Wide variation in prescription and dosing patterns for hydroxychloroquine in SLE

EULAR guidelines concerning long-term use of hydroxychloroquine in systemic lupus erythematosus (SLE), recommending a maximum dose of 5 mg/kg/day and ophthalmological screening at baseline and annually after 5 years of hydroxychloroquine treatment [1], have already affected its prescription patterns in Europe [2]. However, there are large inter- and intra-country variations of hydroxychloroquine dosing. Notably, most centres fail to follow recommendations regarding annual screening of retinopathy in case of long-term hydroxychloroquine use.

Although the long-term use of hydroxychloroquine is very common in patients with SLE, it may come with certain adverse effects such as the development of hydroxychloroquine retinopathy, especially in case of very long-term use (>5 years) and at high doses (>5 mg/kg/day) [3,4]. In 2019, EULAR guidelines addressed this issue by recommending a maximum hydroxychloroquine dose of 5 mg/kg/day and ophthalmological screening at baseline and annually after 5 years of hydroxychloroquine treatment when used in the management of SLE [1]. Zgjim Osmani and colleagues (National Association for Lupus, APS, Scleroderma and MCTD, the Netherlands) assessed whether these EULAR guidelines affected prescription patterns and screening frequencies in Europe.

Data was collected from the online European Survey for Lupus Patients (ESLP) initiated by LUPUS EUROPE online. European patients were offered the opportunity to take part, and to complete 29 questions. Each participant was asked, among other things, to report their body weight, daily hydroxychloroquine dose, and whether they had received baseline screening and/or regular eye examinations. This online survey was completed by 2,938 lupus patients from 36 countries. The majority were female (86.5%) and 85.7% was diagnosed with SLE. Data on the daily hydroxychloroquine dose was available from 57.1% of patients (n=1,678), with a median dose of 4.3 mg/kg/day and a median treatment duration of 7 years.

It emerged that 36.8% of patients exceeded the recommended daily dose of 5 mg/kg/day. Low dose (≤4 mg/kg/day) was reported by 45.8% (n=769). The percentage of patients reporting that they skipped hydroxychloroquine once a week or more often was 15.9% (n=284). Nevertheless, only 8.7% of patients reported that they were more likely to skip hydroxychloroquine than other medication. The highest median hydroxychloroquine dosages were reported by patients from Belgium, Israel, France, and Portugal, whereas Spanish patients reported the lowest hydroxychloroquine dosages (see Figure).

 

Figure: Median hydroxychloroquine dosages in Europe [2]



PRT: Portugal, POL: Poland, NLD: Netherlands, ITA: Italy, ISR: Israel, GRC: Greece, FRA: France, FIN: Finland, ESP: Spain, DEU: Germany, CHE: Switzerland, BEL: Belgium.

 

Furthermore, 82.2% of patients (n=935) who were diagnosed in the past 10 years reported that they received an ophthalmological screening at baseline. Of the 39.7% of patients (n=1,167) who reported long-term use of hydroxychloroquine (i.e. ≥ 5 years), only 64% (n=748) reported that they receive regular eye examinations (i.e. at least once every year). It was stated that these outcomes offer interesting insights into the different practices amongst European countries, and that more research is needed to confirm whether proper screening modalities are being employed as recommended.

1. 
   
   1. Fanouriakis A, et al. Ann Rheum Dis. 2019 Jun;78(6):736-745.
   2. Osmani Z, et al. Abstract SAT0169. EULAR E-Congress, 3-6 June 2020.
   3. Jorge A, et al. Nat Rev Rheumatol. 2018 Dec;14(12):693-703.
   4. Marmor MF, et al. Ophthalmology. 2016;123(6):P1386-94.

Posted on 14 August 202017 May 2024