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Zamani B, Hasan-Abad AM, Rafizadeh SM, Akbari H, Motedayyen H. Skin and ophthalmic complications of chloroquine and hydroxychloroquine in patients with rheumatoid arthritis and systemic lupus erythematous. J Immunoassay Immunochem 2024; 45:178-188. [PMID: 38722204 DOI: 10.1080/15321819.2024.2350544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/25/2024]
Abstract
Immunosuppressive agents are routinely used to control autoimmunity. However, some adverse events are correlated to their clinical applications. The aim of this study was to study the clinical findings and ocular and cutaneous side effects of chloroquine (CQ) and hydroxychloroquine (HCQ), as current immunomodulators, in patients with rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE). This descriptive study was performed on 360 individuals referred to the Rheumatology clinic during 2003-2020. Demographic characteristics and other information were collected from patients with RA and SLE. Skin and ocular complications were evaluated in patients who were on treatment with CQ and HCQ. Study populations consisted of 199 subjects with RA and 161 cases with SLE. The frequencies of skin and ocular complications in all patients treated with CQ and HCQ were 32 (17.65%) and 94 (51.9%), respectively. The prevalence of skin complications in patients with RA and SLE was 20 (10.05%) and 22 (13.66%), respectively. The frequencies of ocular complications in patients with RA and SLE were, respectively, 58 (29.4%) and 36 (22.5%). Multiple logistic regression analysis revealed that ophthalmic complications of CQ and HCQ in all patients were dependent on the effects of the duration of drug uses, disease duration, and cumulative doses (p < 0.05), unlike skin complications. Disease types had no effect on ocular complications. Based on these findings, treatment with CQ and HCQ participates in some skin and ocular complications in patients with RA and SLE which are largely associated with the duration of disease and treatment.
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Affiliation(s)
- Batool Zamani
- Autoimmune Diseases Research Center, Kashan University of Medical Sciences, Kashan, Iran
| | - Amin Moradi Hasan-Abad
- Autoimmune Diseases Research Center, Kashan University of Medical Sciences, Kashan, Iran
| | - Seyed Mohsen Rafizadeh
- Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
- Department of Biostatistics and Epidemiology, School of Health, Kashan University of Medical Sciences, Kashan, Iran
| | - Hossein Akbari
- Trauma Research Center, Kashan University of Medical Sciences, Kashan, Iran
| | - Hossein Motedayyen
- Autoimmune Diseases Research Center, Kashan University of Medical Sciences, Kashan, Iran
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2
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Saad A, de Lima M, Anand S, Bhatt VR, Bookout R, Chen G, Couriel D, Di Stasi A, El-Jawahri A, Giralt S, Gutman J, Ho V, Horwitz M, Hsu J, Juckett M, Kharfan-Dabaja MA, Loren A, Meade J, Mielcarek M, Moreira J, Nakamura R, Nieto Y, Roddy J, Satyanarayana G, Schroeder M, Tan CR, Tzachanis D, Burn J, Pluchino L. Hematopoietic Cell Transplantation, Version 2.2020, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2021; 18:599-634. [PMID: 32519831 DOI: 10.6004/jnccn.2020.0021] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Hematopoietic cell transplantation (HCT) involves the infusion of hematopoietic progenitor cells into patients with hematologic disorders with the goal of re-establishing normal hematopoietic and immune function. HCT is classified as autologous or allogeneic based on the origin of hematopoietic cells. Autologous HCT uses the patient's own cells while allogeneic HCT uses hematopoietic cells from a human leukocyte antigen-compatible donor. Allogeneic HCT is a potentially curative treatment option for patients with certain types of hematologic malignancies, and autologous HCT is primarily used to support patients undergoing high-dose chemotherapy. Advances in HCT methods and supportive care in recent decades have led to improved survival after HCT; however, disease relapse and posttransplant complications still commonly occur in both autologous and allogeneic HCT recipients. Allogeneic HCT recipients may also develop acute and/or chronic graft-versus-host disease (GVHD), which results in immune-mediated cellular injury of several organs. The NCCN Guidelines for Hematopoietic Cell Transplantation focus on recommendations for pretransplant recipient evaluation and the management of GVHD in adult patients with malignant disease.
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Affiliation(s)
- Ayman Saad
- The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | - Marcos de Lima
- Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | | | | | | | | | | | | | | | | | | | - Vincent Ho
- Dana-Farber/Brigham and Women's Cancer Center
| | | | | | | | | | - Alison Loren
- Abramson Cancer Center at the University of Pennsylvania
| | - Javier Meade
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins
| | - Marco Mielcarek
- Fred Hutchinson Cancer Research Center/ Seattle Cancer Care Alliance
| | - Jonathan Moreira
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | | | - Yago Nieto
- The University of Texas MD Anderson Cancer Center
| | - Juliana Roddy
- The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | | | - Mark Schroeder
- Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
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Abstract
Recently, coronavirus disease 2019 (COVID-19) caused by SARS-CoV-2 has spread around the world and is receiving worldwide attention. Approximately 20% of infected patients are suffering from severe disease of multiple systems and in danger of death, while the ocular complications of SARS-CoV-2-infected patients have not been reported generally. Herein, we focus on two major receptors of SARS-CoV-2, ACE2 and CD147 (BSG), in human ocular cells, and interpret the potential roles of coronaviruses in human ocular tissues and diseases.
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Affiliation(s)
- Yan-Ping Li
- Laboratory for Stem Cell & Retinal Regeneration, The Eye Hospital, Wenzhou Medical University, Wenzhou 325027, China
| | - Ya Ma
- Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Ophthalmology & Visual Science Key Laboratory, Beijing 100730 China
| | - Ningli Wang
- Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Ophthalmology & Visual Science Key Laboratory, Beijing 100730 China
| | - Zi-Bing Jin
- Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Ophthalmology & Visual Science Key Laboratory, Beijing 100730 China.
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Al Adel F, Shoughy SS, Tabbara KF. Hydroxychloroquine dosing and toxicity: A real-world experience in Saudi Arabia of 63 patients. Saudi J Ophthalmol 2021; 34:151-155. [PMID: 34085004 PMCID: PMC8081076 DOI: 10.4103/1319-4534.310400] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 05/02/2020] [Accepted: 05/09/2020] [Indexed: 11/05/2022] Open
Abstract
PURPOSE: To assess the ocular toxicity in patients on high doses of hydroxychloroquine (HCQ) per weight, as per the latest American Academy of Ophthalmology (AAO) screening guidelines for HCQ toxicity. METHODS: This is a multi-center study looking at consecutive patients attending the ophthalmology clinics at a tertiary hospital and a private clinic in Saudi Arabia. A data collection sheet was used to collect patient's information regarding the dose per body weight, duration of HCQ use and any risk factors associated with the use of the medication as per the latest AAO guidelines for HCQ screening. Ancillary testing including fundus photography, automated visual field (10-2) and spectral domain ocular coherence tomography were done. Further testing with fundus auto-fluorescence and multifocal ERG were done when needed. The presence or absence of toxicity was recorded. RESULTS: A total of 63 patients were included in the study, 58 females and 5 males. The average patient age was 45 years (range 18–72). The mean dosage of HCQ was 3.9 mg/kg. Fourteen (22%) patients were on doses higher than 5 mg/kg. The duration of treatment ranged from 1-30 years (average 8.3). Thirty six (57%) patients were on the drug for more than 5 years. We found only one (1.58%) patient with HCQ toxic retinopathy over a mean of 8 years treatment period. CONCLUSION: A significant number of our patients were found to be on doses of >5 mg/kg of HCQ, which may put them at a higher risk for retinal toxicity. Low dose HCQ such as 100 mg tablets should be made available to help physicians in adjusting the dose as per the latest reported guidelines by the AAO.
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Affiliation(s)
- Fadwa Al Adel
- Department of Ophthalmology, College of Medicine, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Samir S Shoughy
- The Eye Center and The Eye Foundation for Research in Ophthalmology, King Saud University, Riyadh, Saudi Arabia
| | - Khalid F Tabbara
- The Eye Center and The Eye Foundation for Research in Ophthalmology, King Saud University, Riyadh, Saudi Arabia.,Department of Ophthalmology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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Browning DJ, Yokogawa N, Greenberg PB, Perlman E. Reply to Comment on: Rethinking the Hydroxychloroquine Dosing and Retinopathy Screening Guidelines. Am J Ophthalmol 2021; 222:400-401. [PMID: 33228963 DOI: 10.1016/j.ajo.2020.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 09/09/2020] [Indexed: 11/18/2022]
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Chen C, Pan K, Wu B, Li X, Chen Z, Xu Q, Li X, Lv Q. Safety of hydroxychloroquine in COVID-19 and other diseases: a systematic review and meta-analysis of 53 randomized trials. Eur J Clin Pharmacol 2021; 77:13-24. [PMID: 32780229 PMCID: PMC7417776 DOI: 10.1007/s00228-020-02962-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 07/15/2020] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Many concerns still exist regarding the safety of hydroxychloroquine (HCQ) in the treatment of Coronavirus Disease 2019 (COVID-19). OBJECTIVES The purpose of this study was to evaluate the safety of HCQ in the treatment of COVID-19 and other diseases by performing a systematic review and meta-analysis. METHODS Randomized controlled trials (RCTs) reporting the safety of HCQ in PubMed, Embase, and Cochrane Library were retrieved starting from the establishment of the database till June 5, 2020. Literature screening, data extraction, and assessment of risk bias were performed independently by two reviewers. RESULTS We identified 53 eligible studies involving 5496 patients. The meta-analysis indicated that the risk of adverse effects (AEs) in the HCQ group was significantly increased compared with that in the control group (RD 0.05, 95%CI, 0.02 to 0.07, P = 0.0002), and the difference was also statistically significant in the COVID-19 subgroup (RD 0.15, 95%CI, 0.07 to 0.23, P = 0.0002) as well as in the subgroup for other diseases (RD 0.03, 95%CI, 0.01 to 0.04, P = 0.003). CONCLUSIONS HCQ is associated with a high total risk of AEs compared with the placebo or no intervention in the overall population. Given the small number of COVID-19 participants included, we should be cautious regarding the conclusion stating that HCQ is linked with an increase incidence of AEs in patients with COVID-19, which we hope to confirm in the future through well-designed and larger sample size studies.
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Affiliation(s)
- Can Chen
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Kunming Pan
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Bingjie Wu
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Xiaoye Li
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Zhangzhang Chen
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Qing Xu
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Xiaoyu Li
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, 200032, China.
| | - Qianzhou Lv
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, 200032, China.
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Nicolò M, Ferro Desideri L, Bassetti M, Traverso CE. Hydroxychloroquine and chloroquine retinal safety concerns during COVID-19 outbreak. Int Ophthalmol 2020; 41:719-725. [PMID: 32946004 PMCID: PMC7499926 DOI: 10.1007/s10792-020-01593-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 09/05/2020] [Indexed: 01/17/2023]
Abstract
PURPOSE The current coronavirus disease 2019 (COVID-19) has been declared by the World Health Organization a global pandemic. Chloroquine (CQ) and hydroxychloroquine (HCQ) have been largely adopted in the clinical setting for the management of SARS-CoV-2 infection; however, their known retinal toxicity has raised some safety concerns, especially considering the higher-dosage employed for COVID-19 patients as compared with their suggested posology for their usual indications, including systemic lupus erythematosus and other rheumatic diseases. In this review, we will discuss the optimal dosages recommended for COVID-19 patients when treated with HCQ and CQ. METHODS A comprehensive literature search was performed in PubMed, Cochrane library, Embase and Scopus, by using the following search terms: "chloroquine retinal toxicity" and "hydroxychloroquine retinal toxicity" alone or in combination with "coronavirus", "COVID-19", " SARS-CoV-2 infection " from inception to August 2020. RESULTS Although there is still no consistent evidence about HCQ/CQ retinal toxicity in patients with COVID-19, these possible drug-related retinal adverse events may represent a major safety concern. For this reason, appropriate screening strategies, including telemedicine, should be developed in the near future. CONCLUSION A possible future clinical perspective for patients with COVID-19 treated with HCQ/CQ could reside in the multidisciplinary collaboration between ophthalmologists monitoring the risk of HCQ/CQ-related retinal toxicity and those physicians treating COVID-19 infection.
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Affiliation(s)
- Massimo Nicolò
- IRCCS Ospedale Policlinico San Martino, University Eye Clinic of Genoa, Genova, Italy.
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genova, Italy.
- Macula Onlus Foundation, Genova, Italy.
| | - Lorenzo Ferro Desideri
- IRCCS Ospedale Policlinico San Martino, University Eye Clinic of Genoa, Genova, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genova, Italy
| | - Matteo Bassetti
- Infectious Diseases Clinic, Department of Health Sciences, University of Genova and Ospedale Policlinico San Martino- IRCCS Per L'Oncologia, Genova, Italy
| | - Carlo Enrico Traverso
- IRCCS Ospedale Policlinico San Martino, University Eye Clinic of Genoa, Genova, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genova, Italy
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8
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Ocular Findings in COVID-19 Patients: A Review of Direct Manifestations and Indirect Effects on the Eye. J Ophthalmol 2020; 2020:4827304. [PMID: 32963819 PMCID: PMC7491448 DOI: 10.1155/2020/4827304] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Accepted: 08/12/2020] [Indexed: 01/08/2023] Open
Abstract
The novel pandemic coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has challenged the medical community. While diagnostic and therapeutic efforts have been focused on respiratory complications of the disease, several ocular implications have also emerged. SARS-CoV-2 RNA has been found in tears of the infected patients, and reports suggest that the ocular surface could serve as a portal of entry and a reservoir for viral transmission. Clinically, COVID-19 has been associated with mild conjunctivitis, which can be the first and only symptom of the disease. Subtle retinal changes like hyperreflective lesions in the inner layers on optical coherence tomography (OCT), cotton-wool spots, and microhemorrhages have also been reported. In addition, COVID-19 has been associated with an increased incidence of systemic diseases like diabetes mellitus and Kawasaki disease, which are particularly relevant for ophthalmologists due to their potentially severe ocular manifestations. Several treatment strategies are currently under investigation for COVID-19, but none of them have been proved to be safe and effective to date. Intensive care unit patients, due to risk factors like invasive mechanical ventilation, prone position, and multiresistant bacterial exposure, may develop ocular complications like ocular surface disorders, secondary infections, and less frequently acute ischemic optic neuropathy and intraocular pressure elevation. Among the array of drugs that have shown positive results, the use of hydroxychloroquine and chloroquine has raised a concern due to their well-known retinal toxic effects. However, the risk of retinal toxicity with short-term high-dose use of antimalarials is still unknown. Ocular side effects have also been reported with other investigational drugs like lopinavir-ritonavir, interferons, and interleukin-1 and interleukin-6 inhibitors. The aim of this review was to summarize ophthalmological implications of SARS-CoV-2 infection to serve as a reference for eye care and other physicians for prompt diagnosis and management.
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9
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Michelson M, Chow T, Martin NA, Ross M, Tee Qiao Ying A, Minton S. Artificial Intelligence for Rapid Meta-Analysis: Case Study on Ocular Toxicity of Hydroxychloroquine. J Med Internet Res 2020; 22:e20007. [PMID: 32804086 PMCID: PMC7459430 DOI: 10.2196/20007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 06/15/2020] [Accepted: 07/22/2020] [Indexed: 11/23/2022] Open
Abstract
Background Rapid access to evidence is crucial in times of an evolving clinical crisis. To that end, we propose a novel approach to answer clinical queries, termed rapid meta-analysis (RMA). Unlike traditional meta-analysis, RMA balances a quick time to production with reasonable data quality assurances, leveraging artificial intelligence (AI) to strike this balance. Objective We aimed to evaluate whether RMA can generate meaningful clinical insights, but crucially, in a much faster processing time than traditional meta-analysis, using a relevant, real-world example. Methods The development of our RMA approach was motivated by a currently relevant clinical question: is ocular toxicity and vision compromise a side effect of hydroxychloroquine therapy? At the time of designing this study, hydroxychloroquine was a leading candidate in the treatment of coronavirus disease (COVID-19). We then leveraged AI to pull and screen articles, automatically extract their results, review the studies, and analyze the data with standard statistical methods. Results By combining AI with human analysis in our RMA, we generated a meaningful, clinical result in less than 30 minutes. The RMA identified 11 studies considering ocular toxicity as a side effect of hydroxychloroquine and estimated the incidence to be 3.4% (95% CI 1.11%-9.96%). The heterogeneity across individual study findings was high, which should be taken into account in interpretation of the result. Conclusions We demonstrate that a novel approach to meta-analysis using AI can generate meaningful clinical insights in a much shorter time period than traditional meta-analysis.
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Affiliation(s)
- Matthew Michelson
- Evid Science, El Segundo, CA, United States.,InferLink, El Segundo, CA, United States
| | | | - Neil A Martin
- Pacific Neuroscience Institute, Providence St John's Health Center, Santa Monica, CA, United States
| | - Mike Ross
- Evid Science, El Segundo, CA, United States
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10
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Jauregui R, Parmann R, Nuzbrokh Y, Tsang SH, Sparrow JR. Spectral-Domain Optical Coherence Tomography Is More Sensitive for Hydroxychloroquine-Related Structural Abnormalities Than Short-Wavelength and Near-Infrared Autofluorescence. Transl Vis Sci Technol 2020; 9:8. [PMID: 32879764 PMCID: PMC7442882 DOI: 10.1167/tvst.9.9.8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 06/26/2020] [Indexed: 12/30/2022] Open
Abstract
Purpose To analyze the appearance of structural abnormalities due to hydroxychloroquine (HCQ) toxicity by spectral-domain optical coherence tomography (SD-OCT) and short-wavelength autofluorescence (SW-AF) and near-infrared fundus autofluorescence (NIR-AF) imaging. Methods This retrospective cohort study included 88 eyes from 44 patients who had a history of or were currently taking HCQ. SD-OCT, SW-AF, and NIR-AF images were analyzed by two independent graders for the detection of HCQ-associated abnormalities. Results Sixty eyes (30 patients, 68%) presented with no abnormalities for either imaging modality. Twenty eyes (10 patients, 23%) presented with parafoveal abnormalities (ellipsoid zone attenuation and/or interdigitation zone continuity loss) in SD-OCT scans but with qualitatively normal SW-AF and NIR-AF images. Eight eyes (four patients, 9%) presented with bull's-eye maculopathy in SW-AF and NIR-AF images, with corresponding outer retinal structures disrupted parafoveally in SD-OCT scans ("flying saucer" sign). No patients presented with normal SD-OCT scans and concurrent abnormalities in SW-AF or NIR-AF images. Conclusions SD-OCT was more sensitive in detecting structural abnormalities than either SW-AF or NIR-AF imaging, suggesting its superiority as a screening imaging modality for HCQ toxicity. Maculopathy and abnormalities in the retinal pigment epithelium from HCQ toxicity can be appreciated in both SW-AF and NIR-AF images. Translational Relevance Although debate exists regarding the best imaging modalities for screening patients for potential HCQ toxicity, our study supports the use of SD-OCT over both SW-AF and NIR-AF imaging as a screening modality.
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Affiliation(s)
- Ruben Jauregui
- Department of Ophthalmology, Edward S. Harkness Eye Institute, Columbia University Medical Center, New York, NY, USA.,Jonas Children's Vision Care Laboratory, New York, NY, USA
| | - Rait Parmann
- Department of Ophthalmology, Edward S. Harkness Eye Institute, Columbia University Medical Center, New York, NY, USA.,Jonas Children's Vision Care Laboratory, New York, NY, USA
| | - Yan Nuzbrokh
- Department of Ophthalmology, Edward S. Harkness Eye Institute, Columbia University Medical Center, New York, NY, USA.,Jonas Children's Vision Care Laboratory, New York, NY, USA
| | - Stephen H Tsang
- Department of Ophthalmology, Edward S. Harkness Eye Institute, Columbia University Medical Center, New York, NY, USA.,Jonas Children's Vision Care Laboratory, New York, NY, USA.,Department of Pathology and Cell Biology, Columbia University Medical Center, New York, NY, USA
| | - Janet R Sparrow
- Department of Ophthalmology, Edward S. Harkness Eye Institute, Columbia University Medical Center, New York, NY, USA.,Jonas Children's Vision Care Laboratory, New York, NY, USA.,Department of Pathology and Cell Biology, Columbia University Medical Center, New York, NY, USA
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11
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Sharma M, Kumar M, Dutta D. Hydroxychloroquine in diabetes and dyslipidaemia: primum non nocere. Diabet Med 2020; 37:1404-1405. [PMID: 31557353 DOI: 10.1111/dme.14144] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/24/2019] [Indexed: 01/04/2023]
Affiliation(s)
- M Sharma
- Department of Rheumatology, CEDAR Superspeciality Clinics, Dwarka, New Delhi, India
| | - M Kumar
- Department of Endocrinology, CEDAR Superspeciality Clinics, Zirakpur, India
| | - D Dutta
- Department of Endocrinology, CEDAR Superspeciality Clinics, Dwarka, New Delhi, India
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12
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Downes SM, Leroy BP, Sharma SM, Sivaprasad S, Dollfus H. Hydroxychloroquine hitting the headlines-retinal considerations. Eye (Lond) 2020; 34:1158-1160. [PMID: 32427967 PMCID: PMC7236652 DOI: 10.1038/s41433-020-0934-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 04/24/2020] [Accepted: 04/24/2020] [Indexed: 02/07/2023] Open
Affiliation(s)
- Susan M Downes
- Oxford Eye Hospital, John Radcliffe Hospital, Oxford University NHS Foundation Trust, Oxford, UK.
- Nuffield Laboratory of Ophthalmology, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK.
| | - Bart P Leroy
- Department of Ophthalmology & Centre for Medical Genetics, Ghent University Hospital & Ghent University, Ghent, Belgium
- Division of Ophthalmology & Center for Cellular & Molecular Therapeutics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Srilakshmi M Sharma
- Oxford Eye Hospital, John Radcliffe Hospital, Oxford University NHS Foundation Trust, Oxford, UK
| | - Sobha Sivaprasad
- Moorfields Eye Hospital, London, UK
- Institute of Ophthalmology, London, UK
| | - Hélène Dollfus
- University Hospitals of Strasbourg, Strasbourg, France
- University of Strasbourg, Strasbourg, France
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13
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Defoort-Dhellemmes S. [Is there a need for ophthalmological surveillance in the case of short-term hydroxychloroquine treatment during this COVID-19 pandemic?]. J Fr Ophtalmol 2020; 43:548-549. [PMID: 32451138 PMCID: PMC7190467 DOI: 10.1016/j.jfo.2020.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 04/27/2020] [Indexed: 11/29/2022]
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14
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Mleeh NT, Alzahrani NA, Hariri JO, Mortada HH, Algethami MR. Dermatologists' Adherence to the Latest Recommendations for Screening of Hydroxychloroquine Retinopathy in Saudi Arabia: Cross-Sectional Study. Interact J Med Res 2019; 8:e15218. [PMID: 31855186 PMCID: PMC6940859 DOI: 10.2196/15218] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 10/14/2019] [Accepted: 10/22/2019] [Indexed: 12/17/2022] Open
Abstract
Background Hydroxychloroquine (HCQ) has been used to manage many inflammatory skin conditions. Nevertheless, retinopathy continues to be its most significant adverse effect. The American Academy of Ophthalmology (AAO) recommends baseline ophthalmologic screening in the first year of HCQ treatment. However, a recent study found an inadequate awareness of the recommendations. Furthermore, limited data are available regarding the implementation of the recommendations among dermatologists. Objective The aim of this study was to assess dermatologists’ adherence to recommendations pertaining to their current practice regarding HCQ toxicity detection. Methods A self-administrated questionnaire was distributed between February 2 and May 4, 2018, among members of the Saudi Society of Dermatology. The questionnaire comprised demographic-related questions and questions pertaining to each physician’s routine practice about the follow-up of HCQ-treated patients. Results A total of 76 dermatologists completed the questionnaire. We achieved a response rate of 62.54%. More than half (43/76, 56%) of the dermatologists were male. Furthermore, more than half (41/76, 53%) of them reported treating 1 to 3 patients with HCQ during the last year. Furthermore, two-thirds (47/76, 61%) of them reported screening patients before initiating HCQ treatment. Regarding follow-up recommendations, 59% (45/76) of dermatologists reported yearly after starting treatment for no-risk patients, whereas 94% (72/76) reported “yearly within 5 years of treatment” for at-risk patients. Data were considered significant at P<.05. All analyses were performed using SPSS, version 20 (IBM). Conclusions Dermatologists in Saudi Arabia are not well informed about some aspects of the latest recommendations regarding screening for HCQ toxicity in terms of tests, follow-up timing, cessation of the drug, and causative agents. Therefore, we recommend conducting more studies in Saudi Arabia to determine the adherence of more physicians to the AAO recommendations. Furthermore, patient education regarding HCQ toxicity and increased patient awareness are recommended for effective and safe HCQ use.
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Affiliation(s)
- Nouf Talal Mleeh
- Department of Dermatology, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | | | - Jehad Osama Hariri
- Department of Dermatology, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
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Thomas DE, Lyons JS, Greene BS, Petri MA. Low hydroxychloroquine blood levels in patients who have had gastric bypass surgery. Lupus Sci Med 2019; 6:e000335. [PMID: 31275579 PMCID: PMC6577310 DOI: 10.1136/lupus-2019-000335] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 05/07/2019] [Accepted: 05/25/2019] [Indexed: 11/04/2022]
Abstract
Gastric bypass surgery, also called Roux-en-Y gastric bypass (RYGB), can result in the malabsorption of medications, requiring the use of higher than usual doses in order to achieve a therapeutic effect. We describe the results of hydroxychloroquine (HCQ) blood levels in three patients with systemic autoimmune disease taking standard HCQ doses and their associated disease activity levels. This is a retrospective review of all patients who had undergone RYGB and were taking HCQ in a rheumatology community-based practice. Two patients with SLE and one patient with primary Sjogren's syndrome had previously undergone RYGB. All three had subtherapeutic HCQ blood levels and active disease. Increasing their HCQ doses above the recommended 400 mg a day dosing resulted in therapeutic HCQ levels in all three patients and better disease control in two of the three patients. RYGB patients may not absorb HCQ adequately, resulting in subtherapeutic HCQ blood levels and inadequate disease control. Patients who have undergone RYGB and are taking HCQ should have drug levels monitored. RYGB patients may require higher than recommended doses of HCQ in order to achieve better disease control and avoid unneeded additional immunosuppressive agents.
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Affiliation(s)
- Donald E Thomas
- Practice Partner, Arthritis and Pain Associates of Prince George's County, Greenbelt, Maryland, USA
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Jonathan S Lyons
- Department of Ophthalmology, Georgetown University, Washington, District of Columbia, USA
| | - Barry S Greene
- Practice Partner, Advanced Weight Loss Surgery, Rockville, Maryland, USA
| | - Michelle A Petri
- Department of Rheumatology, Johns Hopkins Medicine, Baltimore, Maryland, USA
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16
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Nti AA, Serrano LW, Sandhu HS, Uyhazi KE, Edelstein ID, Zhou EJ, Bowman S, Song D, Gangadhar TC, Schuchter LM, Mitnick S, Huang A, Nichols CW, Amaravadi RK, Kim BJ, Aleman TS. FREQUENT SUBCLINICAL MACULAR CHANGES IN COMBINED BRAF/MEK INHIBITION WITH HIGH-DOSE HYDROXYCHLOROQUINE AS TREATMENT FOR ADVANCED METASTATIC BRAF MUTANT MELANOMA: Preliminary Results From a Phase I/II Clinical Treatment Trial. Retina 2019; 39:502-513. [PMID: 29324592 PMCID: PMC6039280 DOI: 10.1097/iae.0000000000002027] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE To assess the potential ocular toxicity of a combined BRAF inhibition (BRAFi) + MEK inhibition (MEKi) + hydroxychloroquine (HCQ) regime used to treat metastatic BRAF mutant melanoma. METHODS Patients with stage IV metastatic melanoma and BRAF V600E mutations (n = 11, 31-68 years of age) were included. Treatment was with oral dabrafenib, 150 mg bid, trametinib, 2 mg/day, and HCQ, 400 mg to 600 mg bid. An ophthalmic examination, spectral domain optical coherence tomography, near-infrared and short-wavelength fundus autofluorescence, and static perimetry were performed at baseline, 1 month, and q/6 months after treatment. RESULTS There were no clinically significant ocular events; there was no ocular inflammation. The only medication-related change was a separation of the photoreceptor outer segment tip from the apical retinal pigment epithelium that could be traced from the fovea to the perifoveal retina noted in 9/11 (82%) of the patients. There were no changes in retinal pigment epithelium melanization or lipofuscin content by near-infrared fundus autofluorescence and short-wavelength fundus autofluorescence, respectively. There were no inner retinal or outer nuclear layer changes. Visual acuities and sensitivities were unchanged. CONCLUSION BRAFi (trametinib) + MEKi (dabrafenib) + HCQ causes very frequent, subclinical separation of the photoreceptor outer segment from the apical retinal pigment epithelium without inner retinal changes or signs of inflammation. The changes suggest interference with the maintenance of the outer retinal barrier and/or phagocytic/pump functions of the retinal pigment epithelium by effective MEK inhibition.
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Affiliation(s)
- Akosua A. Nti
- Department of Ophthalmology, Scheie Eye Institute at the Perelman Center for Advanced Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Leona W. Serrano
- Department of Ophthalmology, Scheie Eye Institute at the Perelman Center for Advanced Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Harpal S. Sandhu
- Department of Ophthalmology, Scheie Eye Institute at the Perelman Center for Advanced Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Katherine E. Uyhazi
- Department of Ophthalmology, Scheie Eye Institute at the Perelman Center for Advanced Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ilaina D. Edelstein
- Department of Ophthalmology, Scheie Eye Institute at the Perelman Center for Advanced Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Elaine J. Zhou
- Department of Ophthalmology, Scheie Eye Institute at the Perelman Center for Advanced Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Scott Bowman
- Department of Ophthalmology, Scheie Eye Institute at the Perelman Center for Advanced Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Delu Song
- Department of Ophthalmology, Scheie Eye Institute at the Perelman Center for Advanced Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Tara C. Gangadhar
- Department of Medicine, Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lynn M. Schuchter
- Department of Medicine, Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sheryl Mitnick
- Department of Medicine, Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alexander Huang
- Department of Medicine, Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Charles W. Nichols
- Department of Ophthalmology, Scheie Eye Institute at the Perelman Center for Advanced Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ravi K. Amaravadi
- Department of Medicine, Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Benjamin J. Kim
- Department of Ophthalmology, Scheie Eye Institute at the Perelman Center for Advanced Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Tomas S. Aleman
- Department of Ophthalmology, Scheie Eye Institute at the Perelman Center for Advanced Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Ophthalmology Center for Advanced Retinal and Ocular Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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17
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Affiliation(s)
- Michael F Marmor
- Department of Ophthalmology, Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California
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18
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Ahn SJ, Lee BR. Hydroxychloroquine Retinopathy Update. JOURNAL OF RHEUMATIC DISEASES 2018. [DOI: 10.4078/jrd.2018.25.3.153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Seong Joon Ahn
- Department of Ophthalmology, Hanyang University Seoul Hospital, Hanyang University College of Medicine, Seoul, Korea
| | - Byung Ro Lee
- Department of Ophthalmology, Hanyang University Seoul Hospital, Hanyang University College of Medicine, Seoul, Korea
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19
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Mise à jour des recommandations sur la toxicité rétinienne des antipaludéens de synthèse. J Fr Ophtalmol 2017; 40:793-800. [DOI: 10.1016/j.jfo.2017.08.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 08/08/2017] [Accepted: 08/21/2017] [Indexed: 11/21/2022]
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20
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Updated recommendations on the use of hydroxychloroquine in dermatologic practice. J Am Acad Dermatol 2017; 76:1176-1182. [PMID: 28318681 DOI: 10.1016/j.jaad.2017.01.012] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 01/02/2017] [Accepted: 01/04/2017] [Indexed: 12/27/2022]
Abstract
Hydroxychloroquine has unique immunomodulatory properties and an attractive adverse effect profile. Over the past 10 years, research has led to significant updates in clinical recommendations concerning the optimal use of hydroxychloroquine and monitoring of patients taking it. We discuss updated recommendations concerning hydroxychloroquine daily dosing, retinopathy screening, serologic monitoring, use in smokers, use in pregnant women, and adverse effect risk and monitoring. This review can hopefully serve as an aid to dermatologists and help ensure they continue using hydroxychloroquine safely and effectively.
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21
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Yusuf IH, Sharma S, Luqmani R, Downes SM. Hydroxychloroquine retinopathy. Eye (Lond) 2017; 31:828-845. [PMID: 28282061 DOI: 10.1038/eye.2016.298] [Citation(s) in RCA: 153] [Impact Index Per Article: 21.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Accepted: 08/24/2016] [Indexed: 12/16/2022] Open
Abstract
Hydroxychloroquine (HCQ; Plaquenil) is used increasingly in the management of a variety of autoimmune disorders, with well established roles in dermatology and rheumatology and emerging roles in oncology. Hydroxychloroquine has demonstrated a survival benefit in patients with systemic lupus erythematosus; some clinicians advocate its use in all such patients. However, Hydroxychloroquine and chloroquine (CQ) have been associated with irreversible visual loss due to retinal toxicity. Hydroxychloroquine retinal toxicity is far more common than previously considered; an overall prevalence of 7.5% was identified in patients taking HCQ for greater than 5 years, rising to almost 20% after 20 years of treatment. This review aims to provide an update on HCQ/CQ retinopathy. We summarise emerging treatment indications and evidence of efficacy in systemic disease, risk factors for retinopathy, prevalence among HCQ users, diagnostic tests, and management of HCQ retinopathy. We highlight emerging risk factors such as tamoxifen use, and new guidance on safe dosing, reversing the previous recommendation to use ideal body weight, rather than actual body weight. We summarise uncertainties and the recommendations made by existing HCQ screening programmes. Asian patients with HCQ retinopathy may demonstrate an extramacular or pericentral pattern of disease; visual field testing and retinal imaging should include a wider field for screening in this group. HCQ is generally safe and effective for the treatment of systemic disease but because of the risk of HCQ retinal toxicity, modern screening methods and ideal dosing should be implemented. Guidelines regarding optimal dosing and screening regarding HCQ need to be more widely disseminated.
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Affiliation(s)
- I H Yusuf
- The Oxford Eye Hospital, West Wing, John Radcliffe Hospital, Oxford, UK
| | - S Sharma
- The Oxford Eye Hospital, West Wing, John Radcliffe Hospital, Oxford, UK
| | - R Luqmani
- Department of Rheumatology, Nuffield Orthopaedic Centre, Oxford, UK
| | - S M Downes
- The Oxford Eye Hospital, West Wing, John Radcliffe Hospital, Oxford, UK
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22
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Garza-Leon M, Flores-Alvarado DE, Muñoz-Bravo JM. Toxicidad retiniana asociada al uso de medicamentos antipalúdicos: revisión de la literatura y presentación de un caso. Medwave 2016; 16:e6471. [DOI: 10.5867/medwave.2016.05.6471] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 06/03/2016] [Indexed: 11/27/2022] Open
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23
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Marmor MF, Kellner U, Lai TYY, Melles RB, Mieler WF. Recommendations on Screening for Chloroquine and Hydroxychloroquine Retinopathy (2016 Revision). Ophthalmology 2016; 123:1386-94. [PMID: 26992838 DOI: 10.1016/j.ophtha.2016.01.058] [Citation(s) in RCA: 708] [Impact Index Per Article: 88.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Revised: 01/28/2016] [Accepted: 01/28/2016] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The American Academy of Ophthalmology recommendations on screening for chloroquine (CQ) and hydroxychloroquine (HCQ) retinopathy are revised in light of new information about the prevalence of toxicity, risk factors, fundus distribution, and effectiveness of screening tools. PATTERN OF RETINOPATHY Although the locus of toxic damage is parafoveal in many eyes, Asian patients often show an extramacular pattern of damage. DOSE: We recommend a maximum daily HCQ use of ≤5.0 mg/kg real weight, which correlates better with risk than ideal weight. There are no similar demographic data for CQ, but dose comparisons in older literature suggest using ≤2.3 mg/kg real weight. RISK OF TOXICITY The risk of toxicity is dependent on daily dose and duration of use. At recommended doses, the risk of toxicity up to 5 years is under 1% and up to 10 years is under 2%, but it rises to almost 20% after 20 years. However, even after 20 years, a patient without toxicity has only a 4% risk of converting in the subsequent year. MAJOR RISK FACTORS High dose and long duration of use are the most significant risks. Other major factors are concomitant renal disease, or use of tamoxifen. SCREENING SCHEDULE A baseline fundus examination should be performed to rule out preexisting maculopathy. Begin annual screening after 5 years for patients on acceptable doses and without major risk factors. SCREENING TESTS The primary screening tests are automated visual fields plus spectral-domain optical coherence tomography (SD OCT). These should look beyond the central macula in Asian patients. The multifocal electroretinogram (mfERG) can provide objective corroboration for visual fields, and fundus autofluorescence (FAF) can show damage topographically. Modern screening should detect retinopathy before it is visible in the fundus. TOXICITY Retinopathy is not reversible, and there is no present therapy. Recognition at an early stage (before any RPE loss) is important to prevent central visual loss. However, questionable test results should be repeated or validated with additional procedures to avoid unnecessary cessation of valuable medication. COUNSELING Patients (and prescribing physicians) should be informed about risk of toxicity, proper dose levels, and the importance of regular annual screening.
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Affiliation(s)
- Michael F Marmor
- Department of Ophthalmology and Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California
| | - Ulrich Kellner
- Zentrum für Seltene Netzhauterkrankungen, AugenZentrum Siegburg, Siegburg, Germany
| | - Timothy Y Y Lai
- Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Kowloon, Hong Kong
| | - Ronald B Melles
- Department of Ophthalmology, Kaiser Permanente, Redwood City Medical Center, Redwood City, California
| | - William F Mieler
- Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois, Chicago, Illinois
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