Monitoring for ocular toxicity with hydrochloroquine

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Rheumawire

Mar 17, 2004

Monitoring for ocular toxicity with hydrochloroquine

Leicester, UK - About half of UK rheumatologists do not assess either

baseline visual symptoms or visual acuity before prescribing

hydrochloroquine and so do not conform to national guidelines for

monitoring ocular toxicity of the agent, a survey shows [1]. Moreover,

few rheumatologists order visual monitoring frequently enough and a

quarter prescribe unnecessary referrals to ophthalmologists.

The results of the survey are published in the March 2004 issue of

Rheumatology.

Dr Ash Samanta (Leicester Royal Infirmary, University Hospitals of

Leicester, UK) and colleagues used a questionnaire to assess whether

consultant rheumatologists monitor for ocular toxicity of

hydrochloroquine according to the standards set by the Royal College of

Ophthalmologists (RCO) guidelines. These evidence-based guidelines are

approved by the British Society for Rheumatology (BSR) and reflect the

" gold standard, " the authors comment.

Ocular toxicity is the most serious side effect of

hydrochloroquine. Guidelines for monitoring patients on long-term

treatment from the RCO and approved by the BSR state that:

Before treatment is started, a baseline

assessment should include asking about visual impairment and recording

the best corrected visual acuity.

Patients should then be monitored on a yearly

basis by inquiring about visual symptoms and rechecking acuity.

Referral to ophthalmologists is appropriate only

if the patients have visual symptoms or signs detected at baseline or if

they develop changes in visual acuity or blurred vision while on

treatment.

In total, 465 rheumatologists responded to the survey. Before starting

hydrochloroquine, 47% of them do not assess baseline visual symptoms in

their patients and 49% do not check baseline acuity. They fared better

on monitoring for ocular toxicity, with 61% reporting that they

monitored more than once a year. However, 28% routinely referred their

patients to ophthalmologists for baseline assessment and 27% for

follow-up, whereas such practices are outside the recommendations of the

RCO guidelines. Results were similar for rheumatologists practicing in

district general hospitals or teaching hospitals.

" These results show that practice by rheumatologists diverges from the

standard set by the RCO guidelines, " write the researchers. Guidelines

are stated to achieve the best practice uniformly and consistently and

avoid " postal-code lottery " healthcare provision, they comment. The

survey " demonstrates a lack of conformity " and the need for

intervention, they add.

With a response rate of 85%, the authors believe that their study

" provides a reliable reflection of current practice in this area. " They

acknowledge that it may reflect a " snapshot " picture of a specific

aspect of the rheumatology practice, but they say the literature shows

that " guidelines generally may only have a modest effect on actual

practice. "

" Rheumatologists should reflect on their own practice in relation to

established guidelines, " Samata et al conclude.

Veronique Duqueroy

Sources

1. Samanta A, Goh L, Bawendi A. Are evidence-based guidelines being

followed for the monitoring of ocular toxicity of hydroxychloroquine? A

nationwide survey of practice amongst consultant rheumatologists and

implications for clinical governance. Rheumatology (Oxford) 2004 Mar;

43(3):346-8.

2. Royal College of Ophthalmologists. Ocular toxicity and

hydroxychloroquine: guidelines for screening. London, UK: RCO; 1998.

I'll tell you where to go!

Mayo Clinic in Rochester

http://www.mayoclinic.org/rochester

s Hopkins Medicine

http://www.hopkinsmedicine.org