Hydroxychloroquin-Plaquenil

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Hydroxychloroquin   

Generic Name: Hydroxychloroquine (hye-drox-ee-klor-oh-kwin)
Brand Name: Plaquenil
Drug Class: Antimalarial, Antirheumatic (DMARD)
Pregnancy Category: C

Indications of Hydroxychloroquine

  • Prevention and suppression (chemoprophylaxis) of malaria.
  • Treatment of severe rheumatoid arthritis (RA).
  • Treatment of systemic lupus erythematosus (SLE).

Mechanism of Action

Hydroxychloroquine works by inhibiting protein synthesis in susceptible organisms through the suppression of DNA and RNA polymerase activity.

Therapeutic Effects

  • Kills Plasmodium species responsible for malaria.
  • Provides anti-inflammatory benefits in autoimmune conditions.

Pharmacokinetics

  • Absorption: Variable (31–100%) after oral administration.
  • Distribution: Widely distributed; concentrated in red blood cells; crosses placenta; excreted in breast milk.
  • Metabolism/Excretion: Partially metabolized in the liver; partly excreted unchanged in urine.
  • Half-life: 72–120 hours.

Contraindications & Precautions

Contraindicated in:

  • Known hypersensitivity to hydroxychloroquine or chloroquine.
  • Previous visual damage from these drugs.

Use with caution in patients with:

  • Liver disease, alcoholism, or renal impairment.
  • Severe neurological or blood disorders.
  • Retinal or visual field abnormalities.
  • G6PD deficiency, psoriasis, or obesity (dose should be based on ideal body weight).
  • Pregnant or breastfeeding women (unless treating malaria or amebic abscess).
  • Children (long-term use may increase sensitivity).

Adverse Reactions & Side Effects

  • CNS: Seizures, anxiety, confusion, psychosis, irritability, fatigue.
  • Eyes & Ears: Retinopathy, keratopathy, visual disturbances, tinnitus, ototoxicity.
  • Cardiovascular: Hypotension, ECG changes.
  • Gastrointestinal: Nausea, vomiting, abdominal cramps, diarrhea, hepatic failure.
  • Dermatologic: Hair bleaching, alopecia, hyperpigmentation, photosensitivity, Stevens-Johnson syndrome.
  • Hematologic: Agranulocytosis, aplastic anemia, leukopenia, thrombocytopenia.
  • Neurologic: Neuromyopathy, peripheral neuritis.

Drug Interactions

  • ↑ Risk of hepatotoxicity with hepatotoxic drugs.
  • ↑ Risk of hematologic toxicity with penicillamine.
  • ↑ Risk of dermatitis with other dermatotoxic agents.
  • ↓ Effect of rabies vaccine (human diploid cell).
  • Urinary acidifiers may ↑ renal excretion.
  • May increase digoxin levels.

Dosage & Administration

Malaria (Adults):

  • Prophylaxis: 310 mg orally once weekly (start 1–2 weeks before travel, continue 4 weeks after leaving).
  • Treatment: 620 mg orally once, then 310 mg at 6 hr, 24 hr, and 48 hr after initial dose.

Malaria (Children):

  • Prophylaxis: 5 mg/kg orally once weekly.
  • Treatment: 10 mg/kg initially, then 5 mg/kg at 6–8 hr, 24 hr, and 48 hr after first dose.

Rheumatoid Arthritis (Adults):

  • Initial: 400–600 mg once daily.
  • Maintenance: 200–400 mg/day (1–2 divided doses).

Systemic Lupus Erythematosus (Adults):

  • 400 mg once or twice daily; maintenance: 200–400 mg/day.

Pediatrics (RA & SLE):

  • 3–5 mg/kg/day (max 400 mg/day, not exceeding 7 mg/kg/day).

Nursing Implications

Assessment

  • Monitor deep tendon reflexes (discontinue if muscle weakness develops).
  • Perform ophthalmologic exams prior to and every 3–6 months for long-term therapy.
  • Assess clinical improvement in malaria, lupus, or rheumatoid arthritis.

Laboratory Monitoring

  • Regular CBC and platelet counts.
  • Discontinue if severe hematologic abnormalities occur.

Administration Guidelines

  • Administer with milk or meals to reduce GI upset.
  • Tablets may be crushed and mixed with food for easier swallowing.
  • Begin prophylactic therapy 2 weeks before exposure to malaria and continue 4–6 weeks after leaving endemic areas.

Patient & Family Education

  • Take exactly as prescribed; do not skip or double doses.
  • Avoid alcohol while on therapy.
  • Keep out of reach of children (fatalities reported with ingestion of only 3–4 tablets).
  • Importance of regular eye exams during long-term use.
  • Use dark glasses, protective clothing, and sunscreen to reduce risk of photosensitivity.
  • Report immediately if: fever, sore throat, unusual bleeding, bruising, blurred vision, ringing in ears, or muscle weakness occurs.
  • Women should notify healthcare providers if pregnant or breastfeeding.
  • Malaria prevention should include mosquito avoidance measures (repellent, long clothing, netting).

Desired Outcomes

  • Effective prevention or treatment of malaria.
  • Reduction of signs and symptoms in rheumatoid arthritis.
  • Improvement of lupus erythematosus symptoms.

 

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