Medicines

Call for consensus on HCQ retinopathy screening


Australia should develop local screening guidelines for hydroxychloroquine retinopathy given the number of rheumatology patients using the DMARD long term and at risk of permanent vision loss.

A Perspective article in the MJA said thousands of Australians were potentially at risk given a 7.5% prevalence rate of retinopathy in patients who had taken hydroxychloroquine (HCQ) for at least five years.

Product Information for HCQ mentions the risk of irreversible retinal damage in patients on long-term or high-dose treatment and advises regular eye testing.

Yet authors of the MJA article including dermatologist Dr Monisha Gupta and ophthalmologist Dr Kristopher Rallah-Baker said there was no recommended consensus on screening in Australia.

Their article noted the US and UK guidelines on HCQ retinopathy screening were largely consistent but with some differences.

For example, the US considers pre-existing retinal and macular conditions as risk factors for HCQ retinopathy while the UK does not. In return, the UK considers chloroquine use as a risk factor while the US does not.

The UK screening recommendations currently include annual monitoring – with spectral domain optical coherence tomography (OCT) and widefield fundus autofluorescence –  after five years of HCQ therapy with no risk factors and after one year of HCQ therapy with additional risk factors.

Recommendations also vary regarding the frequency of screening in high risk patients.

The MJA article said local guidelines should also consider the higher proportion of Australian residents with Asian ancestry – a group known to have a more peripheral pattern of retinal damage from HCQ who may need wider visual field tests.

“There are currently no studies discussing the prevalence of hydroxychloroquine retinopathy in Australia, which makes it difficult to determine whether current screening practices are sufficient,” the authors said.

“Another factor to consider is whether Australia’s public health system can support ophthalmology screening at the frequency recommended by the US and UK guidelines. Already, waiting times for non‐urgent appointments for ophthalmologists in the public system can reach years.”

They estimated the cost of screening half the HCQ users in the public system at about $1.5 million annually.

“Given its potential to cause permanent vision loss and the number of Australians taking hydroxychloroquine long term, developing Australian screening guidelines for hydroxychloroquine retinopathy would be beneficial in promoting consistent screening practices tailored to the Australian population.”

“Before these can be established, however, more research needs to be conducted on the prevalence and current detection rates of hydroxychloroquine retinopathy in Australia.”

 

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