI 0.46-0.93), respectively. We found older age modified the association between antimalarial adherence and cardiovascular events (P = 0.02).

CONCLUSION

When people newly diagnosed with RA or SLE take their antimalarial regularly as prescribed (PDC ≥ 0.90), they have a 29% lower risk of sustaining a cardiovascular event than patients with a lower degree of adherence (PDC < 0.90) and a 28% lower risk than if they discontinue antimalarials.

Association of patient copayment and medication adherence in systemic lupus erythematosus

OBJECTIVE

To investigate the association of medication copayment and treatment adherence to hydroxychloroquine and immunosuppressants for SLE.

METHODS

We conducted a retrospective analysis of health claims data using Optum's de-identified Clinformatics Data Mart Database. Individuals with SLE continuously enrolled for 180 days from 1 July 2010 to 31 December 2019 were included. Adherence was defined as the proportion of days covered ≥80%. Copayment for a 30-day supply of medication was dichotomised as high (≥$10) or low (<$10). We examined the association between copayment and odds of adherence in multivariable-adjusted logistic regression models, including age, sex, race or ethnicity, comorbidities, educational attainment and household income.

RESULTS

We identified 12 510 individuals (age 54.2±15.5 years; 88.2% female sex), of whom 9510 (76%) were prescribed hydroxychloroquine and 1880 (15%) prescribed hydroxychloroquine and an additional immunosuppressant (azathioprine, methotrexate or mycophenolate mofetil). Median (IQR) 30-day copayments were $8 (4-10) for hydroxychloroquine, $7 (2-10) for azathioprine, $8 (3-11) for methotrexate and $10 (5-20) for mycophenolate mofetil. High copayments were associated with OR of adherence of 0.61 (95% CI 0.55 to 0.68) for hydroxychloroquine, OR 0.44 (95% CI 0.30 to 0.66) for azathioprine and OR 0.69 (95% CI 0.49 to 0.96) for mycophenolate mofetil. For methotrexate, the association was not significant.

CONCLUSION

In a large, administrative health claims database, we identified that high copayments were associated with reduced adherence to commonly prescribed medications for SLE. Incorporating awareness of the burden of copayments and its consequences into healthcare is essential to promote optimal medication adherence.

Systemic lupus erythematosus: An approach to pharmacologic interventions

ABSTRACT

Drug therapy for patients with systemic lupus erythematosus (SLE) aims to decrease symptom severity. Pharmacologic interventions are divided into four categories: antimalarials, glucocorticoids (GCs), immunosuppressants (ISs), and biological agents. Hydroxychloroquine, the most commonly used antimalarial treatment for this disease, is a mainstay in treating all patients with SLE. The multitude of adverse reactions of GCs has led clinicians to minimize their dosages or discontinue them whenever possible. To speed up the discontinuation or minimization of GCs, ISs are used for their steroid-sparing properties. Furthermore, certain ISs such as cyclophosphamide are recommended as maintenance agents to prevent flares and reduce the reoccurrence and severity of the disease state. Biological agents are recommended when other treatment options have failed due to intolerance or inefficacy. This article presents pharmacologic approaches for managing SLE in patients based on clinical practice guidelines and data from randomized controlled trials.

Risk of Arrhythmia Among New Users of Hydroxychloroquine in Rheumatoid Arthritis and Systemic Lupus Erythematosus: A Population-Based Study

OBJECTIVES

We assessed the association between hydroxychloroquine (HCQ) initiation and risk of arrhythmia among patients with incident rheumatoid arthritis (RA) or with incident systemic lupus erythematosus (SLE).

METHODS

All patients with incident RA or SLE and no arrhythmic events, not receiving antiarrhythmic medications, and not receiving HCQ prior to the index date of disease in British Columbia, Canada, between January 1996 and December 2014 were identified from administrative databases. We identified patients who were dispensed HCQ prescriptions (HCQ initiators) or were not dispensed HCQ prescriptions (HCQ noninitiators) during each study year; groups were matched 1:1 by propensity scores using baseline confounders on demographics, comorbidities, medications, and health care utilization. Outcomes were any new arrhythmias, atrial fibrillation, abnormal electrocardiograms, including long QT syndrome and conduction disorder, and other unspecified arrhythmias during follow-up. We used cause-specific Cox proportional hazards models with death as a competing event to assess the association between HCQ initiation and the outcomes.

RESULTS

We identified 11,518 propensity score-matched patients with RA or SLE in each group. Over the mean follow-up of 8 years, there were 1,610 and 1,646 incident arrhythmias in the HCQ initiator group and the noninitiator group, respectively, with crude incidence rates of arrhythmia of 17.5 and 18.1 in 1,000 persons per year, respectively. The adjusted cause-specific hazard ratio (cHR) for patients who received HCQ was 0.96 (95% confidence interval [95% CI] 0.89-1.03) compared with HCQ noninitiators, and the cHRs for patients who took HCQ and had arrhythmia subtypes of atrial fibrillation, abnormal electrocardiograms, and other unspecified arrhythmias were 0.93 (95% CI 0.83-1.04), 0.98 (95% CI 0.87-1.11), and 0.95 (95% CI 0.84-1.07), respectively.

CONCLUSION

Risk of any type of arrhythmia was not increased among new users of HCQ.

Hydroxychloroquine use reduces mortality risk in systemic lupus erythematosus: A systematic review and meta-analysis of cohort studies

Objective

Hydroxychloroquine (HCQ) is widely used in patients with systemic lupus erythematosus (SLE), but its effects on the mortality have not reached a definite conclusion. In this systematic review and meta-analysis, we aimed to assess whether HCQ use could reduce the risk of mortality in SLE patients.

Methods

PubMed, Embase, Web of Science, and Cochrane database were searched from inception to April 17, 2022 without language restrictions to explore the relationship between HCQ use and SLE mortality. The relative risk (HR) was pooled using the STATA software.

Results

A total of 21 studies with a pooled patient population of 26,037 were included in the study, including 14 studies on the association between HCQ alone and mortality risk and seven studies on the association between HCQ/chloroquine (CQ) and mortality risk. The pooled findings suggested that HCQ significantly reduced the overall mortality risk of SLE (pooled HR 0.46, 95% CI 0.38–0.57, p < 0.001). In subgroup analysis of SLE complications, HCQ use also decreased the risk of death in SLE patients with renal (HR=0.43, 95% CI 0.26–0.70, p = 0.001) and cardiopulmonary involvement (HR=0.37, 95% CI= 0.25–0.54, p < 0.001). In addition, HCQ use was also protective against the risk of mortality in SLE patients in different regions, such as Asia (HR=0.46, 95% CI=0.33–0.64, p < 0.001), Europe (HR= 0.40, 95% CI = 0.22–0.71, p = 0.002), and America (HR=0.52, 95% CI= 0.42–0.64, p < 0.001).

Conclusion

Our data suggested that HCQ use was associated with a reduced risk of mortality in patients with SLE.

RetINal Toxicity And HydroxyChloroquine Therapy (INTACT): protocol for a prospective population-based cohort study

PURPOSE

Hydroxychloroquine (HCQ) is an important medication for patients with systemic lupus erythematosus (SLE), rheumatoid arthritis (RA) and other rheumatic diseases. Although it is well-tolerated and cost-effective, the risk of HCQ retinal toxicity is of increasing concern. The aim of this study is to re-examine the HCQ retinal toxicity incidence rate, risk factors and clinical course after discontinuation.

METHODS

We designed a prospective population-based cohort study in adult patients with SLE or RA, currently receiving HCQ for five or more years, who are residents of British Columbia (BC), Canada. Based on administrative data, we identified 5508 eligible participants (1346 SLE and 4162 RA). They will participate in annual or biannual retinal screening over 5 years in alignment with the recently revised American Academy of Ophthalmology guidelines. To standardise procedures for retinal screening, imaging, diagnostic criteria, severity staging and data transfer, a consensus meeting was convened in December 2019 with participation of BC retinal specialists and the research team. Agreement was attained on: use of spectral domain-optical coherence tomography as the primary objective screening modality; classification of images into categories of normal, equivocal or abnormal; and transferring the equivocal and abnormal images plus corresponding subjective test results via cloud-based server from each clinic to a reading centre. Confirmation of HCQ retinal toxicity diagnoses and severity staging will be performed by three independent and masked reviewers. The incidence of HCQ retinal toxicity will be calculated, accounting for the competing risk of death. Hazard ratios for each risk factor will be calculated for the risk of HCQ retinopathy, after adjusting for confounders. We will also estimate the risk of HCQ retinal toxicity progression over 5 years.

ETHICS AND DISSEMINATION

This study has received approval from the University of British Columbia Clinical Research Ethics Board (H20-00736) and the Vancouver Coastal Health Research Institute.

Cardiovascular Safety of Hydroxychloroquine in US Veterans With Rheumatoid Arthritis

OBJECTIVE

Hydroxychloroquine (HCQ) may prolong the QT interval, a risk factor for torsade de pointes, a potentially fatal ventricular arrhythmia. This study was undertaken to examine the cardiovascular safety of HCQ in patients with rheumatoid arthritis (RA).

METHODS

We conducted an active comparator safety study of HCQ in a propensity score-matched cohort of 8,852 US veterans newly diagnosed as having RA between October 1, 2001 and December 31, 2017. Patients were started on HCQ (n = 4,426) or another nonbiologic disease-modifying antirheumatic drug (DMARD; n = 4,426) after RA diagnosis, up to December 31, 2018, and followed up for 12 months after therapy initiation, up to December 31, 2019.

RESULTS

Patients had a mean ± SD age of 64 ± 12 years, 14% were women, and 28% were African American. The treatment groups were balanced with regard to 87 baseline characteristics. There were 3 long QT syndrome events (0.03%), 2 of which occurred in patients receiving HCQ. Of the 56 arrhythmia-related hospitalizations (0.63%), 30 occurred in patients in the HCQ group (hazard ratio [HR] associated with HCQ 1.16 [95% confidence interval (95% CI) 0.68-1.95]). All-cause mortality occurred in 144 (3.25%) and 136 (3.07%) of the patients in the HCQ and non-HCQ groups, respectively (HR associated with HCQ 1.06 [95% CI, 0.84-1.34]). During the first 30 days of follow-up, there were no long QT syndrome events, 2 arrhythmia-related hospitalizations (none in the HCQ group), and 13 deaths (6 in the HCQ group).

CONCLUSION

Our findings indicate that the incidence of long QT syndrome and arrhythmia-related hospitalization is low in patients with RA during the first year after the initiation of HCQ or another nonbiologic DMARD. We found no evidence that HCQ therapy is associated with a higher risk of adverse cardiovascular events or death.