Hydroxychloroquine

Aka: Hydroxychloroquine, Plaquenil

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II. Indications

  1. Second-Line DMARD in Rheumatoid Arthritis
    1. Especially Antinuclear Antibody positive
    2. May be used in triple combination with Methotrexate and Sulfasalazine
      1. Indicated in moderate to severe disease refractory to single conventional synthetic DMARD
  2. Systemic Lupus Erythematosus
  3. Malaria Prophylaxis and treatment
    1. Regions without Chloroquine resistance, non-severe infections
  4. Rheumatologic off-label uses
    1. Dermatomyositis
    2. Sjogren Syndrome
    3. Sarcoidosis
  5. Infectious off-label uses
    1. Q Fever
  6. NOT indicated in COVID-19 outside of Clinical Trials
    1. Initial studies as of May 2020 suggest no benefit and adverse effect risk (including QTc Prolongation)

III. Contraindications

  1. G6PD Deficiency
    1. Risk of Hemolytic Anemia

IV. Mechanism

  1. Antimalarial agent used in rheumatic disease
  2. Modified Chloroquine to reduce Retinopathy risk
  3. Blocks Sodium and Potassium channels

V. Dosing: Rheumatologic Disorders

  1. Varies significantly based on use
    1. Lower doses are used in infectious disease
  2. Dosing: Adults
    1. Initial: 400 to 600 mg (may consider starting at 200 mg) orally twice daily
    2. Maximum: 600 mg/day
    3. Expect symptom improvement by 2 to 4 months (discontinue if no effect by 6 months)
    4. Taper after 1-2 years when stable to 200 mg orally daily

VI. Dosing: Malaria

  1. Malaria Prophylaxis
    1. Start 1-2 weeks before travel and continue for 4 weeks after leaving Malaria endemic region
    2. Adult: 400 mg salt (310 mg base) orally once weekly
    3. Child: 6.5 mg/kg salt (5 mg/kg base up to adult dose) orally once weekly
  2. Malaria Treatment
    1. Adult: 800 mg salt (620 mg base) to start, then 400 mg salt (310 mg base) at 6, 24 and 48 hours after initial dose
    2. Child: 12.9 mg/kg salt (10 mg/kg base) to start, then 6.5 mg/kg salt (5 mg/kg mg base) at 6, 24 and 48 hours after initial dose

VII. Precautions

  1. One tablet may be lethal in children (lethal dose 30 mg/kg)
  2. Considered safe in pregnancy (all trimesters), despite initially labeled category D

VIII. Adverse Effects

  1. Eye-related Adverse Effects
    1. Epithelial Keratopathy and other Corneal disorders
    2. Retinopathy
      1. Uncommon to Rare (contrast with Chloroquine)
  2. Neurologic adverse effects
    1. Early toxicity (subsides within 2 weeks)
      1. Irritability
      2. Insomnia
      3. Headache
    2. Late toxicity requires medication discontinuation
      1. Tinnitus
      2. Decreased Hearing acuity
    3. Very rare toxicity
      1. Myopathy or muscular weakness
    4. Other adverse effects
      1. Confusion or Delirium
      2. Extrapyramidal Side Effects
      3. Hallucinations
      4. Seizures
  3. Gastrointestinal adverse effects
    1. Increased stool frequency
    2. Diarrhea
    3. Bloating
    4. Nausea or Vomiting
  4. Endocrine Adverse Effects
    1. Hypoglycemia
  5. Hematologic Adverse Effects
    1. Neutropenia
    2. Pancytopenia
  6. Electrolyte adverse effects
    1. Hypokalemia (in toxicity)
  7. Cardiovascular adverse effects
    1. Palpitations
    2. Hypotension (in toxicity)
    3. Premature Atrial Contractions
    4. Cardiomyopathy
    5. QRS Widening (in toxicity)
    6. QTc Prolongation (with risk of Ventricular Tachycardia or Drug-Induced Torsades de Pointes)
      1. Increased risk when combined with other agents causing QTc Prolongation (e.g. Azithromycin)

IX. Pharmacokinetics

  1. Onset: 2-4 hours after oral dose
  2. Half-Life: 20 to 40 days
  3. Lethal dose in young children as low as 750 mg

X. Efficacy: Rheumatoid Arthritis

  1. Response in 70-80% of cases
  2. Response occurs in 3-6 months
  3. Highest efficacy when used early in disease process

XI. Safety

  1. Considered safe in Lactation
  2. In pregnany, use if benefit outweighs risk
  3. Monitoring
    1. Routine Eye Exam every 6-12 months (including a baseline exam)
    2. Complete Blood Count (CBC) periodically

XII. Management: Hydroxychloroquine Overdose or Toxicity

  1. See ABC Management
  2. Activated Charcoal if <1 hour from ingestion and patient maintaining own airway
  3. Ventricular Arrhythmia
    1. Cardioversion
    2. Lidocaine
  4. Wide QRS
    1. Bicarbonate (caution if Hypokalemia)
  5. Hypokalemia
    1. Potassium Replacement (caution)
  6. Seizures
    1. Benzodiazepines
  7. Hypotension
    1. Norepinephrine
  8. Other measures
    1. ECMO (refractory cardiovascular failure)

XIII. Resources

  1. Hydroxychloroquine Tablet (DailyMed)
    1. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=452092b4-7a8f-4d19-8113-f1c2a948d3d8

XIV. References

  1. (2020) LexiComp, Hydroxychloroquine, accessed 5/6/2020
  2. Tomaszekski (2020) Crit Dec Emerg Med 14(4):32
  3. Matteson (2000) Mayo Clin Proc 75:669-74 [PubMed]
  4. Pincus (1999) Clin Rheumatol 17(6 Suppl 18):S2-S124 [PubMed]

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Cost: Medications

hydroxychloroquine (on 12/21/2022 at Medicaid.Gov Survey of pharmacy drug pricing)
HYDROXYCHLOROQUINE 100 MG TAB Generic $0.18 each
HYDROXYCHLOROQUINE 200 MG TAB Generic $0.21 each
FPNotebook does not benefit financially from showing this medication data or their pharmacy links. This information is provided only to help medical providers and their patients see relative costs. Insurance plans negotiate lower medication prices with suppliers. Prices shown here are out of pocket, non-negotiated rates. See Needy Meds for financial assistance information. GoodRx is another tool for finding lower drug prices.

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