Oxfordshire
Clinical Commissioning Group
HYDROXYCHLOROQUINE FOR USE IN ADULT AND PAEDIATRIC RHEUMATOLOGY
Shared Care Protocol
This protocol provides prescribing and monitoring guidance for hydroxychloroquine therapy.
It should be read in conjunction with the shared care responsibilities, the Summary of Product
Characteristics (SPC) available on www.medicines.org.uk/emc and the BNF.
BACKGROUND FOR USE
Hydroxychloroquine (HCQ) is a disease modifying anti-rheumatic drug (DMARD). It is used to treat:
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Systemic lupus erythematosus (SLE) (licensed)
Rheumatoid arthritis (licensed)
Juvenile Systemic Lupus Erythematosus
Juvenile Dermatomyositis and Sarcoidosis
Juvenile Idiopathic Arthritis
Its use in this protocol includes the above two indications. In rheumatology it is often used in
combination with other DMARDs, such as methotrexate or sulfasalazine.
For all renal patients, supply of this medication will be provided in secondary care.
CONTRAINDICATIONS AND PRECAUTIONS
CONTRAINDICATION
Pre-existing maculopathy
Avoid
Breastfeeding
Avoid
PRECAUTIONS
Epilepsy
May reduce threshold for convulsions
Severe gastro-intestinal disorders
Use with caution
Psoriasis
May exacerbate skin symptoms
Moderate to severe hepatic and renal
impairment and drugs which cause renal and
hepatic toxicity
Use with caution
Pregnancy
HCQ has been used relatively safely in pregnancy.
The risk of stopping therapy must be weighed against
the small possible risk to the unborn child.
Myasthenia gravis
May aggravate symptoms
HCQ treatment for more than five years
Discuss with ophthalmologist
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Vaccinations
Live vaccines such as oral polio, rubella, MMR, BCG
and yellow fever should not be given due to the risk of
increased antigenic reaction and possible reduced
immunological response.
Pneumovax is recommended
Annual flu vaccines are safe and recommended.
Remember, for paediatric patients Fluenz Tetra® (nasal
flu vaccine) is live so should not be used.
DOSAGE1
Rheumatology indications:
 Typical regimen 200 – 400 mg orally daily
 Maximum dose 6.5 mg/kg daily (but not exceeding 400 mg daily)
 Doses should be calculated using ideal body weight for obese patients
 Time to response is 3 to 6 months
Paediatric Indications:
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Prescribed according to weight: 5- 6.5mg/kg/day in one or two divided doses. Prescribe
according to ideal body weight especially in overweight children to reduce risk of ocular
toxicity
Maximum 400mg per day.
Benefit is seen after 6 to 8 weeks, improvement may continue over a further 4 to 6 months.
Hydroxychloroquine is available as 200mg tablets. Tablets may be halved or crushed and
dispersed in water.
In children unable to take solid dosage forms, a specially manufactured liquid is required.
Review regularly and switch to tablets as soon as the child can take them.
PRE-TREATMENT ASSESSMENT BY SPECIALIST
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FBC, LFTs, U&Es, CRP.
Antimalarials can cause retinal damage, but recent studies show that this occurs less
frequently with hydroxychloroquine than chloroquine.
The Royal College of Ophthalmologists has produced guidance for screening to prevent
ocular toxicity on long-term treatment with chloroquine and hydroxychloroquine1:
Patients should be asked about visual impairment (not corrected by glasses). If abnormality
detected, refer to ophthalmologist.
Check near visual acuity of each eye (with glasses if appropriate) using a standard reading
chart.
Counsel patient to attend optometrist annually for visual acuity test. Bring test results to the
next appointment.
ONGOING MONITORING SCHEDULE
Parameter
Frequency
Blood tests
Not required for detecting toxicity.
Disease monitoring
Ongoing monitoring to be done by specialist in
accordance with clinical need.
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Ask about visual symptoms including blurred
vision. Request all patients to attend
optometrist for visual acuity test and provide
test report.
Annually
ACTIONS TO BE TAKEN
Side Effect
Action
Change in visual acuity or development of
blurred vision
Gastrointestinal disturbance
Skin rashes
Withhold treatment. Discuss with specialist who
may arrange a review by ophthalmologist.
If severe, drug may have to be discontinued.
Often photosensitive. Stop in all but the mildest
of cases.
HCQ is very toxic in over dosage. Immediate
advice from the Poisons Centre is essential.
Children presenting within 1 hour of ingesting
doses greater than 20mg/kg should be
considered for activated charcoal 1mg/kg.
Over dosage
Notes:
Hydroxychloroquine can be withheld for 2-3 weeks without inducing a flare.
Hydroxychloroquine should not be stopped prior to elective surgery.
NOTABLE DRUG INTERACTIONS
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Antacids: Reduce absorption of hydroxychloroquine and should be avoided within 4 hours of
dose.
Moxifloxacin, amiodarone, quinine: Increase risk of cardiac arrhythmias if used with
hydroxychloroquine and should be avoided.
Mefloquine: Increased risk of convulsions if used with hydroxychloroquine and should be
avoided.
Digoxin, ciclosporin, methotrexate: Hydroxychloroquine may increase plasma concentration
of these drugs. Note that in practice, hydroxychloroquine and methotrexate are often used
together, with dose adjustments.
Neostigmine and pyridostigmine effects are diminished by hydroxychloroquine, causing
increased symptoms of myasthenia gravis. Avoid concomitant use.
NSAIDs may be continued.
BACK-UP INFORMATION AND ADVICE
Contact Details
Oxford University Hospitals NHS Trust
Rheumatology
Rheumatology Helpline (Adult and
Paediatric)
Rheumatology Senior Registrar on call
Medicines
Information
01865 737656
01865 741155, ask for SR on call via
switchboard.
Tel 01865 221505
REFERENCES
1. Royal College of Ophthalmologists. Hydroxychloroquine and ocular toxicity:
Recommendation on screening, 2009
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2. BNF 68, September 2014-March 2015
3. Hydroxychloroquine SPC, http://www.medicines.org.uk/emc/ last updated 25/03/14
4. BSPAR (British Society for Paediatric and Adolescent Rheumatology) Clinical Guidelines
2010 – Hydroxychloroquine
Acknowledge:
Adapted from Buckinghamshire CCG Shared Care Protocols.
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