Noncompliance, however, is preventing patients from fully taking advantage of these benefits, she said, noting a study by Nathalie Costedoat, MD, that reported that 50% of patients hospitalized for severe flare had a 0 blood level of HCQ.
Several studies show improved survival with HCQ, a message that should be communicated to patients at every visit, Dr. Petri said. “Neurologists do blood levels of all their antiepileptics quite routinely. I think we need to start to have blood levels of HCQ available to us as well, not so that we can yell at our patients, but so we can educate them,” she said
To reduce side effects, Dr. Petri recommends keeping the optimal dose of HCQ below 6.5 mg per kilogram and adjusting the dose downward if the patient has renal insufficiency, hepatic problems, or if they are elderly.
The Humphrey Visual Fields that rheumatoid arthritis–symptomatic patients on HCQ once received during their regular ophthalmology visits are now being replaced with ocular coherence tomography and electroretinograms. According to Dr. Petri, these high-tech scans are so sensitive that they pick up abnormalities that may have nothing to do with HCQ, such as a lupus retinopathy or a hypertensive retinopathy. The result is that patients are then being told by their ophthalmologist that the HCQ needs to be stopped.
“My view of this is that these tests should never be done in an asymptomatic patient who has a normal retinal exam and normal Humphrey Visual Fields,” she said. “If they are done and they are abnormal, I always ask that there be a second opinion given by the ophthalmologist at Hopkins, because we have no good replacement for antimalarials.”
Coronary Artery Disease
Dr. Petri also focused her presentation on how rheumatologists can improve coronary artery disease risk in patients with SLE. “This remains our main unmet need. This is the reason why survival in lupus patients has not improved since 1980,” she said.
Specifically, she recommended that rheumatologists aim for their patients to achieve normal blood pressures of 120/80 and LDL cholesterol levels of 100.
She also recommended a reduction in prednisone and described a study she just completed that found that in daily doses of 10 mg or higher, the drug was associated with a 2.4-fold increase in cardiovascular events as compared with controls.2
Give Burst Steroids a Try
Dr. Petri ended her presentation with an idea she hopes “will change your clinical practice right away.”
