1. Long-term low-dose hydroxychloroquine use associated with low risk for retinopathy
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A cohort study of more than 3,000 persons who received hydroxychloroquine for 5 or more years with guideline-recommended serial retinopathy screening found that the overall risk for incident retinopathy was low, with most documented cases being mild. Higher hydroxychloroquine dose was associated with progressively greater risk. The findings are published in Annals of Internal Medicine.
Hydroxychloroquine is recommended for patients with systemic lupus erythematosus and some other inflammatory conditions, but vision-threatening retinopathy is a serious long-term adverse effect. Guidelines recommend keeping dosing at 5 mg/kg of body weight per day or lower. However, available study evidence supporting this is relatively weak.
Researchers from Kaiser Permanente Northern California and Harvard Medical School studied 3,325 persons who received hydroxychloroquine for 5 or more years between 2004 and 2020 to characterize the long-term risk for incident hydroxychloroquine retinopathy and examine the degree to which average hydroxychloroquine dose within the first 5 years of treatment predicts this risk. The researchers used pharmacy and health records to analyze hydroxychloroquine dosing and reviewed annual optical scans over time to determine if there was evidence of retinopathy. If retinopathy cases were identified, they were classified as mild, moderate, or severe. The researchers then estimated the risk for developing retinopathy after 15 years according to average dosing levels during the first 5 years. They found that 81 participants developed hydroxychloroquine retinopathy with overall cumulative incidences of 2.5 and 8.6 percent occurring after 10 and 15 years, respectively, with the risk being greater for those given a higher dose during the first 5 years of treatment. The researchers note that regular screening can identify this issue at an early and treatable stage.
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2. Monitoring Epstein-Barr viral load after liver transplant may reduce risk for rare posttransplant complication
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A study of adult recipients of liver transplants has found that monitoring transplant recipients for Epstein-Barr virus viral load (EBV VL) helped to reduce risk for posttransplant lymphoproliferative disease (PTLD), a rare but serious potential complication of transplantation. The findings are published in Annals of Internal Medicine.
Primary infection with or reactivation of EBV can occur after liver transplant and can lead to PTLD. An EBV VL monitoring strategy, including the reduction of immunosuppression is hypothesized to reduce incidence of PTLD in adult transplant recipients -almost all IgG anti-EBV positive).
Researchers from the Transplantation Centers of Leiden University Medical Center and Erasmus Medical Center, The Netherlands studied health records for adult recipients of first liver transplant at these two university medical centers in Leiden and Rotterdam to examine the effect of an EBV VL monitoring strategy on the incidence of PTLD during long-term follow-up after liver transplant in adults. The researchers conducted a difference-in-difference analysis among 4 groups. Adult recipients of first liver transplant in Leiden between September 2003 and January 2017 with an EBV VL monitoring strategy formed the monitoring group; recipients of first liver transplant in Rotterdam between January 2003 and January 2017 without such a strategy formed the contemporary control group; and those who had transplants in Leiden between September 1992 and September 2003 or Rotterdam between 1986 and January 2003 formed the historical control groups. The analysis showed a numerically larger within-hospital decrease in PTLD in Leiden—with EBV VL monitoring strategy in the contemporary cohort—over time than in Rotterdam—without EBV VL monitoring strategy. According to the authors, these findings suggest that an EBV VL monitoring policy -with reduction of immunosuppression in case of EBV VL detection- should be considered in transplant programs to avoid over-immunosuppression and thereby reduce the incidence of PTLD.
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Also new in this issue:
What Follows From State-Mandated Pregnancy?
Jake Earl, PhD; and Caitlin J. Cain, MD
Ideas and Opinions
Annals of Internal Medicine
Method of Research
Subject of Research
Hydroxychloroquine Dose and Risk for Incident Retinopathy
Article Publication Date