Background/Purpose: Hydroxychloroquine (HCQ) is a treatment option for lupus erythematosus and rheumatoid arthritis. The risk of retinopathy in the first 5 years of therapy is estimated to be less than 1% in patients prescribed doses below 5 mg/kg per day. However, the risk increases to approximately 20% after 20 years of treatment. The American Academy of Ophthalmology (AAO) has identified the following risk factors for retinopathy secondary to HCQ: duration of treatment greater than 5 years, dose greater than 5 mg/kg actual body weight per day, kidney disease, concurrent tamoxifen use and history of macular disease. This study was conducted to identify patients who are at high risk for HCQ-induced retinopathy and to consider dose reduction if possible.

Methods: Data was obtained from the electronic health record (EHR) from July 1, 2016 to July 30, 2017. Clinic practice changed August 1, 2017 to identify patients at high risk for HCQ retinal toxicity and doses were decreased to below 5 mg/kg per day if possible. A repeat assessment was completed using EHR data from August 1 2017 to November 30, 2017 to determine the number of patients who remained at high risk for retinal toxicity, if dose reductions occurred, and if there was any impact on disease control.

Results: The initial assessment included 436 patients. One-hundred and five patients (24.1%) were prescribed HCQ at doses greater than 5 mg/kg per day. Sixty-three of the 105 patients had doses greater than 6 mg/kg per day and of those 63 patients, 20 of them had doses greater than 7 mg/kg per day. One patient was on concurrent tamoxifen therapy and HCQ was decreased to 200 mg per day. Twelve patients were identified to have an eGFR less than 60. There were 151 unique ophthalmology visits during the initial assessment.

The repeat assessment included 145 patients. Twenty-four patients (16.6%) were prescribed HCQ at doses greater than 5 mg/kg per day. Nine of the 24 patients had doses greater than 6 mg/kg per day and of those 9 patients, 3 of them had doses greater than 7 mg/kg per day. Doses did not exceed 8 mg/kg in any of the patients assessed. No patients in the repeat assessment were on concurrent tamoxifen therapy. One patient was identified to have an eGFR less than 60. There were 66 unique ophthalmology visits during the repeat assessment. After the conclusion of the study period, 1 patient with lupus erythematous experienced increased disease activity since dose reduction from 8 mg/kg per day to 4 mg/kg per day. The HCQ dose was increased back to the previous dose in this patient.

Conclusion: Repeat assessment showed that less patients were prescribed HCQ at doses greater than 5 mg/kg/day compared to the initial assessment. Patient assessment to determine if HCQ dose reduction to less than 5 mg/kg per day is clinically appropriate. However, it is important to monitor for increased disease activity in these patients. Assessing the number of ophthalmology visits was not fully informative as it does not indicate the number of patients specifically assessed for HCQ retinal toxicity. A more streamlined method to identity HCQ-related ophthalmology visits would be valuable in monitoring these patients.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/hydroxychloroquine-quality-improvement-project-at-uf-health-jacksonville-rheumatology-clinics/