Hydroxychloroquine Monitoring Recommendations

Ophthalmologic Monitoring

The American Academy of Ophthalmology recommends a baseline fundus examination within the first year of starting hydroxychloroquine to rule out preexisting maculopathy 1, 2
For patients on acceptable doses without major risk factors, the American College of Rheumatology recommends annual screening can be deferred until after 5 years of hydroxychloroquine use 1, 3
Annual screening should include automated visual fields and spectral-domain optical coherence tomography (SD-OCT) for patients on hydroxychloroquine therapy 1, 2

The American College of Rheumatology conditionally recommends annual complete blood count (CBC) and liver function tests (LFTs) for patients on hydroxychloroquine therapy 4, 5, 6

High daily dose (>5.0 mg/kg of actual body weight) is a risk factor for retinal toxicity in patients on hydroxychloroquine therapy 1, 3
Long duration of use (>5 years) is a risk factor for retinal toxicity in patients on hydroxychloroquine therapy 1, 3
Asian descent (may show extramacular pattern of damage) is a risk factor for retinal toxicity in patients on hydroxychloroquine therapy 1, 2

The maximum recommended daily dose is 5.0 mg/kg of actual body weight to minimize the risk of toxicity 1, 3
At recommended doses, the risk of toxicity is under 1% in the first 5 years of therapy, under 2% up to 10 years, and increases to almost 20% after 20 years 1, 7

Retinopathy is not reversible, and there is no present therapy, emphasizing the importance of early detection 1
Visual acuity usually remains excellent until severe stages of damage, highlighting the need for regular screening 7, 8
Questionable test results should be repeated or validated with additional procedures to avoid unnecessary cessation of valuable medication 1, 3

In pediatric patients, the American College of Rheumatology recommends yearly screening rather than waiting 5 years between baseline and subsequent annual screening 4, 5

Patients and prescribing physicians should be informed about the risk of toxicity, proper dose levels, and the importance of regular screening 1, 3

The European League Against Rheumatism (EULAR) recommends a dose of 6.5 mg/kg/day or 400 mg/day (the lower of the two) for patients with lupus, to minimize the risk of retinopathy 9, 10
Patients with severe renal insufficiency (DFG <30 ml/min) should have their dose reduced by 25% 9, 10
Annual monitoring of complete blood count and liver function tests is recommended for all patients on long-term hydroxychloroquine treatment, according to the American College of Rheumatology 11, 12
The American College of Rheumatology recommends against delaying treatment while waiting for a baseline ophthalmologic examination 11, 12

The American College of Rheumatology recommends annual retinal screening for children starting from the beginning of hydroxychloroquine treatment, due to concerns about cumulative and developmental effects 11, 12
Children may receive treatment for extended periods and may not be able to articulate their visual concerns, making regular screening essential 11, 12

In adults receiving hydroxychloroquine whose estimated glomerular filtration rate (eGFR) is ≥ 30 mL/min/1.73 m², routine dose reduction is not required; standard dosing can be continued (American Journal of Kidney Diseases, 2014) 13