SAT0222 Clinical risk stratification for hydroxychloroquine prescribing in a large urban district general hospital

Abstract

Background:New 2017 British Society of Rheumatology guidelines have recommended baseline formal ophthalmic examination, ideally including objective retinal assessment for example using optical coherence tomography, within 1 year of commencing an antimalarial drug. While the feasibility and costing of this recommendation is being assessed, we audited the current risk assessment for hydroxychloroquine prescriptions (HCQ) against the American College of Ophthalmology (ACO) guidelines for HCQ published in 2016. Table 1 shows the clinical criteria for assessment.Methods:We identified all prescriptions of HCQ documented on the electronic patient records (EPR) from January to September 2017 by the Rheumatology department of Croydon University Hospital. This generated 237 records of which 114 were new prescriptions and 117 were continuation prescriptions. 8 records were excluded due to inadequate patient compliance. Cumulative doses were estimated from dates in the EPR going back to 2013Results:New patient records were assessed for compliance with the ACO guidelines. Patients were assessed for kidney function, pre-existing renal disease, pre- existing eye disease. 74.6% patients were counselled regarding side effects and were advised to have optician retinal screening and 3.5% who had pre-existing eye disease were referred to ophthalmologists. 50.0% of patients had their weight documented prior to prescription. There was no documentation of dose calculated by weight. The commonest indication for HCQ were Systemic Lupus Erythmatosis, Inflammatory Arthritis and Sjogren’s Syndrome. 13.2 % discontinued HCQ due to side effects. The commonest side effects were diarrhoea, dizziness, rashes, and mood swings.Long- term patient records were assessed for cumulative dose of HCQ estimated from documentation. The average cumulative dose for these patients was with a maximum of 810,000 mg and a minimum of 49,600 mg. Overall, 3.0% percentage of patients did not have cumulative doses calculated due to documented compliance issues and 64.0% of patients had tightly monitored renal function.Table 1Clinical criteria for HCQ risk assessment based on American College of Ophthalmology guidelines (2016)Conclusions:50% of patients had weight documented prior to prescription and this was not used to determine dosage. The majority of patients were well informed regarding side-effects of HCQ, had tightly monitored renal function and advised to have baseline retinal screening.Disclosure of Interest:None declared

Hydroxychloroquine retinal toxicity- Can we do better with SD-OCT?

“…17 Another study also revealed that half of the patients had weight documented before prescription but not used to determine the doses. 18 Further, a safe dose of 5mg/kg real bodyweight places short, obese patients at unnecessarily increased risk for retinopathy. 20 It is also not uncommon that patients may develop renal disease or experience weight loss (and a higher dose) after 1 year and these patients will probably not realize they are high risk and will go without follow-up for 4 more years.…”

“…Generally, all the patients having good visual acuity and vision remain unchanged for the period of this study except the 3 patients with 6/12 visual acuity who improved with glasses prescription and/or artificial tears. RCOphth, 1993 14 RCOphth, 1998 15 AAO, 2002 16 RCOphth, 2004 17 RCOphth, 2009 18 AAO, 2011 19 AAO, 2017 20 RCOphth, 2018 21 Recommended dosage 6.5 mg/kg lean weight 6.5 mg/kg lean weight 6.5 mg/kg lean weight 6.5 mg/kg lean weight 6.5 mg/kg lean weight 6.5 mg/kg lean weight 5.0 mg/kg real weight Comparing the central macular thickness and optic disc retinal nerve fiber layer thickness (RNFL) using Cirrus SD-OCT in patients with connective tissue diseases on hydroxychloroquine pre-treatment, 3 months, and 6 months post-treatment.…”