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Rosenbaum, Dr. Domingues, and Dr. Averns had no relevant financial disclosures. On Twitter mitchelzoler. A substantial number of rheumatology patients are receiving excess starting and maintenance doses of hydroxychloroquine despite the existence of Skip to main content. Coronavirus News Center.
Hydroxychloroquine dosage recommendations often ignored.
By Mitchel L. Courtesy Dr. If you suspect that you or someone else might have taken an overdose of this medicine, go to the accident and emergency department of your local hospital at once. Take the container with you, even if it is empty. This medicine is for you. Never give it to other people even if their condition appears to be the same as yours.
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If you buy any medicines, check with a pharmacist that they are suitable to take with your other medicines. If you are having an operation or any dental treatment, tell the person carrying out the treatment which medicines you are taking. Do not keep out-of-date or unwanted medicines. Take them to your local pharmacy which will dispose of them for you. Dated June Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions.
How to store hydroxychloroquine Important information about all medicines. The most serious adverse effects affect the eye, with dose-related retinopathy as a concern even after hydroxychloroquine use is discontinued. 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, 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.
Children may be especially vulnerable to developing adverse effects from hydroxychloroquine. One of the most serious side effects is retinopathy generally with chronic use. The daily safe maximum dose for eye toxicity can be computed from one's height and weight using this calculator. Cumulative doses can also be calculated from this calculator. 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.
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Toxicity from hydroxychloroquine may be seen in two distinct areas of the eye: the cornea and the macula. The cornea may become affected relatively commonly 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. Due to rapid absorption, symptoms of overdose can occur within a half an hour after ingestion.
Overdose symptoms include convulsions, drowsiness, headache, heart problems or heart failure , difficulty breathing and vision problems. Hydroxychloroquine overdoses are rarely reported, with seven previous cases found in the English medical literature. Treatment consisted of fluid boluses and dopamine, oxygen, and potassium supplementation.
The presence of hydroxychloroquine was confirmed through toxicologic tests. The patient's hypotension resolved within 4. The drug transfers into breast milk and should be used with care by pregnant or nursing mothers. Care should be taken if combined with medication altering liver function as well as aurothioglucose Solganal , cimetidine Tagamet or digoxin Lanoxin.
Despite Plaquenil dosing recommendations, retinal toxicity remains
HCQ 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 HCQ. Both neostigmine and pyridostigmine antagonize the action of hydroxychloroquine. While there may be a link between hydroxychloroquine and hemolytic anemia in those with glucosephosphate dehydrogenase deficiency , this risk may be low in those of African descent.
Specifically, the FDA drug label for hydroxychloroquine lists the following drug interactions  :.
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Hydroxychloroquine has similar pharmacokinetics to chloroquine , with rapid gastrointestinal absorption and elimination by the kidneys. Antimalarials are lipophilic weak bases and easily pass plasma membranes. The free base form accumulates in lysosomes acidic cytoplasmic vesicles and is then protonated ,  resulting in concentrations within lysosomes up to times higher than in culture media. This increases the pH of the lysosome from 4 to 6. Hydroxychloroquine increases  lysosomal pH in antigen-presenting cells.
In inflammatory conditions, it blocks toll-like receptors on plasmacytoid dendritic cells PDCs. Toll-like receptor 9 TLR 9 recognizes DNA-containing immune complexes and leads to the production of interferon and causes the dendritic cells to mature and present antigen to T cells , therefore reducing anti-DNA auto-inflammatory process. In , a novel mechanism was described wherein hydroxychloroquine inhibits stimulation of the toll-like receptor TLR 9 family receptors.