Researchers Debate Hydroxychloroquine Dosing in SLE

James T. Rosenbaum, MD, and Michelle Petri, MD, discussed whether hydroxychloroquine dosing should be adjusted to more than 5mg/kg in patients with SLE.
James T. Rosenbaum, MD, and Michelle Petri, MD, discussed whether hydroxychloroquine dosing should be adjusted to more than 5mg/kg in patients with SLE.

The following article is part of conference coverage from the 2018 American College of Rheumatology and Association of Rheumatology Health Professionals (ACR/ARHP) Annual Meeting in Chicago, Illinois. MPR's staff will be reporting breaking news associated with research conducted by leading experts in rheumatology. Check back for the latest news from ACR/ARHP 2018 .

CHICAGO – The 2018 ACR/ARHP Annual Meeting featured a debate that examined whether hydroxychloroquine (HCQ) dosing should be more than 5mg/kg in patients with systemic lupus erythematosus (SLE).1

HCQ is currently the major immunomodulatory agent used to treat SLE, but newer screening techniques, such as optical coherence tomography (OCT), have raised concern regarding possible eye toxicity. Current 2016 guidelines from the American Academy of Ophthalmology state that HCQ  dosing should be based on actual weight, rather than ideal weight, and that the safe daily dose is no more than 5mg/kg.2 The recommendations also state that patients should receive a baseline retinal exam and then should be screened annually at 5 years.

James T. Rosenbaum, MD, Oregon Health & Science University, argued that HCQ is a safe and valuable medication if it is monitored appropriately.

Dr Rosenbaum noted that the American Academy of Ophthalmology first issued the guidelines to monitor HCQ in 2002 in order to be less restrictive than the Physicians' Desk Reference recommendation to perform an eye exam on patients receiving HCQ every 3 months. He added that the 2016 guidelines were based on data regarding retinal toxicity that had been published in JAMA Ophthalmology in 2014, and that some recent research has shown cardiac complications attributed to HCQ .3,4

"Antimalarials are a valuable part of a rheumatologist's therapeutic armamentarium, and they have a very low rate of toxicity if appropriate guidelines are followed," Dr Rosenbaum told the attendees.

Michelle Petri, MD, Johns Hopkins University School of Medicine and John Hopkins Hospital in Baltimore, Maryland, countered that the guidelines are not appropriate, noting that HCQ has been shown to improve survival and prevent thrombosis in patients with SLE. She added that when patients hear about the risks of renal toxicity, they are less likely to be adherent to their medication.

Dr Petri noted that she still uses up to 6.5 mg/kg HCQ, in accordance with the 2002 guidelines from the American Academy of Ophthalmology, but not more than 400 mg. In addition, dose should be reduced for renal insufficiency, renal failure, liver disease, and among the elderly.

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Dr Petri also noted that there is a clinical benefit in monitoring blood levels.

"I am protective of HCQ because I am protective of my patients," Dr Petri stated. "The important message should be that HCQ is the most important medication we have for lupus. HCQ is the only medication that improves survival."

Drs Rosenbaum and Petri both emphasized that screening and follow-up guidelines for renal toxicity should be strictly adhered to among patients with SLE. "What I want to do is to have a more collegial relationship when we're talking about [HCQ] dosing," Dr Petri noted.

Dr Rosenbaum agreed that the formulation of the guidelines should be more collaborative, concluding that "Rheumatologists need a seat at the table and the guidelines should be formulated with rheumatologists and ophthalmologists sitting together in the same room."

For more coverage of ACR/ARHP 2018, click here.

Reference

  1. Costedoat-Chalumeau N, Petri M, Rosenbaum JT. ACR: The great debate: guidelines for SLE: HCQ dose should be no more than 5 mg/kg in all patients. Presented at: 2018 ACR/ARHP Annual Meeting; October 19-24, 2018; Chicago, IL. Scientific Sessions 3S092.
  2. Mamor MF, Kellner U, Lai TY, Melles RB, Mieler WF; for the American Academy of Ophthalmology. Recommendations on screening for chloroquine and hydroxychloroquine retinopathy (2016 revision). Ophthalmology. 2016;123(6):1386-94.
  3. Melles RB, Marmor MF. The risk of toxic retinopathy in patients on long-term hydroxychloroquine therapy. JAMA Ophthalmol. 2014;132(12):1453-1460.
  4. Chatre C, Roubille F, Vernhet H, Jorgensen C, Pers YM. Cardiac complications attributed to chloroquine and hydroxychloroquine: a systematic review of the literature. Drug Saf. 2018;41(10):919-931.

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