• In addition to oral communication, written information about hydroxychloroquine/ chloroquine retinopathy and monitoring for hydroxychloroquine/chloroquine retinopathy should be given to all patients by the monitoring service.
• The HCQ Screener will check at each appointment the high-risk characteristics.
• Patients can be reassured that there is no radiation risk, the procedure is quick, and not uncomfortable.
• If the image quality is not sufficient mydriasis may be required to dilate the pupil.
• All patients should undergo both spectral domain optical coherence tomography (SD- OCT) and fundus autofluorescence (FAF), widefield if available.
• Patients with abnormalities on either SD-OCT or fundus autofluorescence imaging should undergo automated visual field testing using either a 10-2 or 30-2 protocol depending on the location of the structural abnormality. Visual field testing is likely to be undertaken at a separate visit if dilating eye drops are used for imaging, or in the setting of virtual clinics when images are reviewed after the patient visit.
• Patients with confirmed structural abnormalities on SD-OCT or FAF who do not demonstrate an anatomically consistent visual field defect on repeated testing should undergo multifocal electroretinography.
• Some patients at risk of hydroxychloroquine/chloroquine retinopathy may not be able to undertake the required monitoring tests, and in some there may be ocular co-pathology that prevents interpretable imaging. This may be identified at the first monitoring episode.
  • Where a patient taking hydroxychloroquine/chloroquine cannot undergo monitoring, or in whom retinal imaging cannot be performed or images interpreted, a discussion between the patient and the Specialist (Dermatologist or Rheumatologist) is recommended to determine whether hydroxychloroquine/chloroquine treatment should be continued without retinal monitoring. 

• The management of incidental findings is not within the scope of the monitoring programme except for an urgent eye condition (need review within 2 weeks), such as Wet AMD, that is deemed to have potential sight loss risk. These will be referred urgently to the local Trust by the monitoring service.
  
• In the event of a failure to attend the monitoring appointment people are not automatically discharged but will be reminded of the purpose of monitoring and advised of the interval to the next monitoring appointment.
• It is the responsibility of the Specialist (Dermatologist or Rheumatologist) to take a decision on the patient continuing hydroxychloroquine if they fail to attend monitoring.

If there are any changes in the severity of the patient's condition or concomitant medication, or if troublesome adverse reactions develop, the GP should seek advice from the specialist.

Visual Disturbance

• If a patient reports a visual disturbance (e.g., blurred vision, changes in visual acuity or abnormal colour vision) before their next retinopathy monitoring appointment, redirect to high street optician or refer to ophthalmology for assessment as appropriate

Drug Safety

For further information please refer to the Formulary guidance: N&E Devon / S&W Devon

1. MHRA Drug Safety Update (February 2022): Hydroxychloroquine/Chloroquine: increased risk of cardiovascular events when used with macrolide antibiotics; reminder of psychiatric reactions:

a. An observational study has shown that co-administration of azithromycin with hydroxychloroquine in patients with rheumatoid arthritis is associated with an increased risk of cardiovascular events (including angina or chest pain and heart failure) and cardiovascular mortality.

b. Carefully consider the benefits and risks before prescribing systemic azithromycin or other systemic macrolide antibiotics (erythromycin or clarithromycin) to patients being treated with hydroxychloroquine/chloroquine.

2. Be vigilant for psychiatric reactions associated with hydroxychloroquine/chloroquine, especially in the first month of treatment; events have been reported in patients with no prior history of psychiatric disorders.

• The specialist will continue to oversee the ongoing management of the condition being treated with hydroxychloroquine/chloroquine (including periodic review of disease response and ongoing need for treatment). 
• For all outcomes – ongoing monitoring under the service, or onward referral – a results letter goes to the person who attended the appointment, their registered GP, and the referring physician or hospital department who originally notified the service.
• For those in whom the outcome is a referral to an ophthalmology service the monitoring service refers directly to the Hospital Eye Unit which the patient chose as their preference at the first monitoring episode. A duplicate referral from either the GP or hospital department is not necessary.
• The management of incidental findings is not within the scope of the monitoring programme except for an urgent eye condition (need review within 2 weeks), such as Wet AMD, that is deemed to have potential sight loss risk. These will be referred urgently to the local Trust by the monitoring service.

• It is the responsibility of the Specialist (Dermatologist or Rheumatologist) to refer patients eligible for monitoring to the community monitoring service.
• The Specialist will refer new patients to the monitoring service at the start of treatment or at the start of care with that provider if the patient has moved into the area.
• The Specialist will identify any existing patients who are receiving hydroxychloroquine and are not known to the monitoring service.