Clinical Audit of Hydroxychloroquine Dosing and Toxicity Screening in Rheumatology Patients


A. Hollywood, C. Drislane, L. Nestor, B. O'Shea, M. Doran, A. Doyle, B. Wynne, R. Conway


Rheumatology Department St. James's Hospital Dublin Dermatology Department St James's Hospital Dublin Ophthalmology Department St James's Hospital Dublin


Hydroxychloroquine (HCQ) is used widely in treating various long-term inflammatory disorders of the joints and skin. HCQ has an excellent safety profile, however, some patients taking HCQ can develop hydroxychloroquine retinopathy resulting in permanent loss of vision. Recent publications have shown that HCQ associated retinal toxicity is not as rare as previously thought, with prevalence in a large demographic study reported at 7.5%. The risk of toxicity was greatly dependent on dosage and duration of use. The American Academy of Ophthalmology and the Royal College of Ophthalmologists have recently revised their guidelines with regard to screening and dosage recommendations to reflect this new evidence.


We wished to assess HCQ prescribing and retinal toxicity monitoring
practices in our department


A clinical audit was conducted in the rheumatology department of St James’s Hospital. Audit standards were based on the Royal College of Ophthalmologists recommendations. Best practice standards included appropriate weight-based dosing of HCQ, baseline visual exam, and appropriate monitoring for retinal toxicity. We audited using a standardised screening form.


23 patients were recruited, 89.4% were female with a mean age of 48 years. Patients were on HCQ for a mean duration of 5.8 years and 74% were aware of the associated adverse effects of HCQ. Regarding dosing, 87% were on an appropriate dose of HCQ and 48% had their weight recorded. Regarding retinal toxicity screening, 56.5% had an eye screen at some stage during treatment. However, 47.8% had been on therapy for greater than five years of which, 45% had undergone an eye screen within the prior 12 months. Taking this into consideration, 43.5% of the sample met current screening recommendations for ocular toxicity.


This study highlights that current guidelines for appropriately dosing HCQ and monitoring for retinopathy are not being met. The current system can be improved and the next step is to develop a combined institutional protocol for HCQ screening.