Rheumatology Vol. 43 No. 8 © British Society for Rheumatology 2004; all rights reserved
Letter to the Editor |
Are evidence-based guidelines being followed for the monitoring of ocular toxicity of hydroxychloroquine? A nationwide survey of practice amongst consultant rheumatologists and implications for clinical governance. Comment on the article by Samanta et al.
Sussex Eye Hospital, Brighton and Sussex University Hospitals, Brighton, UK
Correspondence to: I. Mavrikakis, Sussex Eye Hospital, Eastern Road, Brighton BN2 5BF, UK. E-mail: jmavrikakis{at}yahoo.com
SIR, We read with interest the article by Samanta et al. on the question of whether evidence-based guidelines are being followed for the monitoring of ocular toxicity of hydroxychloroquine [1]. As the authors demonstrate, the nationally set guidelines for the monitoring of ocular toxicity of hydroxychloroquine [2] are not consistently followed by rheumatologists with regard to baseline assessment, referral to ophthalmology, and frequency of monitoring [1].
Notably, 47 and 49% of rheumatologists respectively did not assess either baseline visual symtoms or baseline acuity. Furthermore, 61% of rheumatologists undertook frequent visual monitoring (more than once a year) [1]. Moreover, a recently published survey that examined rheumatologists’ attitudes toward routine screening for hydroxychloroquine retinopathy revealed that 94% of them screen their patients at least once a year because they are unwilling to accept any risk of visual damage [3].
We have recently published the results of a prospective study which was conducted between 1985 and 2000 in our centre to define the risk of hydroxychloroquine-related retinal toxicity in patients with rheumatoid arthritis and systemic lupus erythematosus who are receiving recommended doses of the drug (
6.5 mg/kg/day) [4]. Of the 400 patients using long-term hydroxychloroquine at recommended doses, the incidence of retinal toxicity was very low (0.5%) and no cases of retinopathy were observed during the first 6 yr of treatment. These results allowed us to conclude that, after a baseline examination to confirm the absence of pre-existing fundus pathology, patients with normal renal function may receive hydroxychloroquine at a maximal daily dose of 6.5 mg/kg and continue safely for 6 yr. However, we suggested annual screening in patients who have taken the drug, even at recommended doses, for more than 6 yr [4]. These results substantiated the guidelines developed in 2002 by the American Academy of Ophthalmology Task Force for screening for hydroxychloroquine toxicity [5], which stated that ophthalmological examinations of such patients during the first 5 yr of treatment can be at the frequency of regular examinations recommended by the American Academy of Ophthalmology Preferred Practice Pattern [6] for the age of the patient, provided that no concomitant retinal, renal and/or liver disease exists.
To the best of our knowledge, the literature contains no documented cases of hydroxychloroquine-induced retinopathy in patients who were taking the drug at recommended doses for less than 6 yr and had normal renal function. Moreover, among the millions of patients exposed to hydroxychloroquine worldwide, only five appropriately dosed patients developed irreversible retinal changes within the first 10 yr of treatment; all were diagnosed during the seventh or by the end of the eighth year of hydroxychloroquine exposure [7–10]. Seven additional patients who developed hydroxychloroquine-induced retinopathy after taking the drug for more than 10 yr, at doses less than 6.5 mg/kg/day and in the absence of any associated comorbidities, have been reported so far (reviewed in [4]).
Based on this evidence, it seems appropriate to formally revise the Royal College of Ophthalmologists clinical guidelines for the monitoring of ocular toxicity of hydroxychloroquine.
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The authors have declared no conflicts of interest.
References
- Samanta A, Goh L, Bawendi A. Are evidence-based guidelines being followed for the monitoring of ocular toxicity of hydroxychloroquine? A nationwide survey of practice amongst consultant rheumatologists and implications for clinical governance. Rheumatology 2004;43:346–8. First published January 6, 2004: 10.1093/rheumatology/keh041.
[Abstract/Free Full Text] - Fielder A, Graham E, Jones S, Silman A, Tullo A. Royal College of Ophthalmologists guidelines: ocular toxicity and hydroxychloroquine. Eye 1998;12:907–9.[Medline]
- Fraenkel L, Felson DT. Rheumatologists’ attitudes toward routine screening for hydroxychloroquine retinopathy. J Rheumatol 2001;28:1218–21.
[Abstract/Free Full Text] - Mavrikakis I, Sfikakis PP, Mavrikakis E et al. The incidence of irreversible retinal toxicity in patients treated with hydroxychloroquine: a reappraisal. Ophthalmology 2003;110:1321–6.[CrossRef][Web of Science][Medline]
- Marmor MF, Carr RE, Easterbrook M, Farjo AA, Mieler WF. Recommendations on screening for chloroquine and hydroxychloroquine retinopathy: a report by the American Academy of Ophthalmology. Ophthalmology 2002;109:1377–82.[CrossRef][Web of Science][Medline]
- American Academy of Ophthalmology. Comprehensive adult medical eye evaluation, preferred practice pattern. San Francisco: American Academy of Ophthalmology, 2000.
- Falcone PM, Paolini L, Lou PL. Hydroxychloroquine toxicity despite normal dose therapy. Ann Ophthalmol 1993;25:385–8.[Web of Science][Medline]
- Mavrikakis M, Papazoglou S, Sfikakis PP, Vaiopoulos G, Rougas K. Retinal toxicity in long term hydroxychloroquine treatment. Ann Rheum Dis 1996;55:187–9.
[Abstract/Free Full Text] - Bienfang D, Coblyn JS, Liang MH, Corzillius M. Hydroxychloroquine retinopathy despite regular ophthalmologic evaluation: a consecutive series. J Rheumatol 2000;27:2703–6.[Web of Science][Medline]
- Warner AE. Early hydroxychloroquine macular toxicity. Arthritis Rheum 2001;44:1959–61.[CrossRef][Web of Science][Medline]
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