Hydroxychloroquine is associated with impaired interferon-alpha and tumor necrosis factor-alpha production by plasmacytoid dendritic cells in systemic lupus erythematosus

Introduction: Plasmacytoid dendritic cells (pDCs) constitutively express two members of the Toll-like receptor (TLR) family, TLR-9 and TLR-7, through which they can be stimulated to produce high levels of interferon (IFN)-alpha, a key mediator of the pathogenesis of systemic lupus erythematosus (SLE). Given the known efficacy of hydroxychloroquine (HCQ) in the treatment of SLE, we examined its ability to inhibit such pDC function in vivo. Methods: Peripheral blood mononuclear cells (PBMCs) from SLE subjects treated or not with HCQ and from healthy controls were stimulated with the TLR-9 agonist, CpG oligodeoxynucleotides (CpG-A ODN)-2216, and the TLR-7 agonist, imiquimod. The proportion of monocytes, B cells, myeloid dendritic cells, pDCs, and natural killer (NK) cells producing IFN-alpha and tumor necrosis factor alpha (TNF-alpha) was then analyzed by multiparameter flow cytometry. Results: After TLR-9/7 stimulation in both SLE and healthy subjects, significant production of IFN-alpha and TNF-alpha was only observed in pDCs. TLR-7 and TLR-9 induced IFN-alpha and TNF-alpha production by pDCs from subjects with SLE was decreased relative to that found in controls (TLR-9/IFN-alpha, P < 0.0001; TLR-9/TNF-alpha P < 0.0001; TLR-7/TNF-alpha P = 0.01). TLR-9 and TLR-7 induced IFN-alpha and TNF-alpha production by pDCs was severely impaired in 36% (TLR-9) and 33% (TLR-7) of SLE subjects. In almost all cases, these subjects were being treated with HCQ (HCQ vs. no HCQ: impaired TLR-9/IFN-alpha, P = 0.0003; impaired TLR-7/IFN-alpha, P = 0.07; impaired TLR-9/TNF-alpha, P < 0.009; impaired TLR-7/TNF-alpha, P < 0.01). Conclusions: Treatment with HCQ is associated with impaired ability of pDCs from subjects with SLE to produce IFN-alpha and TNF-alpha upon stimulation with TLR-9 and TLR-7 agonists.