Rheumatologists’ perspective on hydroxychloroquine guidelines

Abstract

ObjectiveHydroxychloroquine (HCQ) retinal toxicity is an ongoing concern for rheumatologists. The revised 2016 American Academy of Ophthalmology (AAO) guidelines created controversy regarding the correct dosing and evaluation of HCQ toxicity. The current study was initiated to further understand rheumatologists’ practices regarding HCQ.MethodsA questionnaire-based survey was distributed electronically to rheumatologists. We collected information on HCQ dosing, clinical decision-making processes, familiarity with the AAO 2016 guidelines, and perceived disparities between the AAO 2016 guidelines and rheumatological clinical practice.Results78 rheumatologists completed the survey (49% from USA, 90% academic practices, 82% self-identified as lupus experts). Only lupus expert (n=64) data were included in subsequent analysis. The mean cohort size was 747 (50–6571), a total cohort 45 612 patients. HCQ was prescribed to >75% of patients with SLE by 81.3% of SLE experts, with routine counselling about ophthalmic risks. The typical dose of HCQ used was 200–400 mg/day. 17% of rheumatologists use doses up to 600 mg/day, while 6.2% use up to 6.5 mg/kg/day. HCQ adherence is routinely assessed. 479 cases of HCQ retinal toxicity (1.05%) and 9 cases of HCQ-associated blindness (1.8 per 10 000 patients) were reported. 89.1% of respondents reported familiarity with the AAO guidelines. Those aware of the guidelines cited limited dosing options (54.7%), lack of supporting evidence (57.8%) and low patient adherence (43.8%) as obstacles to greater implementation of the guidelines.ConclusionThese data suggest that HCQ toxicity and blindness are rare in patients with SLE. Rheumatologists treating patients with SLE are aware of the guidelines and appreciate the importance of partnering with ophthalmologists in preventing retinal toxicity.

Hydroxychloroquine screening in the UK-closing the gaps

“…These results are significantly lower than those of Melles and Marmor 7.5% [ 1 ] ( p = 0.0001) and are more in keeping with the older literature [ 5 – 7 ]. Another recent paper exploring the experience of 68 Lupus experts with a cohort of 46,000 patients between them revealed a prevalence of retinal toxicity of 1.05% [ 14 ].…”

Trends and practices following the 2016 hydroxychloroquine screening guidelines

“…Our study explored the patient and physician characteristics leading to differences in HCQ screening practices since the 2016 AAO screening guidelines. A survey by Winebrake et al 21 in 2020 regarding the perspective of rheumatologists on the 2016 AAO guidelines cited that limited dosing options, lack of supporting evidence, and low patient adherence were the main obstacles to implementing the guidelines. However, in 2020, the American College of Rheumatology, American Academy of Dermatology, Rheumatologic Dermatology Society, and the American Academy of Ophthalmology provided a joint statement on HCQ use with respect to retinal toxicity 22 .…”

A Framework to Overcome Challenges in the Management of Infections in Patients with Systemic Lupus Erythematosus

“…6,7 However, implementation of these measures and their use in clinical practice is inconsistent and rarely applied. 8,9 In this manuscript we analyzed the burden, the types of infection, the factors related to higher risk of infection, and highlight certain tools used in predicting infection in SLE. We propose a framework to overcome challenges in the management of infections in SLE patients and explore opportunities that can benefit the therapeutic and preventive plan of care.…”