Despite retinopathy concerns, hydroxychloroquine still proven to boost survival in lupus
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DESTIN, Fla. — Hydroxychloroquine remains one of the most important drugs in lupus management and should be used as background therapy in nearly all cases, according to a speaker at the Congress of Clinical Rheumatology East annual meeting.
“It is the most important medicine,” Michelle Petri, MD, MPH, the director of the Lupus Center at Johns Hopkins University School of Medicine, told attendees during the hybrid meeting. “But when you talk about hydroxychloroquine with your patients, please emphasize it is the only medicine we have that has been proven in multiple studies, including one of mine, to improve survival.”
An overall reduction in hydroxychloroquine dosing following fears of retinopathy has resulted in a reduction in an average dose for patients from 400 mg to about 200 mg, Petri said. The reduction, however, has not been proven to materially improve the rates and impacts of retinal toxicity.
“The reduction in dosing came about because of a fear of retinopathy,” Petri said. Urging caution, she recommended rheumatologists who manage patients with systemic lupus erythematous or lupus nephritis follow the retinopathy screening guidelines put forth by ophthalmology authorities.
“I want you to obey the ophthalmology screening rules; I think they are so important,” Petri said. At baseline, beginning at 5 years, patients receiving hydroxychloroquine should undergo a retinopathy screening, with the most attention paid to the optical coherence tomography (OCT) screening.
“If you stop hydroxychloroquine when an OCT turns abnormal, I have never seen progression and I have never seen visual loss,” Petri said. In cases where patients with lupus develop vision loss, it is typically a manifestation of hypertension, diabetes or stroke, Petri said. “And guess what hydroxychloroquine does? It helps prevent stroke, diabetes and helps to reduce cardiovascular risk factors.”
Petri argued that the 5 mg per kg rule used for hydroxychloroquine dosing should be “thrown out.” “When you do the weight-based dosing, there is no association whatsoever with the hydroxychloroquine blood levels.”
Rheumatologists seeing patients with lupus should aim for a blood level of 750 to 1,000. “But you don’t want patients to live above 1,500, because our prospective retinopathy study showed that is where you start to get increased risks of retinopathy.”
In cases where hydroxychloroquine alone is not sufficient to manage disease activity, specialized immunotherapy should be used depending on the most impacted organ systems, Petri said. Patients with high levels of joint and skin involvement, she said, might look to methotrexate. Patients with contraindicated manifestations, however, such as renal involvement, will need to use a different therapy, such as mycophenolate.
“You will sometimes have to decide what the primary organ you want to treat is,” Petri aid. “Or, if you have to cover several different organs and you don’t have a perfect drug, maybe you will use something like the old-fashioned azathioprine.
“This is clinical judgement, and you do the best you can,” Petri said. “If you pick the wrong one, you switch to another.”
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Petri M. Comparison of new therapies for SLE. Presented at the Congress of Clinical Rheumatology East; May. 4-7, 2023; Destin, Florida (hybrid meeting).
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