Adherence to Weight‐Based Dosing Guidelines in Patients Receiving Hydroxychloroquine for Systemic Lupus Erythematosus and Rheumatoid Arthritis: Results of a Quality Improvement Initiative

OBJECTIVE: Hydroxychloroquine (HCQ) is commonly prescribed for the treatment of systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), and other rheumatic diseases. To limit retinal toxicity, the 2016 American Academy of Ophthalmology (AAO) guidelines recommended limiting the HCQ dose to 5 mg/kg/day or less. Our objective was to develop a quality improvement program to improve adherence to these guidelines. METHODS: We performed a retrospective analysis of 801 adult patients receiving HCQ for SLE and RA in a single academic rheumatology practice. In 2018, we calculated weight‐based doses of HCQ at two time points at least 6 months apart. We surveyed provider opinions regarding the 2016 AAO guidelines and implemented a quality improvement intervention during which dosing data were shared with all prescribers (individually and in aggregate) and nurse‐aided decision support was provided for HCQ refill requests. One year after the initial analysis and intervention, we again assessed weight‐based doses of HCQ for the 674 patients still taking HCQ. RESULTS: At both measured time points during 2018, 22.8% of patients received doses greater than 5 mg/kg/day. For 60% of those patients, the dose of HCQ was reduced to 5 mg/kg/day or less by the study end. Between the second time point in 2018 and the postintervention time point in 2019, there was a statistically significant increase in the proportion of patients receiving of dose of 5 mg/kg/day or less (from 74% to 87%; P < 0.0001). CONCLUSION: We observed a significant increase in adherence with current AAO guidelines for weight‐based HCQ dosing after providing feedback to providers regarding their prescribing data and reviewing weight‐based dosing prior to refilling prescriptions.