Hydroxychloroquine retinopathy risk may be low at recommended dosing and with appropriate screening, according to updated guidance from the American Academy of Ophthalmology.
In the guideline revision, investigators synthesized advances in retinal imaging and artificial intelligence analysis to update screening recommendations in patients receiving hydroxychloroquine (HCQ) for conditions such as systemic lupus erythematosus and rheumatoid arthritis. The guidance focused on long-term users, a population that is predominantly female.
The primary focus of the guideline revision was the risk and early detection of HCQ retinopathy, with secondary emphasis on risk factors, disease patterns, and screening strategies. Recommended modalities may include optical coherence tomography (OCT) and fundus autofluorescence (FAF) as primary tools, with visual-field testing and multifocal electroretinography used as confirmatory methods.
At doses of no more than 5 mg/kg/day of real body weight, the risk of toxicity was less than 1% within 5 years and less than 2% within 10 years. However, the investigators noted that the risk of toxicity increased with higher daily doses and longer durations of use. Among patients without prior toxicity, the annual risk remained below 5% even after 20 years of therapy.
The risk of toxicity may be doubled among patients with renal disease because of increased circulating drug levels, and those using tamoxifen or starting treatment with HCQ at older ages may also experience a higher risk.
The investigators stated that toxicity doesn't develop as a continuous process. For instance, the retina can remain stable for years prior to the emergence and progression of early structural changes. When detected at mild stages, retinopathy is unlikely to progress following drug discontinuation;however, more advanced disease may continue to worsen even after cessation and can lead to central visual loss.
Baseline screening with OCT and FAF was recommended near treatment initiation to identify preexisting abnormalities and establish a reference point for later comparison. Annual screening was advised during therapy, although this may be deferred for up to 5 years in patients without major risk factors.
The investigators indicated that risk estimates depend on adherence to dosing and screening. Newer technologies, including artificial intelligence–based imaging analysis, have shown potential efficacy but aren't yet fully validated or widely available for routine clinical use.
“With proper dosing and annual screening, most patients can take HCQ for decades with a low risk of retinal toxicity,” wrote Michael F. Marmor, MD, of the Department of Ophthalmology at the Stanford University School of Medicine, and colleagues.
Full disclosures of the study authors can be found in the study.
Source: Ophthalmology
