Hydroxychloroquine


Hydroxychloroquine, sold under the brand name Plaquenil among others, is a medication used to prevent and treat malaria in areas where malaria remains sensitive to chloroquine. Other uses include treatment of rheumatoid arthritis, lupus, and porphyria cutanea tarda. It is taken by mouth, often in the form of hydroxychloroquine sulfate.
Common side effects may include vomiting, headache, blurred vision, and muscle weakness. Severe side effects may include allergic reactions, retinopathy, and irregular heart rate. Although all risk cannot be excluded, it remains a treatment for rheumatic disease during pregnancy. Hydroxychloroquine is in the antimalarial and 4-aminoquinoline families of medication.
Hydroxychloroquine was approved for medical use in the United States in 1955. It is on the World Health Organization's List of Essential Medicines. In 2023, it was the 131st most commonly prescribed medication in the United States, with more than 4million prescriptions.
Hydroxychloroquine has been studied for an ability to prevent and treat coronavirus disease 2019, but clinical trials found it ineffective for this purpose and a possible risk of dangerous side effects. Among studies that deemed hydroxychloroquine intake to cause harmful side effects, a publication by The Lancet was retracted due to data flaws. The speculative use of hydroxychloroquine for COVID-19 threatens its availability for people with established indications.

Medical uses

Hydroxychloroquine treats rheumatic disorders such as systemic lupus erythematosus, rheumatoid arthritis, and porphyria cutanea tarda, and certain infections such as Q fever and certain types of malaria. It is considered the first-line treatment for systemic lupus erythematosus. Certain types of malaria, resistant strains, and complicated cases require different or additional medication.
Hydroxychloroquine blocks the effects of some chemicals released in autoimmune diseases, and is used to treat inflammatory conditions.
It is widely used to treat primary Sjögren syndrome but does not appear to be effective. Hydroxychloroquine is widely used in the treatment of post-Lyme arthritis. It may have both an anti-spirochete activity and an anti-inflammatory activity, similar to the treatment of rheumatoid arthritis.

Contraindications

The US FDA drug label advises that hydroxychloroquine should not be prescribed to individuals with known hypersensitivity to 4-aminoquinoline compounds. There are several other contraindications, and caution is required if the person considered for treatment has certain heart conditions, diabetes, or psoriasis.

Adverse effects

Hydroxychloroquine has a narrow therapeutic index, meaning there is little difference between toxic and therapeutic doses. The most common adverse effects are nausea, stomach cramps, and diarrhea. Other common adverse effects include itching and headache. The most serious adverse effects affect the eye, with dose-related retinopathy as a concern even after hydroxychloroquine use is discontinued. Serious reported neuropsychiatric adverse effects of hydroxychloroquine use include agitation, mania, difficulty sleeping, hallucinations, psychosis, catatonia, paranoia, depression, and suicidal thoughts. In rare situations, hydroxychloroquine has been implicated in cases of serious skin reactions such as Stevens–Johnson syndrome, toxic epidermal necrolysis, and Drug reaction with eosinophilia and systemic symptoms. Reported blood abnormalities with its use include lymphopenia, eosinophilia, and atypical lymphocytosis.
For short-term treatment of acute malaria, adverse effects can include abdominal cramps, diarrhea, heart problems, reduced appetite, headache, nausea and vomiting. Other adverse effects noted with short-term use of Hydroxychloroquine include low blood sugar and QT interval prolongation. Idiosyncratic hypersensitivity reactions have occurred.
For prolonged treatment of lupus or rheumatoid arthritis, adverse effects include the acute symptoms, plus altered eye pigmentation, acne, anemia, bleaching of hair, blisters in mouth and eyes, blood disorders, cardiomyopathy, convulsions, vision difficulties, diminished reflexes, emotional changes, excessive coloring of the skin, hearing loss, hives, itching, liver problems or liver failure, loss of hair, muscle paralysis, weakness or atrophy, nightmares, psoriasis, reading difficulties, tinnitus, skin inflammation and scaling, skin rash, vertigo, weight loss, and occasionally urinary incontinence. Hydroxychloroquine can worsen existing cases of both psoriasis and porphyria.
Children may be especially vulnerable to developing adverse effects from hydroxychloroquine overdoses.

Eyes

One of the most serious side effects is retinopathy. People taking 400 mg of hydroxychloroquine or less per day generally have a negligible risk of macular toxicity, whereas the risk begins to increase when a person takes the medication over five years or has a cumulative dose of more than 1000 grams. The daily safe maximum dose for eye toxicity can be estimated from a person's height and weight. Macular toxicity is related to the total cumulative dose rather than the daily dose. Regular eye screening, even in the absence of visual symptoms, is recommended to begin when either of these risk factors occurs.
Toxicity from hydroxychloroquine may be seen in two distinct areas of the eye: the cornea and the macula. The cornea may become affected by an innocuous cornea verticillata or vortex keratopathy and is characterized by whorl-like corneal epithelial deposits. These changes bear no relationship to dosage and are usually reversible on cessation of hydroxychloroquine.
The macular changes are potentially serious. Advanced retinopathy is characterized by reduction of visual acuity and a "bull's eye" macular lesion which is absent in early involvement.

Overdose

Overdoses of hydroxychloroquine are extremely rare, but extremely toxic. Eight people are known to have overdosed since the drug's introduction in the mid-1950s, of which three have died. Chloroquine has a risk of death in overdose in adults of about 20%, while hydroxychloroquine is estimated to be two or threefold less toxic.
Serious signs and symptoms of overdose generally occur within an hour of ingestion. These may include sleepiness, vision changes, seizures, coma, stopping of breathing, and heart problems such as ventricular fibrillation and low blood pressure. Loss of vision may be permanent. Low blood potassium, to levels of 1 to 2 mmol/L, may also occur. Cardiovascular abnormalities such as QRS complex widening and QT interval prolongation may also occur.
Treatment recommendations include early mechanical ventilation, heart monitoring, and activated charcoal. Supportive treatment with intravenous fluids and vasopressors may be required with epinephrine being the vasopressor of choice. Stomach pumping may also be used. Sodium bicarbonate and hypertonic saline may be used in cases of severe QRS complex widening. Seizures may be treated with benzodiazepines. Intravenous potassium chloride may be required, however this may result in high blood potassium later in the course of the disease. Dialysis does not appear to be useful.

Detection

Hydroxychloroquine may be quantified in plasma or serum to confirm a diagnosis of poisoning in hospitalized victims or in whole blood to assist in a forensic investigation of a case of sudden or unexpected death. Plasma or serum concentrations are usually in a range of 0.1-1.6 mg/L during therapy and 6–20 mg/L in cases of clinical intoxication, while blood levels of 20–100 mg/L have been observed in deaths due to acute overdosage.

Interactions

The drug transfers into breast milk. There is no evidence that its use during pregnancy is harmful to the developing fetus and its use is not contraindicated in pregnancy.
The concurrent use of hydroxychloroquine and the antibiotic azithromycin appears to increase the risk for certain serious side effects with short-term use, such as an increased risk of chest pain, congestive heart failure, and mortality from cardiovascular causes. Care should be taken if combined with medication altering liver function as well as aurothioglucose, cimetidine or digoxin. Hydroxychloroquine can increase plasma concentrations of penicillamine which may contribute to the development of severe side effects. It enhances hypoglycemic effects of insulin and oral hypoglycemic agents. Dose altering is recommended to prevent profound hypoglycemia. Antacids may decrease the absorption of hydroxychloroquine. Both neostigmine and pyridostigmine antagonize the action of hydroxychloroquine.
While there may be a link between hydroxychloroquine and hemolytic anemia in those with glucose-6-phosphate dehydrogenase deficiency, this risk may be low in those of African descent.
Specifically, the US Food and Drug Administration's drug label for hydroxychloroquine lists the following drug interactions:

Pharmacokinetics

Hydroxychloroquine has similar pharmacokinetics to chloroquine, with rapid gastrointestinal absorption, large distribution volume, and elimination by the kidneys; Tmax is 2–4.5 hours. Cytochrome P450 enzymes metabolize hydroxychloroquine to N-desethylhydroxychloroquine. Both agents also inhibit CYP2D6 activity and may interact with other medications that depend on this enzyme.

Pharmacodynamics

Antimalarials are lipophilic weak bases and easily pass plasma membranes. The free base form accumulates in lysosomes and is then protonated, resulting in concentrations within lysosomes up to 1,000 times higher than in culture media. This increases the pH of the lysosome from four to six. Alteration in pH causes inhibition of lysosomal acidic proteases causing a diminished proteolysis effect. Higher pH within lysosomes causes decreased intracellular processing, glycosylation and secretion of proteins with many immunologic and nonimmunologic consequences. These effects are believed to be the cause of a decreased immune cell functioning such as chemotaxis, phagocytosis and superoxide production by neutrophils. Hydroxychloroquine is a weak diprotic base that can pass through the lipid cell membrane and preferentially concentrate in acidic cytoplasmic vesicles. The higher pH of these vesicles in macrophages or other antigen-presenting cells limits the association of autoantigenic peptides with class II MHC molecules in the compartment for peptide loading and/or the subsequent processing and transport of the peptide-MHC complex to the cell membrane.