Aims: Hydroxychloroquine (HCQ) has shown to have significant immunomodulatory effects in the treatment of systemic lupus erythematosus (SLE). Current studies show favorable effects of HCQ on traditional cardiac risk factors in patients with SLE. This review examined the effects of HCQ on serum low-density lipoprotein (LDL) level in patients with SLE.Methods: A systematic search of seven major literature search databases from their inception until 3 April, 2017 identified nine studies. Random-effects pooled mean difference with corresponding 95% confidence intervals (CI) were estimated. Heterogeneity was measured by I 2 . Publication bias was assessed by visual inspection of funnel plots. Sensitivity analysis examined whether HCQ effect on serum total cholesterol level was similar to the main analysis. The Grading of Recommendations Assessment, Development, and Evaluation system was used to assess the overall quality of evidence.Results: Pooled study participants were 559 patients from eight observation studies (two before-after studies; six case-control studies) examining the effects of HCQ on serum LDL. Pooled study participants' characteristics were as follows: mean age 45.719, female 95.262%, and prednisone use 58.366%. HCQ reduced mean LDL levels by 24.397 mg/dL (95% CI 8.921-39.872; P = 0.002). The number of studies identifying statin use was too few to perform meta-regression analysis of statin use. Heterogeneity was extensive (I 2 = 94.739%). Symmetrical funnel plot visualized no evidence of publication bias.Conclusion: HCQ was associated with serum LDL level reduction by mean 24.397 mg/dL in patients with SLE. Future prospective studies are need to fully characterize the treatment effect.

We read with interest the study by Ahmed et al. (1) identifying the cost-effectiveness of all direct-acting antivirals (DAAs) for patients with hepatitis C virus (HCV) awaiting liver transplant (LT) in the United States.A few things should be considered before applying the findings of Ahmed et al. (1) to clinical practice. There are possible selection biases in the base case scenario, for example, the ASTRAL-4 cohort, (2) which may not reflect the full spectrum of the US population. The ASTRAL-4 study (2) included a predominantly white population (90%) According to the United Network of Organ Sharing database in year 2016, approximately 20% of LT waitlist cases resulted in death or removal from the waitlist. The proportion of DAA users among HCV patients awaiting LT is largely unknown. Uncertainty remains regarding the Trump administration's actions on DAA coverage for patients with HCV waiting LT. In these contexts, Kieslich et al. (5) suggested that both the patient and the public should be proactively engaged to promote DAA coverage for HCV treatment as an urgent agenda for the media and policymakers. Simultaneously, newer costeffectiveness analyses of DAA coverage should be tested again, ideally by two reference case perspectives-the societal and payers' perspectives-and should be put forward to identify the most affordable ways to cover DAAs for US patients with HCV awaiting LT. (6)

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