Hydroxychloroquine treatment in European patients with lupus erythematosus: dosing, retinopathy screening and adherence

Abstract

BackgroundUse of hydroxychloroquine (HCQ) is common in patients with lupus erythematosus. Long-term use (ie, ≥5 years) and high-dose HCQ (ie, >5 mg/kg/day) are both risk factors for developing HCQ retinopathy. Advances in our understanding of HCQ retinopathy have led to changes in the recommendations for HCQ dosing and retinopathy screening. The latest EULAR guidelines for the management of SLE recommend a maximum HCQ dose of 5 mg/kg/day and ophthalmological screening at baseline and annually after 5 years of HCQ treatment.ObjectivesThis study aimed to assess whether the EULAR guidelines are affecting HCQ prescription patterns and screening frequencies in Europe. Furthermore, we inventoried adherence to HCQ.ResultsThe online questionnaire was completed by 2936 patients with systemic, cutaneous or juvenile lupus from 33 countries. The majority were female (86.5%) and diagnosed with SLE (81.2%). Among those taking HCQ, the median HCQ dose reported was 4.26 mg/kg/day. More than one-third of respondents (36.8%) exceeded the recommended maximal HCQ dose of 5 mg/kg/day. Baseline ophthalmological screening had been done in 857 out of 1017 respondents diagnosed in the past 10 years (84.3%). Of patients using HCQ ≥5 years, 69.2% reported yearly retinopathy screening. Lastly, 17.3% of patients reported that they skipped HCQ once a week or more often.ConclusionThe results of our study demonstrate that higher than recommended dosages of HCQ are prescribed to more than one-third of patients with lupus in Europe. Recent recommendations regarding screening for retinopathy are incompletely implemented.

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“…Both chloroquine (CQ) and hydroxychloroquine (HCQ) have shown effectiveness in slowing the development of these diseases with minimal and reversible toxicity, particularly when used for a short period of time. The tolerability of CQ/HCQ and its low cost and immunomodulatory effects means that it may be used to treat viral infections and their inflammatory response 38 .…”

Systemischer Lupus erythematodes und Lupusnephritis: neue Therapiestrategien

“…Es gibt einen klaren Nutzen bei relativ geringen Risiken, die jedoch mit der Dauer der Therapie zunehmen. Eine im Jahr 2021 veröffentlichte Studie zur Behandlung des SLE mit HCQ in Europa zeigte jedoch, dass die Therapieempfehlungen der EULAR für HCQ bisher zu unzureichend umgesetzt werden (nur 67 % der Patient*innen mit SLE erhalten HCQ) [10].…”

An update on the management of refractory cutaneous lupus erythematosus

“…The first-line systemic treatment for all types of CLE includes antimalarials, namely hydroxychloroquine (HCQ), chloroquine (CQ) and quinacrine (Q), with HCQ being the most studied and used agent even in pregnancy and pediatric patients. However, long-term use (i.e., ≥ 5 years) and high-dose HCQ (i.e., > 5 mg/kg/day) are both risk factors for the development of HCQ retinopathy (19). Accordingly, dose should be calculated on body weight with a maximum daily dose of 5 mg/kg of real bodyweight for HCQ and 2.3 mg/kg of real bodyweight for CQ to reduce side effects.…”

“…In both Europe and the USA, HCQ is often prescribed as 200 mg film-coated tablets, while 100 mg HCQ tablets are available in China, not yet approved by the US FDA. The most commonly reported daily dose of HCQ was 400 mg. An inappropriate dose of antimalarials could be one of the reasons for refractory skin manifestations (19). Antimalarials are also burdened by low therapeutic adherence (20)(21)(22), especially in younger patients and in patients not convinced of the efficacy of antimalarials in the management of their disease (19).…”

“…The most commonly reported daily dose of HCQ was 400 mg. An inappropriate dose of antimalarials could be one of the reasons for refractory skin manifestations (19). Antimalarials are also burdened by low therapeutic adherence (20)(21)(22), especially in younger patients and in patients not convinced of the efficacy of antimalarials in the management of their disease (19). In fact, 17.3% of CLE patients skip HCQ once a week or more often.…”