Adherence to ophthalmologic monitoring for antimalarial toxicity in a lupus cohort.

OBJECTIVE: Antimalarial agents (hydroxychloroquine and chloroquine) are important in the treatment of various rheumatic diseases, including systemic lupus erythematosus (SLE). Although these agents may lead to ocular complications, little is known about adherence to policies for ophthalmologic monitoring. We investigated adherence to the 1996 American College of Rheumatology (ACR) guidelines (recommending yearly ophthalmologic assessments) at our clinic, and determined the factors associated with nonadherence.

METHODS: Chart review of the Montreal General Hospital lupus clinic cohort.

RESULTS: Of 195 subjects with at least one full year of antimalarial exposure during 1996-2001, 5 refused participation and data on ophthalmology monitoring was incomplete for 42. Of the remaining 148 patients, 47 (32%) had missed at least one annual ophthalmology assessment (were nonadherent) during the interval; almost half of these had missed </= 2 assessments. Nonadherence was present in 50% of the 52 patients who had been taking an antimalarial agent for </= 5 years. In adjusted logistic regression models, cumulative damage (measured by the Systemic Lupus International Collaborating Clinics/ACR Damage Index) and antimalarial exposure </= 5 years were predictive of nonadherence. Adjusted estimates indicated a 1.2-fold increase (95% CI 1.0, 1.5) in the odds of nonadherence for every point increase in the total Damage Index score. The adjusted OR for individuals exposed to an antimalarial for </= 5 years was 5.2 (95% CI 2.1, 13.8).

CONCLUSION: Our results indicate incomplete adherence to ACR guidelines at our center. Because patients with higher Damage Index scores were more likely to have missed ophthalmology appointments, even after adjusting for pertinent covariates, it suggests that sicker patients may be more at risk of nonadherence. The association of nonadherence with duration of antimalarial exposure, while not surprising, is still an important reminder that adherence to ophthalmologic monitoring may decrease as risk for retinal toxicity is increasing.