| Main text |
The Royal College of Ophthalmologists recently published recommendations for monitoring users of hydroxychloroquine and chloroquine in the United Kingdom. This article summarizes the main recommended guidelines.
These recommendations are aimed at patients, ophthalmologists, ophthalmology services, rheumatologists, dermatologists, clinicians, optometry services, patient groups and voluntary organizations that provided information for the development of these guidelines.
Hydroxychloroquine is a drug that is increasingly used in the treatment of lupus erythematosus, rheumatoid arthritis and other autoimmune pathologies. Many times the drug is used in combination with others against rheumatoid arthritis. Every year there are an estimated 11,000 new users in England and Wales.
Retinopathy due to hydroxychloroquine used to be a rare pathology (prevalence 0.5% of patients who consume the drug for 6 years) probably because the diagnosis was made when patients began to present symptoms with visible abnormalities on clinical examination.
Previously, no studies were recommended to control it since the pathology was very rare and there were no studies that could detect it at a stage in which it was reversible. However, with the new images, pre-symptomatic retinopathy can be detected.
Likewise, there are new data that have identified a prevalence of hydroxychloroquine retinopathy in approximately 7.5% of patients who use the drug for more than five years, increasing to 20-50% at 20 years. Currently, protocols vary between different centers with varying effectiveness in detecting the pathology.
Hydroxychloroquine is a safe and effective medication to treat various pathologies . Long-term use of hydroxychloroquine can cause retinopathy , with adverse effects on the retina that can cause vision loss in both eyes. There are specific studies through which the pathology can be detected before patients notice changes in vision.
However, once hydroxychloroquine retinopathy develops vision loss, the damage to the retina is permanent and usually continues to progress even when the medication is stopped.
You are more likely to get retinopathy when the medication is taken for a long time and the doses are high.
The objective of conducting preventive studies to detect hydroxychloroquine retinopathy is to detect the first signs of the disease to allow these patients to seek alternative medication and those patients who do not present any signs can continue using the medication without concern.
Current evidence indicates that patients taking doses of more than 5 mg/kg per day are at greater risk of developing hydroxychloroquine retinopathy. Many patients take 400 mg daily, which is more than the recommended dose for a patient weighing less than 80 kg.
Physicians prescribing the drug should be aware that a dose of less than 5 mg/kg per day reduces the risk of retinopathy, although no absolutely safe dose has been identified.
The rule would be to maintain the dose <5mg/kg/day and carry out studies after five years of using treatment with said drug.
| recommendations |
- All patients taking hydroxychloroquine for more than 5 years should have annual checkups for retinopathy.
- All patients who use chloroquine for more than one year should undergo annual check-ups for retinopathy.
- All patients who consume hydroxychloroquine and have additional risk factors for retinal toxicity should undergo annual check-ups starting before the age of 5, a decision that must be made by the ophthalmologist after the first consultation.
- Additional risk factors are considered: Tamoxifen consumption, renal failure, hydroxychloroquine doses greater than 5 mg/kg/day.
- It is the responsibility of the intervening professional to refer patients to an ophthalmological service for control, informing the characteristics of each case and possible risk factors present.
- All patients about to begin long-term treatment should receive a baseline ophthalmological examination, ideally within the first 6 months of starting treatment. This examination should include color fundus photography and spectral domain optical coherence tomography.
- If macular pathology is observed in the baseline examination, a visual field study should be included.
- In patients with visual field defects that could be the result of hydroxychloroquine retinopathy, even if they do not present structural defects according to OCT, the possibility of performing a multifocal electroretinogram should be considered.
- With two tests (one subjective and one objective) with results coinciding with typical abnormalities of retinopathy due to hydroxychloroquine, toxicity is considered definitive.
- Patients with an abnormal result on images, but with a normal visual field, should undergo an annual check-up. This will reduce the risk of unnecessarily stopping treatment.
- Patients with persistent visual field abnormality and normal retinal images should perform a multifocal electroretinogram and continue with treatment until said result is obtained.
- The ophthalmologist must report the toxicity specifying the severity (mild, moderate or severe) and recommend the cessation of treatment, a decision that will be made by the intervening professional considering the alternative options with the patient.
- Patients who drive should stop doing so until they confirm that the visual field is normal.
- Patients at risk of retinopathy due to hydroxychloroquine should be informed about the risks of treatment with said drug, the need to perform ophthalmological controls and the possibility of having to interrupt treatment and look for alternatives in case of toxicity.
| Conclusions |
Long-term use of hydroxychloroquine can cause retinopathy, with adverse effects on the retina that can cause vision loss in both eyes.
There are specific studies through which the pathology can be detected before patients notice changes in vision.
It is necessary to perform annual ophthalmological checkups 5 years after starting treatment.
