What is the best course of treatment while on Plaquenil (hydroxychloroquine) and receiving Kenalog (triamcinolone) injections?

Management of Patients on Plaquenil and Kenalog Injections

Continue both Plaquenil (hydroxychloroquine) and Kenalog (triamcinolone) injections as prescribed, but implement mandatory ophthalmologic monitoring and work toward minimizing glucocorticoid exposure to prevent long-term complications.

Critical Monitoring Requirements

Ophthalmologic Surveillance for Hydroxychloroquine

Baseline and ongoing eye examinations are non-negotiable for patients on Plaquenil to detect retinal toxicity before irreversible vision loss occurs. 1

• Baseline fundus examination must be performed within the first year of starting hydroxychloroquine to rule out preexisting maculopathy 1
• Annual screening should begin after 5 years of use for patients on acceptable doses without major risk factors 1
• Screening methods must include automated visual fields and spectral-domain optical coherence tomography (SD-OCT) 1
• Earlier screening (before 5 years) is required if high-risk factors are present 1

Risk Factors Requiring Enhanced Monitoring

The following factors increase retinal toxicity risk and warrant more frequent ophthalmologic assessment 2, 1:

• Daily dose exceeding 5.0 mg/kg actual body weight 1
• Duration of use beyond 5 years 1
• Chronic kidney disease 2
• Pre-existing retinal or macular disease 2
• Asian descent (may show extramacular damage patterns) 1

Laboratory Monitoring

• Annual complete blood count (CBC) and liver function tests (LFTs) are conditionally recommended for patients on hydroxychloroquine 1

Glucocorticoid Steroid Management Strategy

The medium to long-term goal should be to minimize glucocorticoid exposure to ≤7.5 mg/day prednisone equivalent or discontinue entirely, as long-term glucocorticoid therapy causes irreversible organ damage. 2

Kenalog Injection Considerations

• Intramuscular Kenalog is indicated for various rheumatic and autoimmune conditions when oral therapy is not feasible 3
• Typical dosing ranges from 40-80 mg for systemic administration, with some patients controlled on as low as 20 mg 3
• Intra-articular dosing ranges from 2.5-15 mg depending on joint size 3
• Strict aseptic technique is mandatory to prevent infectious complications 3

Glucocorticoid-Related Risks

Risks substantially increase at continuous doses above 7.5 mg/day prednisone equivalent, though even lower doses may be harmful 2. The combination of systemic and local steroid injections requires careful tracking of total glucocorticoid exposure.

Treatment Optimization Algorithm

Step 1: Verify Hydroxychloroquine Dosing

• Ensure daily dose does not exceed 5.0 mg/kg actual body weight to minimize toxicity risk 2, 1
• At recommended doses, toxicity risk is <1% in first 5 years, <2% up to 10 years, but increases to nearly 20% after 20 years 1

Step 2: Establish Monitoring Schedule

• If <5 years on hydroxychloroquine: Annual CBC and LFTs; ophthalmologic screening can be deferred until year 5 if low-risk 1
• If >5 years on hydroxychloroquine: Annual ophthalmologic screening with visual fields and SD-OCT, plus annual CBC and LFTs 1
• If high-risk factors present: Consider 6-month ophthalmologic intervals 2

Step 3: Minimize Glucocorticoid Burden

• Assess frequency and dosing of Kenalog injections to calculate cumulative steroid exposure 2
• Consider immunosuppressive agents to facilitate glucocorticoid tapering if disease activity allows 2
• Target prednisone-equivalent dose ≤7.5 mg/day or discontinuation 2

Step 4: Address Disease Activity

• For SLE patients: Hydroxychloroquine is recommended for all patients and provides multiple beneficial effects including prevention of disease flares 2
• Treatment goals: Aim for remission or low disease activity (SLEDAI ≤4, PGA ≤1 with glucocorticoids ≤7.5 mg prednisone) 2
• Monitor adherence: Poor adherence to hydroxychloroquine is common; drug blood levels can assess compliance 2

Critical Safety Warnings

Retinopathy is Irreversible

There is no treatment for hydroxychloroquine retinopathy once it develops, making early detection through screening the only protective strategy. 1 Visual acuity often remains excellent until severe damage occurs, so patients cannot rely on symptoms 1.

Questionable Test Results

If screening tests show questionable abnormalities, repeat or validate with additional procedures before discontinuing hydroxychloroquine unnecessarily 1. The medication provides substantial disease-modifying benefits that should not be abandoned without confirmation of toxicity.

Kenalog Injection Complications

• Subcutaneous fat atrophy may occur if injection technique is improper 3
• Tissue atrophy can result from periarticular injection, particularly in the deltoid region 3
• Sterile endophthalmitis has been reported with intravitreal triamcinolone, though this is not relevant for IM or intra-articular use 4, 5

Patient Education Points

Inform patients about 1:

• The risk of retinal toxicity with long-term hydroxychloroquine use
• Importance of maintaining proper dosing (≤5.0 mg/kg/day)
• Necessity of regular ophthalmologic screening
• Need to report any visual changes immediately (difficulty reading, problems adjusting to low light, blurred vision)
• Long-term risks of glucocorticoid therapy and the goal to minimize exposure