Before starting

Required

• Baseline
  • Albumin
  • ALT or AST
  • Blood pressure
  • Full blood count
  • Height
  • Serum creatinine (for creatinine clearance) or Calculated glomerular filtration rate
  • Weight
  • Vaccination status

Vaccination status

Consider vaccination against pneumococcus and influenza prior to starting treatment.

Consider in patients at risk of infection

• Baseline
  • Hepatitis B
  • Hepatitis C
  • HIV

Consider

• Baseline
  • Lung disease screening

Ongoing once stable

Required

• Annually if increased risk; otherwise once after 5 years and then annually
  • Ophthalmological examination

Patients requiring monitoring

It is the prescriber’s responsibility to refer patients for monitoring.

Patients with additional risk factors may require annual retinopathy monitoring; risk factors include:

• very high dose of drug therapy (hydroxychloroquine dose over 5mg per kg per day- based on actual body weight)
• concomitant tamoxifen therapy
• renal insufficiency (eGFR less than 60ml/min/1.73m²)

Responding to ophthalmological examination

Ophthalmologists should communicate the results of retinal monitoring to the prescribing doctor, patient and GP telling them whether the results are normal, possible or definite hydroxychloroquine retinopathy.

Prescribers should act on the results of monitoring.

Patients who are drivers with definite toxicity should be advised not to drive until reviewed by an ophthalmologist. The patient should inform the Driver and Vehicle Licensing Agency (DVLA).

Consider

• Periodically
  • Albumin
  • ALT or AST
  • Estimated glomerular filtration rate
  • Skeletal muscle function · stop drug if weakness occurs
  • Tendon reflexes · stop drug if weakness occurs
  • Weight

Responding to renal and liver impairment

Adjust dose and consider increasing screening frequency.

Notes

Baseline ophthalmological examination

Before starting hydroxychloroquine, ophthalmological examination is not currently recommended.

Bibliography

• Ledingham J, Gullick N, Irving K et al. BSR and BHPR Standards, Guidelines and Audit Working Group, BSR and BHPR guideline for the prescription and monitoring of non-biologic disease-modifying anti-rheumatic drugs, Rheumatology, Volume 56, Issue 6, June 2017, Pages 865–868 [cited 16/06/2020]
• The Royal College of Ophthalmologists. Hydroxychloroquine and Chloroquine Retinopathy: Recommendations on Monitoring January 2020 [cited 16/06/2020]
• Joint Formulary Committee. British National Formulary (online) London: BMJ Group and Pharmaceutical Press [cited 24/02/2020]
• Zentiva Pharma UK Limited. Summary of Product Characteristics – Hydroxychloroquine sulfate 200mg Film-coated Tablets. Last revised 03/2020 [cited 30/07/2020]
• Bristol Laboratories Ltd. Summary of Product Characteristics – Quinoric 200mg Film-Coated Tablets. Last revised 11/2017 [cited 16/06/2020]