eMedicine Specialties > Ophthalmology > Unclassified Disorders
Chloroquine/Hydroxychloroquine Toxicity: Follow-up
Updated: Apr 1, 2008
Follow-up
Further Outpatient Care
- Once retinal toxicity is identified, the drug is discontinued; the patient is administered other immunosuppressive agents. Chloroquine and/or hydroxychloroquine clear very slowly from the body, so the full effects may not manifest for 3–6 months. Slow, continued deterioration of visual function may occur even after the drug is discontinued. The authors recommend that patients be reevaluated 3 months after a diagnosis of toxicity is made, even after discontinuation of drug use. Annual examinations are recommended until the findings are clearly stable.
- Distance and near acuity
- Color vision
- Visual field examination (red pin and red Amsler grid)
- Slit lamp biomicroscopic examination of the cornea
- Dilated examination of the retina
- Electroretinogram (full field and multifocal)
- Perimetry (Humphrey 10-2)
- Fundus photography
- Fluorescein angiography
Inpatient & Outpatient Medications
- Discontinue use of quinolones.
Deterrence/Prevention
- The recommended safe threshold dose has been reported as 3.5 mg/kg/d for chloroquine and 6.5 mg/kg/d for hydroxychloroquine.
- These dosages are based on lean body weight.
- A body mass index calculator used by endocrinologists is helpful in calculating the recommended dose.
Complications
- See Physical.
Prognosis
- If the maximum daily dosage recommendations are followed, then the likelihood of toxicity is small.
- If diagnosed early, toxicity (eg, corneal epithelial changes, loss of normal foveal reflex) is reversible.
- Once the appearance of a bull's eye maculopathy is noted, disturbances associated with this condition are irreversible.
Patient Education
- Monitor patients on an annual basis. Record visual symptomatology, visual acuity, and Amsler grid testing.
- Advise patients to discontinue treatment and to seek consultation with an ophthalmologist if changes in visual acuity or blurred vision occur while on treatment.
- See Deterrence/Prevention.
Miscellaneous
Medicolegal Pitfalls
- The most important factor in avoiding toxicity with long-term therapy appears to be the daily dose. If the daily dose is below the stated threshold levels, then the chance of encountering any retinopathy is small. However, it is essential that the early symptoms of toxicity are discussed with the patient. A high index of suspicion of toxicity would justify the performance of expensive ancillary procedures to detect possible retinopathy.
- In addition to following the guidelines for the safe administration of chloroquine/hydroxychloroquine therapy, dose adjustments should be made in consideration of lean body weight and renal and hepatic insufficiency.
Special Concerns
- Pediatric: Use of quinolones in children should be monitored closely.
- Geriatric: Elderly patients should be considered part of a high-risk group; therefore, they should be monitored closely.
- Renal insufficiency: Dose adjustments should be made in patients with renal impairment.
- Hepatic insufficiency: Dose adjustments should be made in patients with hepatic impairment.
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Further Reading
Keywords
chloroquine, hydroxychloroquine, Aralen, Plaquenil, bull's eye maculopathy, toxicity
Follow-up: Chloroquine/Hydroxychloroquine Toxicity