A 34-year-old woman comes to the clinic with a facial rash, joint pains, and oral ulcers. She has no associated fever or other systemic symptoms and otherwise feels well. Medical history is unremarkable, and the patient's only concurrent medication is an oral contraceptive. She does not smoke and consumes alcohol only on social occasions. Antinuclear and anti-double-stranded DNA antibody titers are elevated. Creatinine and complement levels are normal. The patient is diagnosed with systemic lupus erythematosus, and therapy with hydroxychloroquine is initiated. Which of the following evaluations should be done periodically while the patient is taking this medication?

Question

A 34-year-old woman comes to the clinic with a facial rash, joint pains, and oral ulcers.  She has no associated fever or other systemic symptoms and otherwise feels well.  Medical history is unremarkable, and the patient's only concurrent medication is an oral contraceptive.  She does not smoke and consumes alcohol only on social occasions.  Antinuclear and anti-double-stranded DNA antibody titers are elevated.  Creatinine and complement levels are normal.  The patient is diagnosed with systemic lupus erythematosus, and therapy with hydroxychloroquine is initiated.  Which of the following evaluations should be done periodically while the patient is taking this medication?

Quizplus · Accepted Answer

11ec25c8_d527_4453_bc81_4737f7d730dd_MD0003_00 This patient, with a new diagnosis of systemic lupus erythematosus (SLE), has limited disease, with skin, joint, and mucosal manifestations. Disease activity in SLE should be monitored with periodic blood counts, inflammatory markers (eg, erythrocyte sedimentation rate), complement levels, and anti-double-stranded DNA antibody titers. Patients should also be screened regularly for lupus nephritis with urinalysis, serum creatinine, and urine protein assay. The choice of drug therapy in SLE depends on the degree of organ involvement. Most patients with active SLE benefit from hydroxychloroquine, a safe and well-tolerated medication. However, it can cause retinal toxicity on rare occasions, with a potential for irreversible vision loss. This is most common after 5-7 years of therapy. For this reason, patients treated with hydroxychloroquine should have a baseline ophthalmologic evaluation, with annual reassessment beginning after 5 years. (Choice A) Ototoxicity is a common adverse effect of aminoglycoside antibiotics and platinum-based chemotherapeutic agents. Hearing impairment has been reported with hydroxychloroquine, but routine audiometry is not currently recommended. (Choice B) Echocardiography is used to assess lupus myocarditis and can identify cardiotoxicity in patients with rheumatoid arthritis taking tumor necrosis factor inhibitors (eg, etanercept). Cardiotoxicity is not a significant concern with hydroxychloroquine. (Choices D and E) Methotrexate is used as a steroid-sparing agent in patients with moderate to severe SLE. Methotrexate is associated with multisystem toxicity affecting liver, lungs, mucosa, and bone marrow. Hepatic markers are frequently monitored in patients with SLE who take methotrexate, but hydroxychloroquine does not require routine liver testing. (Choice F) Amiodarone can cause a variety of endocrinopathies, including both hypo- and hyperthyroidism (for which periodic thyroid function monitoring is recommended). Educational objective: Hydroxychloroquine is used for patients with active systemic lupus erythematosus. However, it can cause retinal toxicity with prolonged use. Patients treated with hydroxychloroquine should have a baseline ophthalmologic evaluation and periodic reassessment. References: Revised recommendations on screening for chloroquine and hydroxychloroquine retinopathy. (http://www.ncbi.nlm.nih.gov/pubmed/21292109)

A 34-Year-Old Woman Comes to the Clinic with a Facial