950: HCQS in diabetes

In 2014, hydroxychloroquine 400 mg got DCGI approval as additional indication as an adjunct to diet and exercise to improve glycemic control of patients on metformin, sulfonylurea combination in type 2 diabetes.

Then why it cannot be given as a routine in all patients with metabolic syndrome with COVID evidence?

Among patients with rheumatoid arthritis (RA) or psoriasis, use of anti-inflammatory, disease-modifying antirheumatic drugs, such as TNF inhibitors and hydroxychloroquine, is associated with a lower incidence of diabetes than other agents.

[Solomon DH, et al. Association between disease-modifying antirheumatic drugs and diabetes risk in patients with rheumatoid arthritis and psoriasis. JAMA. 2011;305(24):2525-31.] 

Rheumatoid arthritis and psoriasis have been linked with insulin resistance and diabetes mellitus (DM). Evidence suggests that systemic immunosuppressive drugs could possibly improve insulin resistance and reduce the risk of DM.

Solomon and colleagues conducted a study to comapre the risk of newly recorded DM among individuals diagnosed with RA or psoriasis based on use of a variety of disease-modifying antirheumatic drugs (DMARDs).

This was a retrospective cohort study involving 121,280 patients with a diagnosis of either RA or psoriasis on at least 2 visits. The mean follow-up was 5.8 months and started with the first prescription for a DMARD after study eligibility was met. Drug regimens were categorized as follows: (1) tumor necrosis factor (TNF) inhibitors with or without other DMARDs; (2) methotrexate without TNF inhibitors or hydroxychloroquine; (3) hydroxychloroquine without TNF inhibitors or methotrexate; or (4) other nonbiologic DMARDs without TNF inhibitors, methotrexate, or hydroxychloroquine (reference exposure).

Newly recorded DM as noted by a new diagnosis of DM with use of a DM-specific medication was assessed.

The study cohort included 13,905 participants with 22,493 treatment episodes starting 1 of the categories of DMARD regimens. New diabetes cases and respective incidence rates per 1000 person-years were reported as: other nonbiologic DMARDs - 55 cases among 3993 treatment episodes; rate, 50.2; TNF inhibitors - 80 cases among 4623 treatment episodes; rate, 19.7; methotrexate - 82 cases among 8195 treatment episodes; rate, 23.8; and hydroxychloroquine - 50 cases among 5682 treatment episodes; rate, 22.2.

The multivariate adjusted hazard ratios for DM were estimated as 0.62 (95% CI, 0.42-0.91) for TNF inhibitors, 0.77 (95% CI, 0.53-1.13) for methotrexate, and 0.54 (95% CI, 0.36-0.80) for hydroxychloroquine, compared with other nonbiologic DMARDS.

Investigators concluded that among patients with RA or psoriasis, the adjusted risk of DM appeared to be lower for those initiating a TNF inhibitor or hydroxychloroquine compared with initiation of other nonbiologic DMARDs.

Division of Pharmacoepidemiology, Department of Medicine, Brigham and Womens Hospital, Boston, Massachusetts 02115, USA. dsolomon@partners.org 

Dr KK Aggarwal

President CMAAO