Hydroxychloroquine can be resumed with close monitoring after retinopathy has developed, without major visual loss: Case Report.

ABSTRACT

PURPOSE: To present a patient with systemic lupus erythematosus on longstanding hydroxychloroquine (HCQ) use for whom HCQ was stopped due to signs of toxicity, and then resumed four years later due to dire systemic need. METHODS: Long term retrospective study. Humphrey visual fields (10-2 and 24-2), fundus autofluorescence imaging, and spectral domain OCT were used to follow progression over time. RESULTS: The patient was on HCQ for 26 years, with a cumulative dose over 3,000g. HCQ was stopped in 2011 due to macular toxicity. She remained off HCQ for four years, during which time she developed type 1 diabetes due to an immunologic attack on the pancreas, and then JC (John Cunningham) viremia after a period of treatment with mycophenolate, which put her at risk for progressive multifocal leukoencephalopathy. Mycophenolate was discontinued and HCQ was resumed with careful follow-up over the next 7 years. The toxic maculopathy showed only mild, slow progression since HCQ was resumed. CONCLUSION: Careful annual monitoring using HVF 10-2 and spectral domain OCT imaging remains the standard of care for patients on HCQ. However, it may be possible with close monitoring, when there is compelling systemic need, to resume HCQ after it has been stopped, with only slow progression of the retinopathy. This allowed the patient to have an improved quality of life and reduced the risk of severe morbidity and mortality.