Hydroxychloroquine

• Initiation: 200-400 mg orally daily until response
• Maintenance: 200 mg daily (Max dose in severe renal impairment is 200mg daily)
• Maximum dosage: 6.5 mg/kg/day - based on actual body weight
• It is more palatable after food - orange juice may mask the bitter after taste

• Baseline ECG (for QT Interval ) may be done in Rheum clinic if on other QT Prolonging medicines/risk profile.
• Further blood monitoring is not required
• Optician assessment 2 yearly and annual assessments at Opthalmology after 5 years
• Referral to Ophthalmologist at 1 year is appropriate if
• Referral to ophthalmologist at 1 year is appropriate if:
• • Visual impairment/eye disease detected at baseline
  • Risk factors for Retinal toxicity (-concurrent Tamoxifen, renal impairment, dose >5mg/kg)
  • Change in acuity or blurred vision whilst on treatment (stop treatment until assessed)

• Treatment is continued indefinitely providing it remains effective and there are no significant side effects. 
• Hydroxychloroquine takes about 3 months to become effective but may take 6 months. 
• During this period there are likely to be continued symptoms or signs of disease activity. 
• It is reasonable to use IM Depo steroids (Kenalog 40 mg or Depo Medrone 80 mg) up to monthly, depending on the requirements of the individual patient.  The dose required is small (eg monthly Kenalog 40 mg = 1.6 mg Prednisolone daily). 

• Disease modifying drugs will not prevent all flares
• These can be managed with IM Depo steroid as outlined above
• If flares become more frequent, or the disease fails to settle between flares, the dosage should be increased, or an alternative discussed with the rheumatologist

• Pre-existing maculopathy (can be discussed with ophthalmologist)
• It must not be co-prescribed with amiodarone (risk of ventricular arrhythmia’s), moxifloxacin, quinine or mefloquine

• Liver disease
• Kidney disease
• Epilepsy
• Blood disorders

• Amiodarone (see contraindications)
• Antacids reduce its absorption
• Antagonism of anticonvulsant effect
• Increase plasma concentration of digoxin
• Increased risk of ciclosporin toxicity if co-prescribed
• Known hypersensitivity to 4-aminoquinolones

Common effects are in bold type.

Mucocutaneous

• pruritis erythematous rash seen after treatment commenced
• blue-black pigmentation of skin

Haematological

• thrombocytopenia
• agranulocytosis (very rare)

Gastrointestinal

• nausea
• diarrhoea
• abdominal cramps

Ocular

• cycloplegia,
• keratopathy (reversible)
• irreversible retinopathy/maculopathy
• photophobia – advise sunglasses in bright light

Other

• headache
• bleaching of skin/hair
• proximal myopathy
• peripheral neuropathy

Secretaries 01387 241776

Helpline 01387 241095 (answering machine) - Rheumatology Nurse Specialists

Department of Rheumatology doctors via Switchboard 01387 246246