Rethinking the Hydroxychloroquine Dosing and Retinopathy Screening Guidelines

Abstract: Purpose To describe the rationale for revising the hydroxychloroquine (HCQ) dosing and screening guidelines and to identify the barriers to more effective guidelines in the future. Design Literature review. Methods A PubMed query of studies on HCQ dosing and hydroxychloroquine retinopathy (HCQR) screening was done with a selective review of the English language literature. Results Three iterations of the American Academy of Ophthalmology HCQ dosing and HCQR screening guidelines have been published without including prescribing physicians on the writing committees. This may contribute prescribing physicians’ low adherence to the guidelines. As ancillary tests have improved, asymptomatic HCQR is being detected earlier, leading to a higher reported prevalence of HCQR and a drop in the ceiling for safe dosing. These trends put stricter constraints on prescribers and their patients, who may have had well-controlled autoimmune disease on HCQ doses previously considered below the high-risk threshold for HCQR. Indeed, stopping HCQ at the earliest sign of HCQR should be reconsidered; for cases of early HCQR, dose reduction and more intensive monitoring for retinopathy may strike a more appropriate balance between HCQ risk and benefits. A prospective study using the DRCR Retina network with standardized collection of data, HCQ blood levels, centralized grading of ancillary tests, and community and academic ophthalmologists would provide a stronger evidence base for future HCQ guidelines. Conclusions The HCQ dosing and screening guidelines should be updated and a prospective study of HCQ dosing and HCQR should be initiated as joint efforts of ophthalmologists and prescribing physicians.