Adherence to Weight‐Based Dosing Guidelines in Patients Receiving Hydroxychloroquine for Systemic Lupus Erythematosus and Rheumatoid Arthritis: Results of a Quality Improvement Initiative

Abstract

Objective Hydroxychloroquine (HCQ) is commonly prescribed for the treatment of systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), and other rheumatic diseases. To limit retinal toxicity, the 2016 American Academy of Ophthalmology (AAO) guidelines recommended limiting the HCQ dose to 5 mg/kg/day or less. Our objective was to develop a quality improvement program to improve adherence to these guidelines. Methods We performed a retrospective analysis of 801 adult patients receiving HCQ for SLE and RA in a single academic rheumatology practice. In 2018, we calculated weight‐based doses of HCQ at two time points at least 6 months apart. We surveyed provider opinions regarding the 2016 AAO guidelines and implemented a quality improvement intervention during which dosing data were shared with all prescribers (individually and in aggregate) and nurse‐aided decision support was provided for HCQ refill requests. One year after the initial analysis and intervention, we again assessed weight‐based doses of HCQ for the 674 patients still taking HCQ. Results At both measured time points during 2018, 22.8% of patients received doses greater than 5 mg/kg/day. For 60% of those patients, the dose of HCQ was reduced to 5 mg/kg/day or less by the study end. Between the second time point in 2018 and the postintervention time point in 2019, there was a statistically significant increase in the proportion of patients receiving of dose of 5 mg/kg/day or less (from 74% to 87%; P < 0.0001). Conclusion We observed a significant increase in adherence with current AAO guidelines for weight‐based HCQ dosing after providing feedback to providers regarding their prescribing data and reviewing weight‐based dosing prior to refilling prescriptions.

Hydroxychloroquine Screening Guidelines: Best Evidence, Controversies, and Future Areas of Research

“…These revised guidelines spurred a significant dose reduction for many patients as prior de facto dosing was frequently 400 mg daily. 29 ' Evolution of Screening Guidelines: The Benefits and Tradeoffs of Each Screening Recommendation HCQ is 40% to 60% renally excreted, 8% to 25% excreted through the gastrointestinal system, and 25% to 45% of HCQ is stored long term in lean body tissues and not fat. Thus, dosing should theoretically be based on lean body mass using ideal body weight (IBW).…”

“…When considering the impact of the current recommendations on dose, consider the example of a 132 lb (60 kg) patient on 300 mg per day; this amounts to 5 mg/kg/d. These revised guidelines spurred a significant dose reduction for many patients as prior de facto dosing was frequently 400 mg daily 29 …”

Trends and practices following the 2016 hydroxychloroquine screening guidelines

“…HCQ can cause retinal toxicity, a rare but well-recognized complication from its long-term use 6 . While the mechanism is not fully understood, it is known that HCQ is deposited in tissues that have a high melanin content, such as skin and the retinal pigment epithelium (RPE) 7 .…”