Would you increase the hydroxychloroquine dose to more than 5 mg/kg/day in a compliant patient with active non-organ threatening lupus (skin+joints) if serum hydroxychloroquine is not at goal until you reach an acceptable concentration?

Absolutely! Thanks for asking as this should be the trend in dosing.

However, let's call this "non-life threatening lupus" instead of "non-organ threatening".

Cutaneous lupus is one of the top reasons for the poor quality of life in lupus patients (Klein et al., PMID 21397983), so remission is our goal. Uncontrolled lupus arthritis can lead to deforming lupus Jaccoud's arthropathy. Once it occurs, it is irreversible, so remission is our goal with lupus arthritis.

Dosing hydroxychloroquine (HCQ) by ...

Yes, absolutely. I monitor levels of HCQ, but more so that I can have conversations about medication adherence, rather than concern for toxicity. I have been doing this for >3 years, and in that time, nearly 80% of my patients were SUB-therapeutic, and only 1 patient was above the recommended therapeutic target range.

Perhaps more importantly, how can we have an evidence-based risk/benefit conversation about using HCQ when almost all studies showing benefit were utilizing doses higher than 5mg/k...

Sharing clinical experiences, like that of Dr. @Dr. First Last is important.

The reason why I seem crazy pushy about using HCQ drug levels is because:

• I started doing them on all patients after seeing Michelle Petri's presentation at SLEuro 2016; checking the HCQ level every visit caused adherence rates to improve from 55% to 85% (but she used a low level cut off of 500 ng/mL so it was certainly even lower rates from the start).
• I had a low adherence rate in my clinic. Several patients even lie...