OPTICAL COHERENCE TOMOGRAPHY FOR HYDROXYCHLOROQUINE EYE MONITORING - SHOULD WE WORRY?
1Luton and Dunstable University Hospital, Luton, United Kingdom
Background: Recent data have highlighted that hydroxychloroquine (HCQ) retinopathy is much more common than previously reported. The overall prevalence appears to be around 7.5% and depending on dose and duration of therapy can increase to 20-50 % after 20 years of therapy. Royal College of Ophthalmology UK recommend that all patients planning to take hydroxychloroquine long term have a baseline examination in a hospital eye department with a colour retinal photograph and spectral domain optical coherence tomorgraphy (SD-OCT) scans of the macula. After five years, annual screening is required with 10-2 Humphrey visual field testing, followed by pupillary dilation and imaging with both SD-OCT and widefield fundus autofluorescence imaging (FAF).
Objectives: Our aim was to review the early findings of the screening program for all rheumatology patients prescribed HCQ at our university hospital.
Methods: A business case was approved to set up eye monitoring in accordance with above guidelines. All patients with rheumatic diseases prescribed HCQ were identified through departmental database. They were invited for ophthalmological examination and those with drug exposure >5 yrs were prioritised. An MDT pathway was established to manage anyone with signs of HCQ toxicity.
Results: 2,132 patients are prescribed HCQ in our county with population of 669,000. 997 patients fell under our unit’s remit. 136 patients (82% women) have been screened with mean age of 58 yrs (24-84y). 65 (48%) have RA and remaining with connective tissue diseases. Median disease duration is 10 yr (0.75-30 yrs) and median drug exposure is 10 yr (0.4-27yr). Three doses of HCQ are prescribed: 200mg daily (53%), 300mg daily (13%) and 400mg daily (34%). Ten (7.3%) patients were found to have abnormal results. Three were consistent with HCQ toxicity pattern and one with likely toxicity. Two of them had already developed severe sight loss. HCQ was discontinued in all these cases. Six had other incidental anomalies requiring further input.
Conclusion: Hydroxychloroquine is used increasingly in the treatment of autoimmune diseases with emerging role in oncology. It has a favourable safety and tolerability profile with survival benefit demonstrated in SLE. In the UK, it’s adoption has been particularly high owing to the requirement of trialling two DMARDs prior to being eligible for biologic therapy in RA and PsA. In the absence of modern retinal imaging techniques, HCQ toxicity was perhaps underestimated and hence older guidelines did not emphasise strict monitoring practice. Our preliminary data, in line with published evidence, represents a greater public health problem than previously estimated. It is clear that implementing the new guidelines not only recognises hitherto undiagnosed drug toxicity but also identifies incidental significant eye pathology which puts pressure on healthcare resources and needs robust service planning. Rheumatologists need to be aware of the potential impact requiring informed discussion with patients and perhaps a fundamental shift in prescribing behaviour to avoid this rapidly developing health concern.
Disclosure of Interests: Amr Moharram: None declared, Freddy Raj: None declared, Jose Maya: None declared, Ranjit Sandhu: None declared, Muhammad Khurram Nisar Grant/research support from: Muhammad Nisar undertakes clinical trials and received support (including attendance at conferences, speaker fees and honoraria) from Roche, Chugai, MSD, Abbvie, Pfizer, BMS, Celgene, Novartis and UCB
, Consultant of: Muhammad Nisar undertakes clinical trials and received support (including attendance at conferences, speaker fees and honoraria) from Roche, Chugai, MSD, Abbvie, Pfizer, BMS, Celgene, Novartis and UCB
, Speakers bureau: Muhammad Nisar undertakes clinical trials and received support (including attendance at conferences, speaker fees and honoraria) from Roche, Chugai, MSD, Abbvie, Pfizer, BMS, Celgene, Novartis and UCB
Citation: Ann Rheum Dis, volume 79, supplement 1, year 2020, page 1877
Session: Public health, health services research, and health economics
(Abstracts Accepted for Publication)