Ab1342 Hydroxychloroquine Toxicity Monitoring Challenges: Results of a Regional Survey Covering 6.3 Million People

Background: Hydroxychloroquine (HCQ) is a disease modifying drug widely used in the management of rheumatological conditions. Side effects include ocular toxicity and thus screening with Optical Coherence Tomography (OCT) is required for all patients with identified risk factors, such as long duration of therapy >5 years, high-dose administration (>5mg/kg/day), older age, concomitant use of tamoxifen and renal impairment. The most recent EULAR guidelines for the management of SLE recommend a maximum HCQ dose of 5 mg/kg/day and ophthalmological screening at baseline and annually after 5 years of HCQ treatment. Both European and American guidelines advocate a baseline OCT screening prior to initiating HCQ treatment. Most recently the UK guidance in 2020 has updated their recommendation negating the need for a baseline screen. We wanted to explore the variation of HCQ monitoring pathways and service delivery challenges across a defined large geographical area in East of England to document the practice and variation, and identify areas of good practice that can influence pathways nationally. Objectives: Our aim was to assess the extent to which hospitals within this region have successfully implemented a systematic pathway to facilitate the referral process for eye toxicity screening among eligible patients using Hydroxychloroquine (HCQ) for over five years or underlying risk factors, to undergo eye toxicity screening tests within our region. Methods: We designed an online survey comprising of 18 questions, distributed electronically via the East Anglian Rheumatology Society network and regional educational and business meetings and via email, targeting rheumatology clinicians working in secondary and tertiary care hospital across the region. Each hospital was asked to complete one response by the most appropriate individual. We examined ways the hospitals utilised to promote adherence to the national guidelines and if the 5 documented risk factors for HCQ eye toxicity were assessed and taken into account. Further inquiries delved into the responsibilities related to recalling patients for annual eye toxicity screenings, concluding with an evaluation of the communication between the rheumatology and ophthalmology teams concerning screening results. Results: The survey was completed by 15 hospitals, each equipped with an active rheumatological department. Our findings showed that 67% of these hospitals have established a direct pathway for referral to ophthalmology. Additionally, 60% typically refer directly to ophthalmology, while 33% refer to local high street optometrists, due to the absence of hydroxychloroquine toxicity screening services within their hospital facilities. Following the initial screening process, the ophthalmology/optician or patient were responsible to arrange the OCT screening in subsequent years in 14/15 hospitals, whereas 1/15 hospitals this stayed with the rheumatology department. Some 67% of the hospitals routinely referred everyone after 5 years of HCQ use, whilst the remaining 33% utilised clinical judgment based on risk factors. Only 40% of the hospitals had a "shared agreement" specific for HCQ initiation with the primary care physicians. Lastly, among the 60% that referred directly to the ophthalmology department, 89% maintained robust communication channels with ophthalmology. Conclusion: Our survey has yielded insightful observations regarding the prevalent practices surrounding HCQ toxicity screening in the East of England. The results show diverse strategies, with a significant 67% of hospitals having started a direct referral pathway to ophthalmologists, reflecting a dedicated commitment to proactive patient care. The subtle variations in approaches, such as the 33% preference for referral to local high street optometrists in the absence of in-hospital screening services, could highlight the adaptability of healthcare institutions in ensuring access to essential screening. It is reassuring to see an 89% communication between ophthalmology and rheumatology, but channels between opticians and rheumatologists to communicate screening results could be initiated. REFERENCES: NIL. Acknowledgements: NIL. Disclosure of Interests: None declared.