Time to Revise Hydroxychloroquine, Retinopathy Guidelines, Say Authors

October 21, 2020
Peter Wehrwein
Peter Wehrwein

Rather than stopping hydroxychloroquine altogether, doses could be reduced and patients monitored if there are signs of retinopathy, say the authors of a commentary in the American Journal of Ophthalmology.

A commentary in the November issue of the American Journal of Ophthalmology argues that it is time to revisit the retinopathy screening guidelines for people taking hydroxychloroquine
Rather than discontinuing the drug at the first sign of retinopathy, prescribers should put patients on lower doses of hydroxychloroquine and monitored their eyes closely, the commentary argues.

Ophthalmologists have more sensitive tests for retinopathy than they used to, so taking people off hydroxychloroquine because of early retinopathy has become more common than missing the diagnosis, argue David J. Browning of Charlotte (North Carolina) Eye, Ear, Nose and Throat Associates and his colleagues.

“It is a fair question, therefore, whether the emphasis on early detection of HCQR

(hydroxychloroquine retinopathy) has been pushed too far,” they write. “Ophthalmologists set the guidelines based on a concern for HCQR but the prescribing physicians and their patients are the ones that must live with the ramifications of the guidelines.”

Hydroxychloroquine has been in the news as a possible treatment and preventive of COVID-19 It failed for that purpose. But the drug is a mainstay of the treatment of many autoimmune diseases, especially systemic lupus erythematosus. There are alternatives but, as noted by Browning and his co-authors — Naoto Yokogawa, Paul B. Greenberg and Elliot Perlman — the alternatives have cost and side effect drawbacks.

Because retinopathy related to hydroxychloroquine can be detected at a subclinical stage these days, Browning and his colleagues say lowering doses and monitoring patients should be considered by guideline writers rather than having people stop taking hydroxychloroquine altogether.

The dosing of hydroxychloroquine is currently based on body weight; Browning and his colleagues suggest that blood levels be considered instead. They also suggest that guideline writers consider the thresholds for diagnosing retinopathy related to hydroxychloroquine and the sensitivity and specificity levels. And they call for inclusive guideline committees that would have the specialists involved hydroxychloroquine prescribing and monitoring.

“By acknowledging the complementary roles of prescribers and ophthalmologists, this approach will lead to wider acceptance of the guidelines and better care for our patients,” concluded Browning, Yokogawa, Greenberg and Perlman.