Hydroxychloroquine Retinal Toxicity Reviewed Save
Hydroxychloroquine (HCQ or Plaquenil) retinopathy is rare, but still a major concern among patients and prescribers.
In those affected the damage may be subclinical and there are examples when the retinopathy occurs on low-dose HCQ, and others with no evidence of retinopathy despite years of high dose HCQ.
This review article discusses newer methods of retinal assessment beyond the technique of central visual field testing. These newer modalities are increasingly being used for screening and include optical coherence tomography (OCT), fundus autofluorescence (FAF) and multifocal electroretinogram (mfERG). The hope being these will provide earlier evidence of deposition, structural or functional toxicity. However the ideal single best test (with high sensitivity and high specificity) for HCQ retinopathy has universally agreed upon and great debate exists over with methodology should be used.
Nevertheless, well known risk factors for HCQ retinal toxicity include receiving >6.5 mg/kg/day or a cumulative dose of >1000 g of HCQ, being on treatment for >5 years, having renal or liver dysfunction, having pre-existing retinopathy and being elderly. HCQ continues to be a valuable drug in treating rheumatic disease, but clinicians need to be aware of the associated risks and to have arrangements in place that would enable early detection of toxicity.
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I do take a counter view to our saying that HCQ retinopathy is rare as we are misleading physicians and patients. I'll preface my comments in saying that absolutely almost all patients with SLE should be on an antimalarial as the benefits outweigh the risks.
- I now have 12 HCQ retinopathies in my lupus cohort
- The largest series to ever look at the prevalence of HCQ-retinopathy by Welles and Marmor last year showed close to a 20% prevalence after 20 years of tx (looking at those who were dosed at 5mg/kg actual body weight). http://archopht.jamanetwork.com/article.aspx?articleID=1913588&
- Since when can we call a 20% prevalence "rare"?
- Although this is after 20 years of tx, we must keep in mind that we began to use HCQ universally in the late 90s. Our SLE pts are living longer; those pts who were in their 20s and 30s at that time are now in their 40s and 50s. We are just now seeing the "tip of the iceberg" in my opinion.
What we rheumatologists need to do:
- Stop saying "rare"
- Ensure all our pts get the VF 10-2 + either SD-OCT or mfERG or FAF yearly (don't assume it is done)
- Dose HCQ at 5 mg/kg actual body weight if their SLE can handle that lower dose.
Disclosures
The author has no conflicts of interest to disclose related to this subject
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