Clinical Practice Audit of Hydroxychloroquine Prescription and Monitoring in Rheumatology Practice

Objectives Hydroxychloroquine (HCQ) is widely used for autoimmune conditions but carries retinal toxicity risk. Guidelines recommend weight-based dosing (≤5 mg/kg of body weight/day) and regular ophthalmological monitoring, yet clinical adherence varies. This study audits HCQ prescribing practices and monitoring adherence in a community-based rheumatology practice. Methods We conducted a retrospective audit examining HCQ prescribing and monitoring patterns from 2 rheumatologists sharing an electronic medical record (EMR) system. All patients with HCQ exposure between 1999 and May 2025 were included. Data collected included patient demographics, weight, height, rheumatological diagnoses, prescribed doses, treatment duration, and ophthalmological examinations. We identified patients discontinuing HCQ per eye specialist recommendations and collected detailed information on suspected or confirmed retinopathy cases. Results Among 1,073 patients prescribed HCQ, 86% were female with mean age 61 years and mean weight 71.5 kg. Mean treatment duration was 116.2 months. Primary diagnoses included rheumatoid arthritis (51.6%), systemic lupus erythematosus (30.4%), and mixed connective tissue disease (6.7%). Fifty patients (4.7%) had missing data that precluded accurate dose calculations. These missing data categories included patient weight, HCQ start/end date, initial dosage, or a combination of all categories. Among patients with complete data, 60.5% received doses ≤5 mg/kg of body weight/day, while 35.9% exceeded this threshold. Regarding monitoring, only 37.5% had documented ophthalmological visits within 5 years of starting HCQ, and 15.7% had visits after 5 years; 46.8% lacked any visit documentation. Twenty-four patients (2.2%) discontinued HCQ per eye specialist advice, with 11 having confirmed HCQ-induced retinopathy. Among these 11 patients, the mean dose was 4.93 mg/kg/day (median 4.71 mg/kg/day). More details regarding these results can be found in (Table 1). Table 1: Compilation of Audit Results Conclusion This audit revealed significant gaps in HCQ prescribing and monitoring practices. Over one-third of patients received excessive weight-based doses, and documentation of ophthalmological monitoring was inadequate in nearly half of patients. Key improvements needed include improved documentation of patient weight for accurate dosing calculations, systematic recording of treatment duration and ophthalmological examinations, and clearer documentation of discontinuation reasons. Implementing standardized protocols and regular audit cycles could enhance patient safety and optimize outcomes while minimizing retinal toxicity risk.