Electrophysiological Profile of Different Antiviral Therapies in a Rabbit Whole-Heart Model.

Antiviral therapies for treatment of COVID-19 may be associated with significant proarrhythmic potential. In the present study, the potential cardiotoxic side effects of these therapies were evaluated using a Langendorff model of the isolated rabbit heart. 51 hearts of female rabbits were retrogradely perfused, employing a Langendorff-setup. Eight catheters were placed endo- and epicardially to perform an electrophysiology study, thus obtaining cycle length-dependent action potential duration at 90% of repolarization (APD90), QT intervals and dispersion of repolarization. After generating baseline data, the hearts were assigned to four groups: In group 1 (HXC), hearts were treated with 1 µM hydroxychloroquine. Thereafter, 3 µM hydroxychloroquine were infused additionally. Group 2 (HXC + AZI) was perfused with 3 µM hydroxychloroquine followed by 150 µM azithromycin. In group 3 (LOP) the hearts were perfused with 3 µM lopinavir followed by 5 µM and 10 µM lopinavir. Group 4 (REM) was perfused with 1 µM remdesivir followed by 5 µM and 10 µM remdesivir. Hydroxychloroquine- and azithromycin-based therapies have a significant proarrhythmic potential mediated by action potential prolongation and an increase in dispersion. Lopinavir and remdesivir showed overall significantly less pronounced changes in electrophysiology. In accordance with the reported bradycardic events under remdesivir, it significantly reduced the rate of the ventricular escape rhythm.

Evaluation of weak genotoxicity of hydroxychloroquine in human TK6 cells.

Hydroxychloroquine (HCQ), a derivative of chloroquine (CQ), is an antimalarial and antirheumatic drug. Since there is limited data available on the genotoxicity of HCQ, in the current study, we used a battery of in vitro assays to systematically examine the genotoxicity of HCQ in human lymphoblastoid TK6 cells. We first showed that HCQ is not mutagenic in TK6 cells up to 80 µM with or without exogenous metabolic activation. Subsequently, we found that short-term (3-4 h) HCQ treatment did not cause DNA strand breakage as measured by the comet assay and the phosphorylation of histone H2A.X (γH2A.X), and did not induce chromosomal damage as determined by the micronucleus (MN) assay. However, after 24-h treatment, both CQ and HCQ induced comparable and weak DNA damage and MN formation in TK6 cells; upregulated p53 and p53-mediated DNA damage responsive genes; and triggered apoptosis and mitochondrial damage that may partially contribute to the observed MN formation. Using a benchmark dose (BMD) modeling analysis, the lower 95% confidence limit of BMD50 values (BMDL50) for MN induction in TK6 cells were about 19.7 µM for CQ and 16.3 µM for HCQ. These results provide additional information for quantitative genotoxic risk assessment of these drugs.

Hydroxychloroquine Toxicity in the Vital Organs of the Body: In Vivo Study.

BACKGROUND: Hydroxychloroquine (HCQ) toxicity can adversely affect vital organs, cause pathologic ocular damage, and can have direct cardiovascular effects. This study aims to identify the biochemical, hematological, and histological alterations of the vital organs associated with the effects of HCQ. METHODS: Male albino rats were exposed to the equivalent of HCQ therapeutic doses given to human patients being affected by malaria, lupus erythematosus, and COVID-19. The animal blood samples were subjected to hematological analysis, biochemical analysis, liver function tests, kidney function tests, and cardiac biomarkers. Liver, kidney, heart, spleen, and testis biopsies were subjected to histological examination. RESULTS: HCQ significantly lowered the values of erythrocytes, hemoglobin, hematocrit, platelets, leucocytes, and lymphocytes but significantly increased the values of aspartate aminotransferase (AST), alanine aminotransferase (ALT), amylase, alkaline phosphatase, lactate dehydrogenase, cholesterol, and chlorine ions. The renal tissues of HCQ-treated animals demonstrated glomerular fragmentation, partial atrophy degeneration, renal tubules hydropic degeneration, hyaline cast formation, and interstitial edema formation. Additionally, the heart exhibited myofiber necrosis, myolysis, wavy appearance, disorganization, and disarray. The testicular tissues also demonstrated spermatocyte degeneration, spermatogenic cell sloughing, testicular interstitial edema, and occasional spermatogenic arrest. Additionally, the spleen showed a decrease in the number and size of the white pulp follicles, a decrease in the number of apoptotic activity, and a decline in the number of T-rich cells. However, the red pulp demonstrated a diffuse decline in B rich-lymphocytes and macrophages. The liver was also the least affected but showed Kupffer cell hyperplasia and occasional hepatocyte dysplasia. CONCLUSIONS: The results indicate that chronic exposure to HCQ could alter the structures and functions of the vital organs.

A novel 5-ring multifocal electroretinography stimulus for detecting hydroxychloroquine retinal toxicity.

PURPOSE: Multifocal electroretinogram (mfERG) shows great utility as a screening tool to detect early hydroxychloroquine (HCQ) retinopathy, but its widespread use is limited by the lack of accessibility and long test duration. In this study, we evaluated a novel concentric 5-ring mfERG stimulus to provide a simplified and rapid protocol for screening HCQ toxicity. METHODS: Patients referred for HCQ retinopathy screening were consented to this observational cross-sectional study. Patients with amblyopia, high refractive error (more than 8 diopters), other retinal diseases precluding appropriate evaluation or history of retinal surgery were excluded. The data were collected from patients undergoing HCQ screening at a single center from July 2019 to March 2020. Patients were tested with the new concentric 5-ring mfERG stimulus, standard 61-hexagon mfERG stimulus, spectral domain optical coherence tomography and automated 10-2 visual fields. For the main outcome, the 5-ring mfERG was compared to 61-hexagon stimulus to determine the time-to-test completion and assess the association between ring (R1-R5) amplitude and ring ratio compared against cumulative dose, dose by real body weight and duration of therapy using Pearson correlation. RESULTS: In total, 52 patients (104 eyes; 5 males and 47 females) were recruited with a mean age of 59 years (range 23-85 years). The 5-ring protocol was markedly quicker to perform (1.3 ± 0.2 min; mean (SD)) compared to the 61-hexagon protocol (5.2 ± 0.6 min), p < 0.0001; n = 10 patients. The new R2/R5 ring ratio showed a moderate correlation with daily dose (r = - 0.640), cumulative dose (r = - 0.581) and duration of therapy (r = - 0.417). Similar correlations were observed with the new R2/R4 ring ratio which were not significantly different from the new R2/R5 correlation coefficients. The new R2/R5 ring ratio demonstrated a stronger correlation with daily (p = 0.002) and cumulative dose (p = 0.0001) compared to the 61-hexagon stimulus. CONCLUSIONS: In this exploratory study, our novel 5-ring mfERG protocol significantly shortened data acquisition time while providing comparable results to the standard 61-hexagon stimulus for detecting HCQ-induced electrophysiological changes that are correlated with HCQ dosages and treatment duration. Our protocol has the potential to be more clinically practical by simplifying routine screening.

Environmental impacts of COVID-19 treatment: Toxicological evaluation of azithromycin and hydroxychloroquine in adult zebrafish.

One of the most impact issues in recent years refers to the COVID-19 pandemic, the consequences of which thousands of deaths recorded worldwide, are still inferior understood. Its impacts on the environment and aquatic biota constitute a fertile field of investigation. Thus, to predict the impact of the indiscriminate use of azithromycin (AZT) and hydroxychloroquine (HCQ) in this pandemic context, we aim to assess their toxicological risks when isolated or in combination, using zebrafish (Danio rerio) as a model system. In summary, we observed that 72 h of exposure to AZT and HCQ (alone or in binary combination, both at 2.5 µg/L) induced the reduction of total protein levels, accompanied by increased levels of thiobarbituric acid reactive substances, hydrogen peroxide, reactive oxygen species and nitrite, suggesting a REDOX imbalance and possible oxidative stress. Molecular docking analysis further supported this data by demonstrating a strong affinity of AZT and HCQ with their potential antioxidant targets (catalase and superoxide dismutase). In the protein-protein interaction network analysis, AZT showed a putative interaction with different cytochrome P450 molecules, while HCQ demonstrated interaction with caspase-3. The functional enrichment analysis also demonstrated diverse biological processes and molecular mechanisms related to the maintenance of REDOX homeostasis. Moreover, we also demonstrated an increase in the AChE activity followed by a reduction in the neuromasts of the head when zebrafish were exposed to the mixture AZT + HCQ. These data suggest a neurotoxic effect of the drugs. Altogether, our study demonstrated that short exposure to AZT, HCQ or their mixture induced physiological alterations in adult zebrafish. These effects can compromise the health of these animals, suggesting that the increase of AZT and HCQ due to COVID-19 pandemic can negatively impact freshwater ecosystems.

The toxic effects of chloroquine and hydroxychloroquine on skeletal muscle: a systematic review and meta-analysis.

The aim of this systematic review was to perform qualitative and quantitative analysis on the toxic effects of chloroquine (CQ) and hydroxychloroquine (HCQ) on skeletal muscles. We designed the study according to PRISMA guidelines. Studies for qualitative and quantitative analyses were selected according to the following inclusion criteria: English language; size of sample (> 5 patients), adult (> age of 18) patients, treated with CQ/HCQ for inflammatory diseases, and presenting and not presenting with toxic effects on skeletal muscles. We collected data published from 1990 to April 2020 using PubMed, Cochrane Library, EMBASE, and SciELO. Risk of bias for observational studies was assessed regarding the ROBIN-I scale. Studies with less than five patients (case reports) were selected for an additional qualitative analysis. We used the software Comprehensive Meta-Analysis at the confidence level of 0.05. We identified 23 studies for qualitative analysis (17 case-reports), and five studies were eligible for quantitative analysis. From case reports, 21 patients presented muscle weakness and confirmatory biopsy for CQ/HCQ induced myopathy. From observational studies, 37 patients out of 1,367 patients from five studies presented muscle weakness related to the use of CQ/HCQ, and 252 patients presented elevated levels of muscle enzymes (aldolase, creatine phosphokinase, and lactate dehydrogenase). Four studies presented data on 34 patients with confirmatory biopsy for drug-induced myopathy. No study presented randomized samples. The chronic use of CQ/HCQ may be a risk for drug-induced myopathy. There is substantiated need for proper randomized trials and controlled prospective studies needed to assess the clinical and subclinical stages of CQ/HCQ -induced muscle myopathy.

Afectaciones oftalmológicas causadas por la infección del SARS-CoV-2 / Ophthalmologic conditions caused by SARS-Cov-2 infections

La epidemia de la enfermedad por coronavirus del año 2019 (COVID-19) comenzó en Wuhan, en la provincia de Hubei, China, y en poco tiempo se extendió a otros continentes.1 El primer médico en alertar sobre esta nueva enfermedad en China fue Li Wenliang, especialista en oftalmología que enfermó y falleció a causa de la enfermedad.2 La transmisión de mayor rapidez se reporta por vía respiratoria, aunque existen estudios que describen la existencia de transmisibilidad del síndrome respiratorio agudo grave 2 (SARS-CoV-2 por sus siglas en inglés) mediante la lágrima y la conjuntiva de los pacientes infectados por COVID-19.3 La primera evidencia sobre esta vía de contagio se relata desde el 22 de enero, cuando Guangfa Wang, miembro del panel nacional de expertos en neumonía, informó que fue infectado por el SARS-CoV-2 durante la inspección en Wuhan. Llevaba una máscara N95 pero no usaba equipamiento para proteger sus ojos. Varios días antes del inicio de la neumonía, Wang se quejó de enrojecimiento ocular.4 Varios autores plantean que particularmente el conducto lagrimal funciona como un canal para recoger y transportar el fluido lagrimal desde la superficie ocular hasta el meato nasal inferior. Esto es conveniente para el drenaje del virus desde los tejidos del tracto ocular hasta el tracto respiratorio. Otra teoría propuesta para la afección oftalmológica es la diseminación del virus por vía hematógena a la glándula lagrimal.4,5 Algunos protocolos presentaron casos de aislamiento de cultivos en uno de cada tres pacientes, procedentes de muestras lagrimales, sin precisarse el mecanismo exacto al momento de cómo es que su diseminación culmina a ese nivel. Algunas de las propiedades de afinidad del el SARS-CoV-2 se debe a la alta adherencia de las células diana de la enzima convertidora de angiotensinógeno II (ACE2). De este modo, participan a nivel sistémico en los diferentes ejes, como el sistema renina-angiotensina-aldosterona, para así ejercer su virulencia.3 Sobre su cuadro clínico se describe como característica la presencia de conjuntivitis viral inespecífica. Además se reportan alteraciones atípicas como anosmia, hiposmia y disgeusia. Estas últimas corresponden al cuadro del protocolo inicial del interrogatorio por parte de la Sociedad de Oftalmología de México, España e Italia.3 Lu Chen, Meizhou Liu y otros6 del Hospital Chinchen, en China, reportaron en marzo de 2020 manera específica las manifestaciones oculares en relación con el SARS-CoV-2. Se trata de un paciente positivo mediante la prueba de reacción en cadena de la polimerasa con transcriptasa inversa (RT-PCR), con conjuntivitis folicular viral bilateral, con 19 días de evolución, donde se destaca la aparición de manifestaciones oculares como: ojo rojo, sensación de cuerpo extraño, epífora y visión borrosa, todo esto de manera bilateral. A la exploración por biomicroscopia se pueden definir hallazgos como: inyección conjuntival moderada; secreciones acuosas; nodulaciones foliculares conjuntivales en párpado inferior sin presentarse hemorragia; y manifestaciones en córnea, segmento anterior o posterior.3 Científicos brasileños han descrito en The Lancet algunas alteraciones en la retina de pacientes de COVID-19 utilizando la Tomografía de Coherencia Óptica (OCT), y han encontrado microhemorragias y lesiones a nivel de la capa de células ganglionares y de la plexiforme interna.1,2 La presencia de COVID-19 ha determinado la posible progresión de enfermedades tales como: el glaucoma crónico, la retinopatía diabética, la degeneración macular asociada a la edad, enfermedades corneales e inflamatorias, entre otras.5 Se ha descrito la presencia del SARS-CoV-2 en las lágrimas de pacientes con COVID-19.3 Algunos estudios confirman que los pacientes con síntomas oculares tenían más probabilidades de tener recuentos más altos de glóbulos blancos y neutrófilos y mayores niveles de procalcitonina, proteína C reactiva y lactato deshidrogenasa que los pacientes sin síntomas oculares, lo cual evidencia mayor gravedad del cuadro.4 En el Tratamiento de la COVID-19 se han estudiado determinados fármacos que pudieran producir alteraciones oftalmológicas.1 La cloroquina y la hidroxicloroquina, con efecto antiviral, causarían toxicidad ocular con altas dosis y tratamientos prolongados la expresión de dicha toxicidad se manifiesta por la aparición de depósitos corneales, catarata subcapsular posterior, disfunción del cuerpo ciliar y retinopatía. Por otra parte se ha confirmado que el Lopinavir/ritonavir (Kaletra) tiene entre sus efectos adversos sistémicos la hepatopatía, que puede provocar un tinte ictérico conjuntival.5 Consideramos que, al tratarse de un virus con tan fácil diseminación, el contagio por vía ocular es una posibilidad real e inminente, por ello se precisan de manera intencionada las medidas de protección ocular, sobre todo para el personal de salud. Dentro de ellos el personal que brinda atención oftalmológica es especialmente vulnerable por su proximidad a las vías respiratorias y ojos de pacientes. Los sistemas de salud deberán garantizar recursos de desinfección y control necesarios para evitar la propagación de la enfermedad(AU)

"Protenuria in SLE: Is it always lupus?"

Proteinuria is one of the most typical manifestations of kidney involvement in Systemic Lupus Erythematosus (SLE). We report the case of a 23-year-old woman with a 6-year-long history of SLE presenting with proteinuria after a three-year remission on hydroxychloroquine. Kidney histological examination showed alterations inconsistent with lupus nephritis and suggestive of hydroxychloroquine toxicity or Fabry disease. The latter was confirmed by genetic assay.

Improving eye screening practice among pediatric rheumatology patients receiving hydroxychloroquine.

OBJECTIVE: Hydroxychloroquine (HCQ) is commonly used in the treatment of various autoimmune diseases related to its many benefits and favorable safety profile. Although HCQ retinopathy was considered to be uncommon, a prevalence of 7.5% was described in a recent study making early detection critical. The most updated screening guidelines by the American Academy of Ophthalmology were published in 2016; however, it lacked pediatric-specific recommendations and the overall compliance with screening guidelines was poor in previous studies. We developed a quality improvement (QI) initiative aiming to create institutional screening recommendations. Additionally, to increase eye screening in pediatric rheumatology clinic for patients receiving HCQ from 65% to 85% in 12 months and to sustain that rate for at least 6 months. METHODS: We formed a multidisciplinary team of pediatric rheumatologists and ophthalmologists, clinical pharmacist, clinic nurses, QI specialist, quality data technician and administrative staff. We included patients receiving HCQ and who were evaluated at Nationwide Children's Hospital rheumatology clinic. A key driver diagram was formulated to identify barriers to compliance and determine possible interventions. Main interventions included summarizing screening guidelines in a step by step algorithm, increasing awareness of these guidelines among patients and providers, improving collaboration and communication with ophthalmologists, and initiating pre-visit planning. RESULTS: Baseline performance data included 164 patients. Fifty-four (33%) of those patients were at high risk for HCQ retinopathy. Of them, 50% were on HCQ dose of >5 mg/kg/day and 31.5% had been taking HCQ for ≥5 years. Two center line shifts were noticed over the course of the project. The target of 85% compliance was reached in February 2019 and was sustained until December 2019. CONCLUSIONS: Our study highlights the importance of interdisciplinary communication to increase awareness of screening guidelines among medical providers and patients. Pre-visit planning played a major role in identifying patients and opportunities for optimizing eye screening in patients at risk for HCQ retinopathy. Collaboration between rheumatologists and ophthalmologists is crucial in managing patients on HCQ. The implementation of same-day eye screening allowed this collaboration to be more efficient. Future efforts are being directed at monitoring and improving utilization of the effective interventions.

Ototoxic effects of hydroxychloroquine

SUMMARY OBJECTIVE To present scientific evidence based on a systematic review of the literature (PRISMA), aiming to systematize evidence of the ototoxic effects of hydroxychloroquine (HCQ). METHODS The studies were selected using a combination based on the Medical Subject Headings (MeSH). The databases searched were MEDLINE (PubMed), LILACS, SciELO, and BIREME, encompassing articles from January 2010 to May 2020, with no restrictions of language and place of publication. RESULTS A total of 148 articles with the potential to be included were retrieved. Of these, two answered the research question, which consisted of seeking evidence of the ototoxic effects of hydroxychloroquine. These studies scored 11 in their quality assessment with the modified protocol by Pithon et al.13. CONCLUSIONS The studies reported possible ototoxicity of HCQ. Audiovestibular changes, such as hearing loss, peripheral vestibular syndrome, and tinnitus were evidenced in patients submitted to HCQ. The improvement in the audiological examinations and the regression in the vestibular syndrome after stopping the treatment with HCQ are strong arguments in favor of the ototoxicity caused by this medication. However, there are still divergences about the relationship between ototoxic effects and the use of HCQ.

LC-MS based metabolomics reveals metabolic pathway disturbance in retinal pigment epithelial cells exposed to hydroxychloroquine.

Hydroxychloroquine (HCQ) is frequently used medications for many auto-immunity diseases. However, HCQ induced retinal toxicity, which might result in irreversible retinopathy, is one of the most important complications of HCQ. However, the molecular mechanism underlying the HCQ retinal toxicity is still not well known. Retinal pigment epithelium, in which HCQ is highly enriched due to the tissue-specific affinity of HCQ, is considered to play important role in HCQ retinopathy. Herein, we used a metabolomics approach based on liquid chromatography-mass spectrometry to investigate the metabolic changes in retinal pigment epithelial cells (ARPE-19) with HCQ exposure at 6 h and 24 h. ARPE-19 cells were treated with HCQ at sub-lethal concentration 20 (IC 20), which was determined with MTT assay. Untargeted metabolic profiling revealed 9 and 15 metabolites that were significantly different between control group and HCQ exposure group at 6 h and 24 h, respectively. Enrichment and pathway analysis highlighted ascorbate and aldarate metabolism, d-Glutamine and d-glutamate metabolism and C5-Branched dibasic acid metabolism were disturbed after HCQ exposure. These findings increased our knowledge about the metabolic perturbation induced by HCQ exposure and indicated that metabolic profiling in the ARPE-19 cells might be helpful in understanding the mechanism of HCQ retinal toxicity and exploring potential biomarker.

Efetividade e toxicidade da cloroquina e da hidroxicloroquina associada (ou não) à azitromicina para tratamento da COVID-19. O que sabemos até o momento? / Effectiveness and toxicity of chloroquine and hydroxychloroquine associated (or not) with azithromycin for the treatment of COVID-19. What do we know so far?

Objetivos: identificar as evidências científicas existentes até o presente momento sobre a efetividade do uso da cloroquina, da hidroxicloroquina associada (ou não) à azitromicina para tratamento da afecção pelo coronavírus e seus possíveis efeitos adversos e tóxicos aos seres humanos. Métodos: a revisão narrativa utilizou-se das bases de dados PubMed, LILACS, SciElo e Google Acadêmico. Nessas, buscaram-se estudos, utilizando-se dos descritores "covid", "coronavirus", "SARS-CoV-2", "chloroquine", "hydroxychloroquine", "azithromycin" e "adverse effects" junto com os operadores booleanos "AND" e "OR". Resultados: sete artigos, das trinta publicações encontradas, atenderam aos critérios de inclusão, sendo utilizados para compor a presente revisão. Dos sete ensaios clínicos analisados, cinco apresentaram resultados de cura e/ou remissão dos sintomas e/ou redução da carga viral dos pacientes, no entanto apresentaram muitas limitações. Conclusão: a literatura científica é escassa e divergente quanto à efetividade dos medicamentos cloroquina e hidroxicloroquina associada (ou não) à azitromicina no tratamento da COVID-19, pela rápida disseminação e instalação da pandemia na esfera global. É necessário a realização de ensaios clínicos pragmáticos, envolvendo um número maior de pacientes, para que seja possível analisar a efetividade no combate ao coronavírus, bem como a segurança do uso desses fármacos.(AU)

Objective: to identify the scientific evidence existing to date on the effectiveness of the use of chloroquine, hydroxychloroquine associated (or not) to azithromycin for the treatment of COVID-19 disease and its possible adverse drug events and toxicity to human health. Methods: the narrative review was performed using the PubMed, LILACS, SciElo and Google Academic databases. In these, studies were sought, using the descriptors "covid", "coronavirus", "SARS-CoV-2", "chloroquine", "hydroxychloroquine", "azithromycin", "adverse effects" and "toxicity", together with the Boolean operator "AND" and "OR". Results: seven studies of thirty publications met the inclusion criteria and were used in the present review. Of the seven clinical trials analyzed, five showed results of cure and/or remission of symptoms and/or reduction of patients' viral load, however these studies had many limitations. Conclusion: scientific literature is scarce and divergent as to the effectiveness of the drugs chloroquine and hydroxychloroquine associated (or not) with azithromycin in the treatment of COVID-19, due to the rapid spread and installation of the pandemic in the global sphere. It is necessary to carry out pragmatic clinical trials, involving a larger number of patients, so that it is possible to analyze the effectiveness in combating the coronavirus, as well as the safety of the use of these drugs.(AU)

Implementation of recommendations for the screening of hydroxychloroquine retinopathy: poor adherence of rheumatologists and ophthalmologists.

The American Academy of Ophthalmology published in 2011 revised recommendations regarding screening for hydroxychloroquine (HCQ) toxicity. We aimed to assess implementation of these recommendations by rheumatologists and ophthalmologists. A questionnaire regarding screening practices for HCQ toxicity was distributed among all members of the Israeli societies of Rheumatology and Ophthalmology. A total of 128 physicians responded to the questionnaire (rheumatologists: 60, ophthalmologists: 68). Only 5% of the rheumatologists and 15% of the ophthalmologists are aware of ophthalmologic assessments recommended for baseline and follow-up evaluation. When an abnormal test is detected, even if inappropriate for HCQ toxicity screening, 60% of the responders recommend cessation of therapy. Only 13% of the responders recommend first follow-up after five years for patients without risk factors; the remainder recommend more frequent testing. Ninety-six percent of the responders are not aware of all of the known risk factors for HCQ toxicity. Use of inappropriate tests to detect HCQ retinal toxicity may lead to unnecessary cessation of beneficial treatment with risk of disease flare, while lack of consideration of risk factors may put patients at risk for toxicity. These results emphasize the importance of implementing the recommendations to ensure safe and effective use of this drug.

Recommendations on Screening for Chloroquine and Hydroxychloroquine Retinopathy (2016 Revision).

BACKGROUND: The American Academy of Ophthalmology recommendations on screening for chloroquine (CQ) and hydroxychloroquine (HCQ) retinopathy are revised in light of new information about the prevalence of toxicity, risk factors, fundus distribution, and effectiveness of screening tools. PATTERN OF RETINOPATHY: Although the locus of toxic damage is parafoveal in many eyes, Asian patients often show an extramacular pattern of damage. DOSE: We recommend a maximum daily HCQ use of ≤5.0 mg/kg real weight, which correlates better with risk than ideal weight. There are no similar demographic data for CQ, but dose comparisons in older literature suggest using ≤2.3 mg/kg real weight. RISK OF TOXICITY: The risk of toxicity is dependent on daily dose and duration of use. At recommended doses, the risk of toxicity up to 5 years is under 1% and up to 10 years is under 2%, but it rises to almost 20% after 20 years. However, even after 20 years, a patient without toxicity has only a 4% risk of converting in the subsequent year. MAJOR RISK FACTORS: High dose and long duration of use are the most significant risks. Other major factors are concomitant renal disease, or use of tamoxifen. SCREENING SCHEDULE: A baseline fundus examination should be performed to rule out preexisting maculopathy. Begin annual screening after 5 years for patients on acceptable doses and without major risk factors. SCREENING TESTS: The primary screening tests are automated visual fields plus spectral-domain optical coherence tomography (SD OCT). These should look beyond the central macula in Asian patients. The multifocal electroretinogram (mfERG) can provide objective corroboration for visual fields, and fundus autofluorescence (FAF) can show damage topographically. Modern screening should detect retinopathy before it is visible in the fundus. TOXICITY: Retinopathy is not reversible, and there is no present therapy. Recognition at an early stage (before any RPE loss) is important to prevent central visual loss. However, questionable test results should be repeated or validated with additional procedures to avoid unnecessary cessation of valuable medication. COUNSELING: Patients (and prescribing physicians) should be informed about risk of toxicity, proper dose levels, and the importance of regular annual screening.

Enhanced autophagy in cytarabine arabinoside-resistant U937 leukemia cells and its potential as a target for overcoming resistance.

Autophagy is a lysosomal degradation mechanism that is essential for cell survival, differentiation, development, and homeostasis. Autophagy protects cells from various stresses, including protecting normal cells from harmful metabolic conditions, and cancer cells from chemotherapeutics. In the current study, a cytarabine arabinoside (Ara­C)­sensitive U937 leukemia cell line and an Ara­C­resistant U937 (U937/AR) cell line were assessed for baseline autophagy activity by investigating the LC3­I conversion to LC3­II, performing EGFP­LC3 puncta, an acidic autophagolysosome assay, and measuring the expression of various autophagy­related genes. The results demonstrated significantly higher autophagic activity in the U937/AR cells compared with the U937 cells, when the cells were cultured with or without serum. Furthermore, an increase in the autophagic activity in starved U937/AR cells was demonstrated, compared with that in the starved U937 cells. Administration of an autophagy inhibitor demonstrated no change in cell death in the two cell lines when cultured with serum, however, it induced cell death regardless of the Ara­C sensitivity when the cell lines were cultured without serum. In addition, the U937 cells demonstrated an Ara­C resistance when cultured without serum. Co­treatment with Ara­C and the autophagy inhibitor significantly induced cell death in the U937/AR and Ara­C­sensitive U937 cells. In conclusion, autophagy serves an important role in protecting U937 cells from Ara­C and in the development of Ara­C resistance. Inhibition of autophagy combined with the Ara­C treatment in the U937 cells augmented the anti­leukemic effect of Ara­C and overcame Ara­C resistance, suggesting that autophagy may be an important therapeutic target to further improve the treatment outcome in patients with acute myeloid leukemia.

Hydroxychloroquine screening practice patterns within a large multispecialty ophthalmic practice.

PURPOSE: To determine provider compliance with hydroxychloroquine screening following the revised recommendations published in 2011 by the American Academy of Ophthalmology. DESIGN: Evaluation of adherence to a screening protocol. METHODS: Subjects were identified with hydroxychloroquine as a medication by electronic query at a large multispecialty ophthalmic practice. Patients were excluded if patients: (1) were screened by an outside physician; (2) lacked recorded height, weight, start date, or dosing; or (3) took hydroxychloroquine for malaria prophylaxis. Screening tests were stratified by ophthalmic subspecialty. Guidelines define proper screening as 1 subjective test-Humphrey visual field (HVF), and 1 objective test-spectral-domain optical coherence tomography (SD OCT), fundus autofluorescence (FAF), or multifocal electroretinography (mfERG). Adherence to guidelines was determined by categorizing practices as: (1) "appropriate"-consistent with guidelines; (2) "underscreened"-insufficient testing; or (3) "inappropriate"-no testing. RESULTS: The study comprised 756 patients with a mean age of 56 years undergoing 1294 screening visits. Twenty-one patients received initial screenings outside the institution. Most common screening tests employed included SD OCT (56.6%), 10-2 HVF (55.0%), and Amsler grid (40.0%). Of the 735 initial screenings, 341 (46.4%) were appropriately screened, 204 (27.8%) underscreened, and 190 (25.9%) inappropriately screened. Of those who presented solely for screening (560), 307 (54.8%) were appropriately screened, 144 (25.7%) underscreened, and 109 (19.5%) inappropriately screened. CONCLUSIONS: Of patients presenting for hydroxychloroquine screening, 54.8% of patients received appropriate evaluation, indicating lack of adherence to guidelines. Overall, SD OCT and 10-2 HVF were the preferred screening modalities, with FAF and mfERG less frequently ordered.

Multimodal imaging in a severe case of hydroxychloroquine toxicity.

Retinal toxicity from hydroxychloroquine (HCQ) can be detected most readily on fundus autofluorescence, spectral-domain optical coherence tomography, and multifocal electroretinogram. The authors describe a case of a 60-year-old woman with a history of systemic lupus erythematosus undergoing HCQ treatment for 30 years who presented with visual loss over several years. Examination and multimodal imaging showed bilateral retinal pigment epithelium (RPE) changes in a bull's-eye distribution associated with cystoid macular edema. A novel imaging modality, multi-spectral imaging, appeared sensitive in detecting a bull's-eye pattern of RPE disturbance involving the entire macular region of both eyes. Cessation of drug was advised with close follow-up.

[Retinal damage by (hydroxy)chloroquine intake: published evidence for an efficient ophthalmological follow-up]. / Netzhautschädigung bei (Hydroxy-)Chloroquin-Einnahme: Evidenzlage als Basis für eine rationale augenärztliche Untersuchungsstrategie.

BACKGROUND: Irreversible maculopathy and retinopathy are well-known adverse effects of chloroquine and hydroxychloroquine. For this article the literature was screened for relevant risk factors. The results were used for recommendations concerning the extent and frequency of ophthalmological monitoring. METHODS: A systematic literature review was undertaken. RESULTS: Very few studies on a high evidence level could be retrieved for this problem. Most of the risk factors have not been addressed sufficiently. A higher dosage per kg body mass, long therapy duration, presence of keratopathy and renal or hepatic dysfunction are probably associated with an increased risk to develop a maculopathy/retinopathy. Additional factors such as age, genetic disposition, additional retinal disease, sunlight exposition and nature plus duration of the underlying disease have not sufficiently been demonstrated. Gender, body mass and even the accumulated dosage do not contribute as risk factors according to current knowledge. CONCLUSION: Beside patient risk factors, the spectrum of ophthalmological methodology and cost considerations have to be considered when thinking about content and frequency of monitoring for the risk of acquiring a (hydroxy)chloroquine-induced maculopathy or retinopathy. In principle, a baseline examination comprising visual acuity (near and far), 10 degree threshold perimetry, colour vision, slit lamp (cornea) and funduscopy is reasonable. One of the high investment techniques such as multifocal ERG, fundus autofluorescence and high resolution optical coherence tomography should be used depending on the existing equipment and experience but not more often than once a year. In suspicious cases or high risk-patients a flexible approach is mandatory.