Background/Purpose: Hydroxychloroquine (HCQ) is used in many rheumatologic diseases. The American Academy of Ophthalmology (AAO) put forth guidelines in 2012 regarding retinal screening and dosing in regards to HCQ. These include a retinal exam in the first year after initiation of HCQ and a maximum dose of 5mg/kg/day of actual body weight. The Los Angeles County + University of Southern California Medical Center (LAC+USC MC) serves a largely underinsured urban population and is associated with an academic institution. LAC+USC MC utilizes an online third-party system for ophthalmology referrals. Our aim is to evaluate the LAC+USC MC rheumatology clinic’s effectiveness at pursuing ophthalmologic care for HCQ patients and adhering to the appropriate dosing recommendations put forward by the AAO.

Methods: This is a retrospective chart review of rheumatology clinic patients prescribed HCQ in the LAC+USC MC rheumatology clinic. Charts of patients with clinic visits between March 2018 and May 2018 were reviewed. Patients were included if they had a clear first-time HCQ initiation date. Gender, age, ethnicity, diagnosis, prescribed dose and recommended weight-based dose of HCQ, and date of ophthalmology referral and exam were noted. Fisher’s exact test was used for statistical analysis to see if there was any difference in screening or dosing between different groups of patients.

Results: One hundred and thirty-eight patients qualified for analysis. They were predominantly female (121; 87.7%). Average age was 45.7 (range 18 – 88). Forty-two (30.4%) had lupus, 55 (39.9%) had rheumatoid arthritis, and 41 (29.7) had . Of the 138 patients, 30 (21.7%) received ophthalmologic assessment within the first year of HCQ use. Of the remaining patients who were not screened, 97 patients (89.8%) lacked a timely referral to ophthalmology. Thirty-nine (28.3%) patients were prescribed a HCQ dose higher than the AAO guidelines; the average amount in excess of the recommended dose was 24.3% (range 1-122%). The rheumatoid arthritis patients tended towards lower rates of screening; however, this was not statistically significant.

Conclusion: To our knowledge, this is the first review that has evaluated compliance to AAO recommendations for HCQ retinal screening and dosing in an underserved population at an academic institution. Our findings are congruent with the literature, which demonstrate that providers are not meeting the guidelines for ophthalmologic screening when prescribing HCQ. Additionally, a large proportion of our patients are prescribed more than the recommended HCQ dose. It is important to note that a lowest effective dose of HCQ has not been established for the various rheumatologic conditions for which it is used, and at times, there may be a need for a higher than recommended dose for any particular patient. We hope to use this data to better pinpoint barriers rheumatologists face when following the AAO guidelines. Given our results, possible difficulties include a cumbersome referral system, a lack of knowledge about the guidelines, or difficulty with individualized dosing. Educating providers on AAO guidelines and working with third party referral systems to ensure ease of referrals could help providers meet recommendations.  

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/hydroxychloroquine-retinal-screening-and-dosing-in-an-unique-rheumatologic-patient-population/