Hydroxychloroquine Management in Rheumatic Diseases

Rationale for Continuing Hydroxychloroquine

The American College of Rheumatology recommends hydroxychloroquine for all patients with rheumatic diseases due to its beneficial effects, including reduction in disease flares, prevention of organ damage accrual, decreased thrombotic events, and improved long-term survival 3, 4
Hydroxychloroquine reduces the risk of lupus flares by 2.5-fold compared to discontinuation, including prevention of renal flares 4
The medication allows for reduction of corticosteroid doses, minimizing their harmful effects and preventing irreversible organ damage 3, 4
Hydroxychloroquine improves cardiovascular outcomes, lipid profiles, and bone preservation 4

At 200mg daily, the patient is likely well below the recommended maximum dose of 5.0 mg/kg real body weight, which correlates with very low toxicity risk 5, 6
The risk of retinopathy at recommended doses is under 1% up to 5 years and under 2% up to 10 years 5
Even after 20 years of use at proper dosing, a patient without toxicity has only a 4% risk of converting to toxicity in the subsequent year 5

The American College of Rheumatology recommends that hydroxychloroquine should not be stopped until evidence of retinopathy is definitive, particularly in patients with active rheumatic or cutaneous disease 1, 2
Questionable or borderline screening findings should be rechecked after a few months or validated with additional procedures before discontinuation 1, 2

Annual screening should begin after 5 years of therapy for patients on acceptable doses without major risk factors 5
Primary screening tests are spectral-domain OCT and automated visual fields (10-2 protocols), which can detect damage before it becomes visible on fundoscopy 2, 5
Modern screening should detect retinopathy at an early stage (before RPE loss) when damage can stabilize without serious visual loss if the drug is discontinued 2, 5

Leflunomide is an alternative immunosuppressive agent that may be considered when hydroxychloroquine is contraindicated or when additional disease control is needed 3
However, leflunomide is not a replacement for hydroxychloroquine but rather an adjunctive therapy 3

Continue hydroxychloroquine 200mg daily with appropriate annual ophthalmologic screening after 5 years of therapy (or earlier if risk factors present) 5, 7
Ensure screening includes spectral-domain OCT and automated visual fields performed by practitioners experienced in detecting hydroxychloroquine toxicity 2, 5
Consider adding leflunomide or other immunosuppressive agents only if disease activity is inadequately controlled, not as a replacement for hydroxychloroquine 3
Maintain open communication between ophthalmology and rheumatology to ensure coordinated care and appropriate interpretation of screening results 1, 2