Rheumatology Vol. 43 No. 8 © British Society for Rheumatology 2004; all rights reserved
Letter to the Editor |
Adherence to guidelines for the monitoring of antimalarial-related retinal toxicity
1 Division of Clinical Epidemiology, 2 Department of Rheumatology, 3 Department of Ophthalmology and 4 Division of Clinical Allergy and Immunology, Montreal General Hospital, Montreal, Quebec, Canada
Correspondence to: S. Bernatsky, 1650 Cedar Ave., Room L10-520, Montreal, Quebec, H3G 1A4, Canada. E-mail: Sasha.bernatsky{at}mail.mcgill.ca
SIR, We read with great interest the article by Samanta et al. [1] on the self-reported behaviour by rheumatologists, who did not adhere to the Royal College of Ophthalmology (RCO) guidelines for the monitoring of ocular toxicity of hydroxychloroquine [2]. Our interest stems from our recent findings regarding the actual practice of ophthalmology monitoring for patients on antimalarial therapy [3]. Our group also found incomplete adherence to guidelines (in our case, we assessed adherence to the ACR guidelines [4]). We noted that non-adherence was associated with duration of antimalarial exposure, which, while not surprising, is still an important reminder that adherence to ophthalmological monitoring may decrease as the risk of retinal toxicity is increasing.
In 1997, a scientific review was mandated by the Clinical Affairs Committee of the British Society of Rheumatology. One of the statements proceeding from this review [5] was that ‘There is no consensus as to the appropriate approach for screening, and no method is ideal’. We suggest that perhaps this statement still holds, and is possibly one of the reasons why the subjects in the sample of Samanta et al. responded as they did.
Furthermore, since the readership of Rheumatology extends beyond the UK, we thought it might be relevant to make the following point. Though the guidelines assessed by Samanta et al. have been endorsed by the RCO, the British Association of Dermatologists and the British Association of Rheumatologists, other recognized guidelines do exist. In North America, the American College of Rheumatology (ACR) guidelines suggest ophthalmological examinations, including visual field tests, every 6–12 months (more frequently than this when a patient has been exposed to more than 10 yr of therapy) [4]. Canadian rheumatology guidelines suggest ophthalmological examinations at 12- to 18-month intervals, including visual acuity, colour vision, slit lamp examination, fundoscopy and visual fields [6]. More recent guidelines have been suggested by the American Academy of Ophthalmology (AAO) Task Force [7]. All of these guidelines can be considered evidence-based (as the RCO guidelines have been designated), yet they differ.
Certainly it might be possible to consider harmonization of the various guidelines. We believe that if the influential bodies (including the major ophthalmology and rheumatology bodies) could produce a single guideline statement, this could only help promote better adherence. However, as our group suspects, and as Samanta et al. point out, lack of adherence to guidelines is probably multifactorial.
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.
[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]
- Bernatsky S, Pineau C, Joseph L, Clarke A. Adherence to ophthalmologic monitoring for antimalarial toxicity in a lupus cohort. J Rheumatol 2003;30:1756–60.
[Abstract/Free Full Text] - American College of Rheumatology Ad Hoc Committee on Clinical Guidelines. Guidelines for monitoring drug therapy in rheumatoid arthritis. Arthritis and Rheumatism 1996;39:723–31.[Medline]
- Silman A, Shipley M. Ophthalmologic monitoring for hydroxychloroquine toxicity. Br J Rheumatol 1997;36:599–601.
[Free Full Text] - Canadian Rheumatology Association. Canadian Consensus Conference on hydroxychloroquine. J Rheumatol 2000;27:2919–21.[Medline]
- Marmor M, Carr R, Easterbrook M, Farjo A, Mieler W, American Academy of Ophthalmology. 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]
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