Laboratory Surveillance

Up to now, published dermatologic expert opinions recommend all or some of the following tests before initiating therapy: complete blood cell counts, liver function tests, glucose-6-phosphate dehydrogenase levels, and urine porphyrin determinations, as well as blood cell count and liver function tests at follow-up every 3 to 4 months (Dutz and Ho 1998). However, this does not seem to be cost beneficial (Sontheimer 2000). In several studies, no significant hematologic or hepatic toxic effects were observed when using the previously mentioned dosing guidelines (Fox et al. 1996, Fries et al. 1993, Kuhn et al. 2000). It is questionable whether routine testing would have prevented the only three cases with severe side effects using the recommended doses: one report of a nonfatal case of serious hematologic toxic effects (McDuffie 1965) and two reports of idiosyncratic fatal hepatotoxic effects in the first 2 weeks of treatment (Makin and Wendon 1994).

Since 1996, the American College of Rheumatology guidelines for the use of hydroxychloroquine, although for rheumatoid arthritis, have stated explicitly that pretreatment and follow-up laboratory tests of any type are not necessary (American College of Rheumatology 1996). This recommendation is supported by the experience of Sontheimer and may hold true also for correctly dosed chloroquine (Sontheimer 2000). He estimates savings of approximately $1.1 million per year if routine laboratory tests for hydroxychloroquine would be abandoned by dermatologists and recommends cost-benefit analysis for laboratory analysis during the treatment of dermatologic diseases with antimalarials.

During quinacrine therapy, blood counts should be performed every 2-3 months. If significant decreases in hemoglobin levels and reticulocyte counts are observed, therapy has to be stopped.

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