Inflammopharmacology

https://doi.org/10.1007/s10787-018-0512-y Inflammopharmacology
ORIGINAL ARTICLE

Efficacy analysis of hydroxychloroquine therapy in systemic lupus

erythematosus: a study on disease activity and immunological
biomarkers
Seyed Mostafa Monzavi1 · Aida Alirezaei1,2 · Zhaleh Shariati‑Sarabi1,2   · Jalil Tavakol Afshari3 ·
Mahmoud Mahmoudi3 · Banafsheh Dormanesh4 · Faezeh Jahandoost1,2 · Ali Reza Khoshdel4 · Ali Etemad Rezaie5

Received: 15 May 2018 / Accepted: 22 June 2018

© Springer International Publishing AG, part of Springer Nature 2018

Abstract
Background  Hydroxychloroquine (HCQ) is a widely prescribed medication to patients with systemic lupus erythematosus
(SLE), with potential anti-inflammatory effects. This study was performed to investigate the efficacy of HCQ therapy by
serial assessment of disease activity and serum levels of proinflammatory cytokines in SLE patients.
Methods  In this prospective cohort study, 41 newly diagnosed SLE patients receiving 400 mg HCQ per day were included.
Patients requiring statins and immunosuppressive drugs except prednisolone at doses lower than 10 mg/day were excluded.
Outcome measures were assessed before commencement of HCQ therapy (baseline visit) as well as in two follow-up visits
(1 and 2 months after beginning the HCQ therapy). Serum samples of 41 age-matched healthy donors were used as controls.
Results  Median levels of IL-1β (p < 0.001), IL-6 (p = 0.001), and TNF-α (p < 0.001) were significantly higher, whereas,
median CH50 level was significantly lower (p < 0.001) in SLE patients compared with controls. Two-month treatment with
HCQ resulted in significant decrease in SLEDAI-2K (p < 0.001), anti-dsDNA (p < 0.001), IL-1β (p = 0.003), IL-6 (p < 0.001)
and TNF-α (p < 0.001) and a significant increase in CH50 levels (p = 0.012). The reductions in SLEDAI-2K and serum
levels of IL-1β and TNF-α were significantly greater in the first month compared with the reductions in the second month.
Conclusion  HCQ therapy is effective on clinical improvement of SLE patients through interfering with inflammatory signal-
ing pathways, reducing anti-DNA autoantibodies and normalizing the complement activity.

Keywords  Complement system proteins · Cytokines · Hydroxychloroquine · Systemic lupus erythematosus · Treatment
outcome

Introduction

Antimalarials (AMs), namely hydroxychloroquine (HCQ),

are widely prescribed medications to patients with systemic
* Aida Alirezaei
lupus erythematosus (SLE). According to current guidelines,
aidaalirezaee@gmail.com
AMs are recommended in combination therapy regimens
* Zhaleh Shariati‑Sarabi
for constitutional SLE, lupus arthritis and lupus nephritis
shariatij@mums.ac.ir
(Tunnicliffe et al. 2015). AMs have been shown to reduce
1
Rheumatic Diseases Research Center, Mashhad University disease activity, prevent flares, retard the onset of damage
of Medical Sciences, Mashhad, Iran and increase the survival of SLE patients (Ruiz-Irastorza
2
Department of Internal Medicine, Imam Reza Hospital, et al. 2010; Rainsford et al. 2015; Ponticelli and Moroni
Mashhad University of Medical Sciences, Mashhad, Iran 2017; Shariati-Sarabi et al. 2013a, b; Akhavan et al. 2013),
3
Immunology Research Center, Buali Research Institute, although the underlying mechanism(s) of action is not
Mashhad University of Medical Sciences, Mashhad, Iran completely clarified. They are, however, known to upregu-
4
AJA University of Medical Sciences, Tehran, Iran late apoptosis in autoreactive lymphocytes (van Loosdregt
5
Rosalind Franklin University of Medicine and Science, et al. 2013), induce anti-inflammatory effects (Monteith
North Chicago, IL, USA et al. 2016; Fox and Kang 1993; Müller-Calleja et al. 2017;

13
Vol.:(0123456789)

Durcan and Petri 2016), inhibit lipid peroxidation (Raley
et al. 1997), protect against thrombosis (Jung et al. 2010),
and have antihyperlipidemic properties (Cairoli et al. 2012).
SLE as a prototypic autoimmune disease is associated
with abnormal levels of cytokines (Manukyan et al. 2010;
Willis et al. 2017; Pacheco et al. 2017). Proinflammatory
cytokines, which are a class of signaling proteins responsible
for the promotion of inflammatory reactions, are increased
in SLE patients especially in the active phase of the disease
(Tackey et al. 2004; Aringer and Smolen 2008; Pacheco
et al. 2017; Koenig et al. 2012; Wozniacka et al. 2006).
Some studies have demonstrated that AMs can suppress
the synthesis of proinflammatory cytokines (Müller-Calleja
et al. 2017; Wozniacka et al. 2006; Willis et al. 2012). There-
fore, these cytokines may be used as the indicators of the
drug efficacy.
Although HCQ therapy has been effective in treating
rheumatic diseases, much of the evidence demonstrating its
efficacy in SLE has originated from observational clinical
studies (Ruiz-Irastorza et al. 2010). Hence, in this study,
we sought to investigate the efficacy of HCQ therapy (in
combination with limited dose of prednisolone) in SLE by
assessment of serum levels of a group of proinflammatory
cytokines in association with clinical parameters during a
2-month course of the treatment.
Methods
Study setting and subjects
In this prospective cohort study, 41 newly diagnosed patients
with mild SLE (100% female), who were referred to the
rheumatology clinic of the Imam Reza Hospital, Mash-
had University of Medical Sciences during September
2013–October 2016, were included. The diagnosis of SLE
was confirmed by two rheumatologists according to Sys-
temic Lupus International Collaborating Clinics (SLICC)
criteria (Petri et al. 2012). HCQ therapy (400 mg per day)
was started for all patients. Patients requiring statins and
immunosuppressive treatments such as azathioprine and
cyclophosphamide as well as those receiving predniso-
lone at doses greater than 10 mg/day were excluded from
the study. In addition, patients with life-threatening organ
involvement including (but not limited to) pericarditis, cen-
tral nervous system and lupus nephritis who required more
intensive treatments such as higher doses of steroids and/
or mycophenolate mofetil were excluded from the analyses.
Data collection
The patients were evaluated in baseline visit (the day of
commencement of HCQ therapy) as well as in two follow-up
13
S. M. Monzavi et al.
visits (1 and 2 months after beginning the HCQ therapy)
based on the following parameters: serum levels of IL-1β,
IL-6, IL-8 and TNF-α using human enzyme-linked immu-
nosorbent assay (ELISA) kits (Affymetrix eBioscience, San
Diego, CA), total complement activity by CH50 assay using
ELISA kits (DRG International Inc., Springfield, USA) and
disease activity using the Systemic Lupus Erythematosus
Disease Activity Index 2000 (SLEDAI-2K) (Gladman et al.
2002). The serum level of anti-ds DNA was measured in
each visit using ELISA kit (EUROIMMUN AG, Luebeck,
Germany). Serum levels of the cytokines and CH50 of 41
age-matched healthy women (controls) with no history of
allergy, autoimmune or inflammatory disease and being
under any regular medication were also assessed to serve as
a comparison with baseline results in SLE patients.
Laboratory assays
5 mL blood samples were collected from brachial vein into
heparinized tubes in each of the three visits (baseline and
the two subsequent visits described earlier). Samples were
immediately centrifuged at 946 g for 5 min to obtain plasma.
Then, all plasma samples were assayed using immunologic
kits as per manufacturers’ supplied instructions.
Ethics
The study was performed according to the ethical norms
and standards expressed in the Declaration of Helsinki. The
patients were treated according to the standard guideline for
the management of SLE (Tunnicliffe et al. 2015), and they
received no additional intervention. The study was approved
by the institutional review board of the Mashhad University
of Medical Sciences (approval code: MUMS-940187). The
patients and healthy controls were informed about the study
objectives and gave their written informed consent.
Statistical analysis
Data were analyzed using SPSS version 20 (IBM, Armonk,
NY). The normality of quantitative data was analyzed using
the Shapiro–Wilk test. All quantitative data had non-normal
distribution, and so are expressed with median and range.
Qualitative variables are reported with frequency and per-
centage. Friedman’s test was used to analyze the changes
in the mean rank of each parameter among the three visits.
Mann–Whitney U test was used to analyze the differences
of clinical and immunological parameters between two
independent groups. To analyze the correlation of a pair of
Efficacy analysis of hydroxychloroquine therapy in systemic lupus erythematosus: a study…

quantitative variables, Spearman’s rho test was used. p val-
ues less than 0.05 were considered statistically significant.
Results
Demographic and clinical profile
In this study, 41 female SLE patients with median age of
31 (range 21–44) years were enrolled. Clinical character-
istics of the subjects are shown in Table 1. As can be seen
the most common clinical findings of the patients were
ANA positivity (90.2%) and photosensitivity (63.4%).
Comparison of proinflammatory cytokines
between SLE patients and controls
Comparing SLE patients at baseline with controls, except
IL-8, the serum levels of proinflammatory cytokines and
complement activity were found to be significantly differ-
ent. In this respect, median levels of IL-1β (7.3 vs. 4.0;
p < 0.001), IL-6 (3.9 vs. 1.7; p = 0.001), and TNF-α (6.6
Table 1  Clinical characteristics of the patients at diagnosis (baseline
visit)
Parameter
vs. 2.5; p < 0.001) were significantly elevated, whereas,
the median CH50 level was significantly lower (74 vs.
121; p < 0.001) in SLE patients compared with controls
(Table 2).
Correlation of variables
Bivariate correlation analyses showed that baseline level
of SLEDAI is significantly correlated to IL-6 (r = 0.512,
p = 0.001), TNF-α (r = 0.539, p < 0.001) and CH50
(r = -0.604, p = 0.013), which means the higher SLEDAI
is, the more the IL-6 and TNF-α levels and the lower the
CH50 level are. In addition, there was a significant direct
relationship between baseline anti-dsDNA and TNF-α levels
(r = 0.631, p < 0.001).
Considering the clinical criteria of SLICC classification
system, only the serum levels of IL-6 and TNF-α were found
to be significantly different between patients with and with-
out synovitis and leukopenia (Table 3). In this regard, the
baseline serum levels of IL-6 and TNF-α were significantly
higher in patients with synovitis and leukopenia compared
to those without them. Of note, regarding the rest of SLICC
clinical criteria, no significant differences in cytokines and
CH50 levels were found between the patients with and with-
out them.
n (%)

ANA positivity 37 (90.2)

Photosensitivity 26 (63.4)
Table 3  Comparison of serum levels of IL-6 and TNF-α between
Increased anti-ds DNA antibody 22 (53.7) patients with and without synovitis and leukopenia
Leukopenia 19 (46.3)
SLICC clinical criteria IL-6, pg/mL, median TNF-α, pg/mL,
Low complement 18 (43.9)
(range) median (range)
Thrombocytopenia 18 (43.9)
Synovitis (arthritis) 17 (41.5) Synovitis
Malar rash 16 (39.0)  Positive (n = 17) 7.5 (2.2–18.4) 7.3 (2.0–27.8)
Mucosal ulcer 10 (24.4)  Negative (n = 24) 1.8 (1.1–12.7) 3.3 (1.9–16.1)
Discoid rash 9 (22.0)  p value < 0.001 0.001
Fever 8 (19.5) Leukopeniaa
Antiphospholipid antibody positivity 7 (17.1)  Positive (n = 19) 5.8 (1.5–18.4) 7.0 (3.0–23.2)
Alopecia 6 (14.6)  Negative (n = 22) 2.0 (1.1–11.8) 3.4 (1.9–27.8)
 p value 0.020 0.041
Combination of parameters in SLICC classification system and SLE-
a
DAI  White blood cell count < 4000/mm3

Table 2  Comparison of Immunologic marker Patients Controls p value

proinflammatory cytokines and
complement activity between IL-1β, pg/mL, median (range) 7.3 (3.6–18.7) 4 (2.5–7.2) < 0.001
SLE patients at baseline visit
IL-6, pg/mL, median (range) 3.9 (1.1–18.4) 1.7 (1.1–7.1) 0.001
and healthy controls
IL-8, pg/mL, median (range) 16.8 (2.6–28.5) 10.7 (5.8–55.8) 0.767
TNF-α, pg/mL, median (range) 6.6 (1.9–27.8) 2.5 (1.3–4.8) < 0.001
CH50, U/mL, median (range) 73 (35–123) 121 (60–158) < 0.001

13
 S. M. Monzavi et al.

Fig. 1  Median value with quartile range and extreme values of the study outcomes measures presented with box with whiskers

Efficacy of HCQ therapy [6.0 (3.0–20.0) to 1.0 (0.0–12.0), p < 0.001], anti-dsDNA

[90 (20–850) to 40 (10-96) IU/mL, p < 0.001], IL-1β [7.3
Repeated measure analysis revealed that 2-month treatment (3.6–18.7) to 5.2 (3.8–10.4) pg/mL, p = 0.003], IL-6 [3.9
with HCQ resulted in significant decrease in SLEDAI-2K (1.1–18.4) to 0.9 (0.5–16.6) pg/mL, p < 0.001] and TNF-α

13
Efficacy analysis of hydroxychloroquine therapy in systemic lupus erythematosus: a study…
Table 4  Change in the outcome measures of the study during the 2-month HCQ therapy
Total change during
the two ­monthsa
SLEDAI-2K, median (range) − 5 (− 18 to +2)
Anti-dsDNA, IU/mL, median − 40 (− 810 to +534) − 20 (− 710 to +371)
(range)
IL-1β, pg/mL, median (range) − 2.4 (− 11.9 to +4.3)
IL-6, pg/mL, median (range) − 1.2 (− 11.4 to +1.9)
IL-8, pg/mL, median (range) − 1.4 (− 16.5 to +7.5)
TNF-α, pg/mL, median (range) − 1.8 (− 16.8 to +5.7)
CH50, U/mL, median (range) +12.5 (− 12 to +48)
“−” indicates decrease and “+” indicates increase
a
 Difference between the 3rd and 1st visit
b
 Difference between the 2nd and 1st visit
c
 Difference between the 3rd and 2nd visit
[6.6 (1.9–27.8) to 2.5 (1.6–24.7) pg/mL, p < 0.001] from
the baseline visit to 3rd visit (Fig. 1). Moreover, CH50 lev-
els significantly improved from 73.0 (35.0–123.0) to 95.7
(63.0–141.0) (p = 0.012). These figures translate to the
reduction of the median levels of SLEDAI-2K, anti-dsDNA,
IL-1β, IL-6 and TNF-α by 83.4, 55.6, 28.8, 76.9 and 62.1%,
respectively, and the increment of the median level of CH50
by 31.1% after 2-month HCQ therapy. Of note, no signifi-
cant change in serum levels of IL-8 was observed during the
2-month treatment course.
Table 4 shows the median of changes occurred in out-
come measures during the study period. As can be seen,
the reductions in disease activity, serum levels of IL-1β and
TNF-α were significantly higher in the first month compared
with the reductions in the second month. This shows that
the HCQ therapy exerts its effect mainly in the first month.
The changes in the other outcome measures were not signifi-
cantly different between the first and second month.
Discussion
Serum levels of biomarkers and disease activity
SLE is an autoimmune disease known to be associated with
cytokine dysregulations arguably resulting from lymphocyte
autoreactivity (Dörner et al. 2011; Cheng et al. 2013; Fer-
raccioli and Houssiau 2013). Proinflammatory cytokines are
the widely studied cytokines in the pathophysiology of SLE,
especially IL-1, IL-6 and TNF-α (Durcan and Petri 2016;
Manukyan et al. 2010; Willis et al. 2017; Pacheco et al.
2017; Koenig et al. 2012; Wozniacka et al. 2006; Willis et al.
2012; Zharkova et al. 2017; Umare et al. 2014; Sabry et al.
2006; Arora et al. 2012; Aringer and Smolen 2008). In this
study, we found that IL-1β, IL-6 and TNF-α are significantly
­ onthb Change in the 2nd m
Change in the 1st m ­ onthc Comparison of changes in the
1st and 2nd month (p value)
− 4 (− 11 to +1) − 1 (− 5 to +1) < 0.001
− 20 (− 320 to +163) 0.078
− 2.1 (− 11.7 to +1.2) 0.0 (− 5.8 to +3.3) 0.002
− 0.6 (− 10 to +1.4) − 0.6 (− 10.1 to +7.7) 0.064
− 3.8 (− 14.4 to +5.1) +1 (− 8 to +12.5) 0.062
− 1.3 (− 16 to +5) − 0.5 (− 6.2 to +10.8) 0.021
+5.5 (− 4 to +44) +5.5 (− 10 to +49) 0.738
higher in newly diagnosed untreated SLE patients compared
with normal healthy people supporting many earlier stud-
ies (Wozniacka et al. 2006; Willis et al. 2012; Umare et al.
2014; Sabry et al. 2006; Arora et al. 2012; Ripley et al. 2005;
Talaat et al. 2015). Nonetheless, similar to the study by Wil-
lis et al. (2012), no change was observed in serum level of
IL-8 in our patients, despite limited evidence demonstrating
the up-regulation of IL-8 gene expression in SLE (Hsieh
et al. 2001).
Moreover, in the present study there was a direct sig-
nificant correlation of disease activity with serum levels
of IL-6 and TNF-α replicating the findings of five other
studies (Umare et al. 2014; Sabry et al. 2006; Arora et al.
2012; Ripley et al. 2005; Talaat et al. 2015). This shows that
serum levels of IL-6 and TNF-α can be used as indicators
of disease activity in SLE patients. In this respect, Sabry
et al. proposed that IL-6 and TNF-α are useful independ-
ent markers for prediction of SLE disease activity and even
can be used as diagnostic markers (Sabry et al. 2006). In
addition, these two cytokines were significantly associated
with some clinical features of our SLE patients, as they were
significantly higher in patients with arthritis and leukopenia.
These findings are in agreement with various studies. Umare
et al. (2014) and Eilertsen et al. (2011) have shown a signifi-
cant association between increased level of IL-6 and joint
involvement. Segal et al. (2001) and Su et al. (1998) showed
that TNF-α blockade improves arthritis, nephritis and leu-
kopenia in lupus mouse models. In our study, TNF-α levels
also correlated significantly with the levels of anti-dsDNA
antibodies, a fact that was ascertained in two other studies
(Gabay et al. 1997; Studnicka-Benke et al. 1996). In this
regard, the findings by Sun et al. (2000), which revealed that
anti-dsDNA antibodies upregulate expression and release
of TNF-α mRNA from human mononuclear cells, further
confirm this correlation.
13

Hypocomplementemia is a common phenomenon in SLE
(Shariati-Sarabi et al. 2013a; Petri et al. 2012; Gladman
et al. 2002; Shariati-Sarabi et al. 2013b; Leffler et al. 2014;
Costabile 2010; Illei et al. 2004; Spronk et al. 1995). The
decreased levels of complements result in lower ability to
activate the classic pathway of complement system (Leffler
et al. 2014; Costabile 2010). Unsurprisingly, the CH50 assay
showed significantly lower levels in our SLE patients com-
pared with controls. Moreover, CH50 levels were inversely
correlated with disease activity in our SLE patients, sug-
gesting CH50 a monitoring biomarker of disease activity,
although Illei et al. (2004) and Spronk et al. (1995) have
questioned its sensitivity and specificity.
Efficacy of HCQ therapy
AM therapy is a mainstay of treatment in patients with SLE
especially for those with skin, joint and constitutional mani-
festations (Tunnicliffe et al. 2015; Ruiz-Irastorza et al. 2010;
Rainsford et al. 2015; Ponticelli and Moroni 2017). AMs
are recommended for treatment of SLE as they can produce
immunomodulation without immunosuppression, increase
the survival and prevent disease flares and complications
(Ruiz-Irastorza et al. 2010; Rainsford et al. 2015; Ponti-
celli and Moroni 2017; Akhavan et al. 2013). The under-
lying mechanism, by which these medications exert their
effects, although not clearly known, is majorly attributed to
anti-inflammatory action and reduction of proinflammatory
cytokines (Ruiz-Irastorza et al. 2010; Rainsford et al. 2015;
Ponticelli and Moroni 2017; Fox and Kang 1993; Müller-
Calleja et al. 2017; Durcan and Petri 2016). In this study,
we showed that a 2-month course of HCQ therapy with lim-
ited dose of prednisolone significantly reduces the disease
activity, anti-dsDNA autoantibody and proinflammatory
cytokines in patients with mild SLE. These findings further
corroborate the results of a handful of clinical and experi-
mental studies which showed the lessening effect of AMs on
disease activity and proinflammatory cytokines. Willis et al.
(2012) in a multi-national, multi-center study on 35 SLE
patients demonstrated that disease activity, IL-6 and TNF-α
decreased after 6 months of treatment with HCQ and limited
dose of prednisolone (≤ 10 mg/day), although the reductions
of IL-6 and TNF-α were not statistically significant. Wozni-
acka et al. (2006) proved that after 3 months of chloroquine
therapy, the mean level of IL-6, TNF-α as well as disease
activity declined significantly in 25 SLE patients. In addi-
tion, in three in vitro studies on peripheral blood mononu-
clear cells from SLE and rheumatoid arthritis patients, addi-
tion of HCQ and/or chloroquine to cell culture inhibited the
production of some of key inflammatory cytokines including
IL-1, IL-6 and TNF-α (Danis et al. 1992; Silva et al. 2013;
van den Borne et al. 1997).
13
S. M. Monzavi et al.
AMs including HCQ, as intrinsically weak bases, can
affect the subcellular vesicles and change their acidic envi-
ronment by raising their pH. This interferes with physi-
ological function of these subcellular compartments, and
therefore, causes interference with the assembly of endoso-
mal NADPH oxidase, inhibition of toll-like receptor (TLR)
activation, stabilization of lysosomal membranes, inhibi-
tion of intracellular processing and secretion of proteins
such as cytokines and prostaglandins, attenuation of anti-
gen processing of autoantigens, blockade of autoantibody
production, and interference with natural killer cell activity
(Ruiz-Irastorza et al. 2010; Rainsford et al. 2015; Ponticelli
and Moroni 2017; Fox and Kang 1993; Müller-Calleja et al.
2017; Durcan and Petri 2016; Lenert 2006; Wozniacka et al.
2002). Moreover, substantial evidence verifies that AMs are
able to reduce lymphocyte proliferation and induce apop-
tosis in lymphocytes and endothelial cells (van Loosdregt
et al. 2013; Lenert 2006). Hence, both the acidification of
endosomal vesicles and reduction of lymphocytes following
HCQ therapy may contribute to the decreased production
of proinflammatory cytokines. In addition, HCQ-mediated
inhibition of TLR activation results in deactivation of plas-
macytoid dendritic cells and autoreactive B cells in SLE
patients (Lenert 2006), which in return downregulates the
inflammation.
According to an internationally recognized compen-
dium for management of SLE (Aviña-Zubieta and Esdaile
2012), the clinical response to HCQ is considered to appear
between 8th and 12th weeks after starting the treatment.
However, in the present study, we found that the majority of
HCQ effects take place in the first month compared with the
second month after the beginning of the treatment. In this
respect, the improvement in inflammatory biomarkers and
disease activity was significantly greater in the first month
compared with the second month. This somehow shows
that the logarithmic phase of HCQ effect occurs in the first
month and at the end of the second month it perhaps starts
reaching the plateau; nonetheless, as we did not continue our
evaluations longitudinally after the 2nd month, our data are
not enough to draw such inference with certainty.
Limitations
First, small sample size of the study may weaken the infer-
ences. However, to reduce the effect of this limitation, we
compared the level of immunologic mediators between
patients and healthy control subjects. Second, the effects
of HCQ on disease activity and immunologic biomarkers
were only evaluated during 2 months, although the effects
may further progress. Hence, to analyze the HCQ efficacy in
SLE, we propose to assess the HCQ effects in a longitudinal
study with larger sample size in the future. Third, all our
Efficacy analysis of hydroxychloroquine therapy in systemic lupus erythematosus: a study…
patients received a low-dose prednisolone (≤ 10 mg) which
by itself has anti-inflammatory effects, and so it seems logi-
cal if one assume that our observations may not solely be
attributed to HCQ alone. However, as the patients receiving
higher doses of prednisolone were excluded from the study,
it can be said that the clinical and immunological improve-
ments occurred following the inception of the treatment
are majorly due to HCQ. In addition, it was not reasonable
to compare our study group with SLE patients who do not
receive the HCQ (as a comparison group), as they are gen-
erally those with major organ involvements receiving other
medications such as azathioprine and, therefore, the pool of
study group and the comparison group would be clinically
different with many confounding factors.
Conclusion
In autoimmune disorders, measurements of cytokines offer
a window into the understanding of pathogenesis and pro-
vide a setting to monitor the efficacy of treatments. In this
study, we showed that HCQ therapy is effective on clini-
cal improvement of SLE patients through interfering with
inflammatory signaling pathways, reduction of anti-DNA
autoantibodies and normalizing the complement activity.
Acknowledgements  The authors would like to thank vice chancellor
for research of Mashhad University of Medical Sciences who kindly
supported this study. The authors would also like to acknowledge Dr.
K. Hashemzadeh and the staff of the department of internal medicine,
Imam Reza Hospital, for their kind assistance during this study.
Compliance with ethical standards  sus. Arthritis Rheum 62:863–868
Conflict of interest  All authors declared that they have no conflict of
interest.
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