Microsoft word - hydroxychloroquine shared care guideline v1.doc

Shared Care Guideline
Hydroxychloroquine (Adults)
Indication:
Rheumatoid arthritis and inflammatory osteoarthritis, discoid and systemic
lupus erythematosus, and dermatological conditions caused or aggravated
by sunlight.
Licensing Information:
Treatment of rheumatoid arthritis, discoid and systemic lupus
erythematosus, and dermatological conditions caused or aggravated by
sunlight.
Formulations:
200mg film coated tablets
Dosage & administration:
Administered on expert advice, 200 mg or 400 mg daily (but not exceeding
6.5 mg/kg daily based on ideal body-weight). The minimum effective dose
should be used.
Contraindications Contraindications:
& Warnings:
 Known hypersensitivity to 4-aminoquinoline compounds e.g.  Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption Society of Rheumatology states that hydroxychloroquine has been used relatively safely in pregnancy. The risks of stopping treatment should be weighed against the small possible risk to the unborn child
Caution should also be applied when it is used in the following:
 Patients with hepatic or renal disease, and in those taking drugs  Patients with severe gastrointestinal, neurological or blood disorders.  Breast feeding (patients should be advised not to breast feed)  Patients with porphyria cutanea tarda which can be exacerbated by hydroxychloroquine and in patients with psoriasis since it appears to increase the risk of skin reactions.  Myasthenia gravis – may be aggravated  Amiodarone, moxifloxacin and droperidol increased risk of
ventricular arrhythmias AVOID concomitant use  Ciclosporin - concomitant use increases plasma levels of
 Digoxin- concomitant use increases plasma levels of digoxin.
 Insulin and antidiabetic drugs- doses of such medication may
need decreasing due to enhanced effects caused by hydroxychloroquine Name: HYDROXYCHLOROQUINE Shared Care Guideline
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 Antacids – antacids may reduce absorption of hydroxychloroquine.
Avoid administration within 4 hours of dose
For full list see SPC at www.medicines.org.uk/EMC
Gastrointestinal disturbances such as nausea, diarrhoea, anorexia,
abdominal pain – usually resolve with dose reduction or on drug
discontinuation

Headache- resolves on drug discontinuation

Skin reactions including skin rashes sometimes occur- these usually
resolve on drug discontinuation. Treatment may exacerbate porphyria
cutanea tarda or psoriasis

Corneal deposits- These occur early and may be transient. They are
reversible on stopping treatment
Retinal damage- may be permanent: see monitoring requirements
below. The occurrence of retinopathy is rare if the recommended daily
dose is not exceeded. The administration of doses in excess of the
recommended maximum is likely to increase the risk of retinopathy, and
accelerate its onset
Muscle myopathy- Is rare and reversible after discontinuation of the drug
but recovery may take many months
Bone marrow depression is rare. Ensure patient is informed on how to
identify signs of infection
For full list see SPC at www.medicines.org.uk/EMC
Responsibilities of General:
the specialist
 To assess the suitability of the patient for treatment  As per national, regional and local guidelines, to ensure that the patient/carer has received counselling and understands the therapy, its benefits, limitations, continued monitoring (where applicable), adverse effects, and is aware of actions to take if adverse effects are suspected  Go through patient information leaflet with patient  Inform patients of the long term monitoring requirements  Inform the GP of the information provided to the patient  To review the patient at agreed intervals and copy any relevant  Carry out disease and initial drug monitoring as listed below  Formally hand over to GP by letter and patient informed - send a copy (either electronically or paper copy) of the Shared Care Guideline to the GP and ask them to participate in shared care Prescribing:
 Secondary care will prescribe the first month of treatment Name: HYDROXYCHLOROQUINE Shared Care Guideline
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Disease & drug monitoring:
 Carry out baseline monitoring as listed below Renal and Liver
function
Ophthalmological  Ask patient about visual impairment (not
corrected by glasses). If impairment or eye disease present, assessment by an optometrist is advised and any abnormality should be referred to an ophthalmologist
 Optional: Record near visual acuity of each
eye (with glasses where appropriate) using a standard reading chart  Discuss shared care arrangement with patient  Assess response to treatment and initiate any dose changes as clinically appropriate including discontinuation of treatment Responsibilities of General and Prescribing:
other prescribers
 To reply to the request for shared care within 2 weeks of receipt of  Prescribe as recommended by the specialist. The GP will typically be asked to take up the monitoring and prescribing of hydroxychloroquine one month after it has been initiated  Ensure continued prescribing of hydroxychloroquine remains clinically appropriate at the dose advised by initiating team  Notify consultant if treatment with hydroxychloroquine is discontinued and patient still under the care of the specialist  Ensure there are no drug interactions with any other medications  If patient develops renal or liver insufficiency review dosage and seek  Ask rheumatology team to review patient after 5 years if still on hydroxychloroquine and/or the cumulative dose of 1000g is reached and the patient has been discharged to primary care. Disease & drug monitoring:
 Urgent drug discontinuation/ referral to ophthalmologist as clinically  To stop treatment on the advice of the ophthalmologist or specialist.  To refer back to the specialist if the patient’s condition deteriorates  To identify adverse effects if the patient presents with any signs and liaise with the hospital specialist where necessary. To report adverse effects to the specialist and where appropriate to the Commission on Human Medicines/MHRA (Yellow Card scheme)
Unless otherwise stated by the secondary care specialist, apply the
following monitoring frequencies following handover from secondary
care:

Name: HYDROXYCHLOROQUINE Shared Care Guideline
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At clinic
Ask patient about visual symptoms
appointments
Reinforce advice that patients should be advised to
stop taking the drug immediately and seek the advice
of their prescribing doctor if any disturbances of vision
are noted, including change of colour vision.

If patient presents with changes in visual acuity or
if vision blurred

If care not yet been transferred from secondary care
 Contact the specialist for urgent advice.
If care has been transferred to the GP, initially withold treatment:  Request vision assessed by an optician. Then refer to ophthalmologist depending upon findings. Every 12 months Optician to conduct an annual visual assessment
The optician examination should include testing visual
acuity, careful ophthalmoscopy, fundoscopy, central
visual field testing with a red target, and colour vision

Discontinue hydroxychloroquine immediately and
refer to an ophthalmologist if a patient develops a
retinal pigmentary abnormality, visual field defect, or
any other abnormality not explainable by difficulty in
accommodation or presence of corneal opacities
Responsibilities of General :
the Patient /
 Report any possible side effects to their GP o Stop taking the drug immediately, refrain from driving and seek the advice of their prescribing doctor if any disturbances of vision are noted, including change of colour vision.  Attend appointments and annual optician visits (advise the optician of  Inform GP if pregnancy is suspected, but can be continued Disease & drug monitoring:
As above –contact GP if side effects develop (see adverse effects) and
attend appointments including those for ophthalmological monitoring
Specialist to GP:
 The specialist will inform the GP when they have initiated hydroxychloroquine and when there are any subsequent changes in treatment – standard clinic letter  Send a copy (either electronically or paper copy) of the shared care guideline to the GP and ask whether they are willing to participate in shared care  Inform the GP of the information provided to the patient GP to Specialist:
 To reply to the request for shared care within 2 weeks of receipt of  Irrespective of whether you accept prescribing responsibility or not, Name: HYDROXYCHLOROQUINE Shared Care Guideline
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you should inform the consultant of relevant medical information regarding the patient and changes to the patient’s medication regime irrespective of indication  Notify consultant if treatment with hydroxychloroquine is discontinued Contact names & details:
If you have any concerns regarding individual patients, see consultant letter
for medical contact details or contact one of the following:
Name Title/Location
Telephone
Drug Tariff Nov 2013 - 60 x200mg £5.05
 SPC for Plaquenil accessed 5th September 2013  BSR/BHPR guideline for disease-modifying anti-rheumatic drug (DMARD) therapy in consultation with the British Association of Dermatologists. Rheumatology 2008  Hydroxychloroquine and ocular toxicity recommendations on screening. The Royal College This information is not inclusive of all prescribing information and potential adverse effects. Please refer
to the SPC (data sheet) or BNF for further prescribing information.
The original Microsoft Word file of this document is located on: York Teaching Hospital NHS Foundation Trust Pharmacy Department X:\MEDICINES INFORMATION\Shared Care Guidelines\Approved Shared Care Guidelines\HYDROXYCHLOROQUINE Shared Care Guideline V1 Shared Care Guidelines are also available electronically via http://www.yorkandscarboroughformulary.nhs.uk/
Jane Crewe (Pharmacy YH) Diane Tomlinson (Pharmacist NY and Humber Commissioning Support Unit)- for suitability in primary care Drug and Therapeutics Committee, November 2013 Name: HYDROXYCHLOROQUINE Shared Care Guideline
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Source: http://www.yorkandscarboroughformulary.nhs.uk/docs/sc/HYDROXYCHLOROQUINE%20Shared%20Care%20Guideline%20V1.pdf