What is Hydroxychloroquine Really Used for?

Can you say hydroxychloroquine five times fast?

These days, even people with zero healthcare experience have likely heard of the medication hydroxychloroquine as it has been discussed as a potential (and controversial) treatment in Covid-19. What was once a drug that existed in general obscurity has now been propelled to the headlines. Rather than get caught up in the controversy surrounding this drug and the people claiming its benefits, let’s dive into the actual information you may need to know in order to give this drug safely or take care of those hypothetical patients on your exams. As always, we’ll use the Straight A Nursing pharmacology framework, DRRUGS to get all the most-important facts squared away. Ready? Let’s do this.

D: Drug Class

Hydroxychloroquine (Plaquenil) is an antimalarial quinoline and is also considered a DMARD, or a disease-modifying anti-rheumatic drug.

R: Routes

Unlike a lot of the drugs we’ve been reviewing recently, hydroxychloroquine has only one route. PO…all day every day.

R: Regular Dose Range

Hydroxychloroquine is typically dosed at 200 to 600 mg/day depending on indication. Initial doses are often higher, with maintenance doses typically being a bit lower. 

U: Uses

Hydroxychloroquine has been traditionally used as an antimalarial drug in areas of the world where tolerance to the drug has not developed. Though the exact mechanism of action against malaria is unclear, it is known that the drug accumulates in the malaria parasite lysosomes, which raises the pH and interferes with the parasite’s ability to break down hemoglobin. This, in turn, prevents normal growth and replication of the parasite. 

Hydroxychloroquine is also considered a DMARD and is used to treat rheumatic disease such as rheumatoid arthritis and systemic lupus erythematosus. In rheumatic disease, hydroxychloroquine is used to decrease the pain and swelling associated with arthritis, prevent joint damage, and prevent or ease the intensity of lupus flares. 

G: Guidelines

Probably the most interesting thing about hydroxychloroquine is that it comes with a pretty significant safety profile. And that, my friends, is one of the reasons it’s been so controversial as a treatment for Covid-19. So, what sorts of guidelines should you follow if administering this medication?

• Make note if the patient is taking any hepatotoxic medications or has a history of liver disease, as this medication can potentiate the liver-harming effects of these drugs.
• Since this medication crosses the placenta and is excreted in breast milk, it would only be used in pregnant or breastfeeding women in very specific circumstances.
• If your patient is on digoxin, you will need to monitor digoxin levels carefully as hydroxychloroquine can increase serum levels of this medication.
• Patient will need eye exams prior to starting high-dose therapy and again every three to six months. Retinal damage risk can be reduced by wearing dark glasses when in bright light.
• Monitor CBC and platelet count periodically throughout therapy.
• GI upset can occur, so teach patients to take with food or milk.
• If the patient is taking for malaria prophylaxis, they need to start the regimen two weeks before exposure and continue it for up to six weeks post exposure.
• The medication can be crushed and mixed with something like jam or Jell-o for easy administration if the patient is unable to swallow pills.
• Assess patient for muscle weakness by testing deep tendon reflexes.
• Monitor for prolongation of QT interval, which you can read more about here. The short version is that a long QT interval can put the patient at high risk for fatal ventricular dysrhythmias.

S: Side Effects

Some common side effects of hydroxychloroquine are…

• Cardiac: prolonged QT interval, ventricular dysrhythmias, hypotension
• GI: upset stomach (advise patient to take with food), nausea, vomiting, liver failure, loss of appetite
• CNS: seizures, confusion, fatigue, headache, psychoses
• Hematology: aplastic anemia, agranulocytosis, thrombocytopenia, leukopenia
• Dermatology: hyperpigmentation, alopecia, Stevens-Johnson syndrome
• Muscular: neuromyopathy
• EENT: retinopathy, ototoxicity, tinnitus

As far as a treatment for Covid-19, clinical trials are currently underway so the jury is still out on this one (as of the date of writing, which is April, 2020). Unfortunately, the media hype around this medication did lead to some shortages of hydroxychloroquine for lupus patients, which is rather unfortunate since it is a proven medication for this condition. 

For the most part, you will most likely see hydroxychloroquine used to treat patients with lupus, so if you’re interested in learning about that disorder, then check out podcast episode 56.

Get this on audio in Podcast Episode 103.

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References

Deglin, J. H., & Vallerand, A. H. (2007). Davis’s drug guide for nurses(11th ed.). F. A. Davis Company.

Drugs.com. (n.d.). Hydroxychloroquine. https://www.drugbank.ca/drugs/DB01611

Sandhu, V. (n.d.). Hydroxychloroquine (Plaquenil). Retrieved April 29, 2020, from https://www.rheumatology.org/I-Am-A/Patient-Caregiver/Treatments/Hydroxychloroquine-Plaquenil