Kelly Weselman, MD, FACR, WellStar Rheumatology, Smyrna, Ga., said the guidelines will likely result in some dosing adjustments for patients whose ideal and real body weight differ significantly.
Petros Efthimiou, MD, FACR, associate chief of rheumatology, New York Methodist Hospital, and associate professor of clinical medicine and rheumatology, Weill Medical College of Cornell University, New York, may ask patients to split tablets or use variable dosing by alternating or skipping doses on some days. “This way, hydroxychloroquine will be dosed according to the guidelines and retinal toxicity can be minimized, provided a careful ophthalmologic monitoring is also in place,” he said.
Some rheumatologists request that patients on HCQ and CQ get screened every year; the guidelines show that this is not usually necessary until five years of use. In fact, Dr. Weselman will change her recommendation for patients based on the update. “I will have some reassurance that such annual exams could be delayed until the patient has been maintained on the medication for five years,” she said.
All patients beginning long-term HCQ or CQ therapy should have a baseline eye exam in the first year of starting the drug.
Ophthalmologist Frederick W. Fraunfelder, MD, MBA, Roy E. Mason and Elizabeth Patee Mason Distinguished Professor, and chairman, ophthalmology, University of Missouri Health System, Columbia, focused on the value of making sure patients have a screening eye examination within the first year of treatment. “Any symptoms of visual loss or disturbance should be followed promptly by an ophthalmologist,” he said.
Dr. Efthimiou stressed the important role of HCQ and CQ for certain patients. “I want to emphasize how valuable antimalarial drugs are in the treatment of our diseases, especially SLE, where hydroxychloroquine is the cornerstone drug. While it is important to diagnose retinal toxicity, this has to be done carefully, using objective measures and confirmatory methods,” he said.
“Making a decision to stop this medication can present major problems for managing the underlying inflammatory disease,” Dr. Weselman said. However, she believes the guidelines strive for balance in stating the importance of the medications but also recommending further testing for verification of certain findings before making a decision to stop the medication.
Ophthalmologist Adrian W. Jachens, MD, EyeCare 20/20, East Hanover, N.J., applauded the fact that specific screening tools are recommended for annual screening. “SD-OCT is much more prevalent in ophthalmologists’ practices, so it makes sense to make it part of the required screening,” he said.
Based on the new guidelines, Dr. Jachens will ask patients using HCQ or CQ if they have any renal disease or have used tamoxifen, to help guide how often they should return after baseline screening.