From the Guidelines
Hydroxychloroquine overdose is a life-threatening medical emergency that requires immediate hospitalization and careful management to prevent fatal arrhythmias and other complications. The treatment of hydroxychloroquine overdose involves supportive care, including cardiac monitoring, correction of electrolyte abnormalities, and management of symptoms such as seizures and hypotension 1. It is essential to note that hydroxychloroquine can cause QT prolongation and potentially fatal arrhythmias, particularly in individuals with underlying genetic predispositions or multiple modifiable and nonmodifiable QTc risk factors 1.
Some key considerations in the management of hydroxychloroquine overdose include:
- Immediate hospitalization and cardiac monitoring to detect potential arrhythmias
- Administration of activated charcoal if the ingestion was recent
- Correction of electrolyte abnormalities, particularly potassium
- Management of symptoms such as seizures with diazepam and hypotension with vasopressors
- Potential use of mechanical ventilation in severe cases
It is crucial to emphasize that there is no specific antidote for hydroxychloroquine toxicity, and treatment is primarily focused on supportive care and management of complications 1. Prevention of overdose is also essential, particularly in children, and includes keeping the medication securely stored away from children and taking exactly as prescribed.
In the context of the COVID-19 pandemic, the use of hydroxychloroquine has been associated with an increased risk of QT prolongation and torsades de pointes, highlighting the need for careful monitoring and management of patients receiving this medication 1. The use of FDA-approved consumer mobile ECG devices, such as the KardiaMobile 6L, may be useful in monitoring QTc intervals in patients receiving hydroxychloroquine, particularly in settings where traditional 12-lead ECGs may not be feasible 1.
From the FDA Drug Label
Hydroxychloroquine sulfate overdosage symptoms have an onset within 1 hour to 3 hours of ingestion. The following have been reported with hydroxychloroquine sulfate overdosage: Cardiovascular toxicity, including QRS or QTc prolongation, ventricular tachycardia, ventricular fibrillation, torsade de pointes, atrioventricular block, cardiac arrest and death. Life-threatening hypotension is common. Severe hypokalemia secondary to an intracellular shift is common in severe toxicity. Central nervous system (CNS) depression, seizures, visual disturbances, transient blindness, and coma may occur.
Gastrointestinal decontamination procedures warrant consideration in patients that present within the first hour post-ingestion. If the level of consciousness rapidly deteriorates in severe poisoning, consider intubation before gastrointestinal decontamination procedures. Monitor plasma potassium levels and manage accordingly. Hemofiltration, hemodialysis, and hemoperfusion are not of benefit. Consider contacting a poison center (1-800-221-2222) or a medical toxicologist for overdosage management recommendations.
Hydroxychloroquine overdose symptoms can occur within 1 hour to 3 hours of ingestion and may include:
- Cardiovascular toxicity: QRS or QTc prolongation, ventricular tachycardia, ventricular fibrillation, torsade de pointes, atrioventricular block, cardiac arrest, and death
- Life-threatening hypotension
- Severe hypokalemia
- Central nervous system (CNS) depression: seizures, visual disturbances, transient blindness, and coma Management of hydroxychloroquine overdose may involve:
- Gastrointestinal decontamination procedures within the first hour post-ingestion
- Intubation if the level of consciousness rapidly deteriorates
- Monitoring and managing plasma potassium levels
- Contacting a poison center or a medical toxicologist for overdosage management recommendations 2 2
From the Research
Hydroxychloroquine Overdose Symptoms
- Cardiac conduction abnormalities, such as ventricular tachyarrhythmias and QTc prolongation 3, 4, 5
- Seizure activity 4, 5
- Muscle weakness, including proximal muscle weakness 4, 5
- Hypokalemia and hypotension 3
- Electrolyte derangements with resultant dysrhythmias 5
Hydroxychloroquine Overdose Management
- Decontamination 5
- Stabilization of cardiac dysrhythmias 5
- Hemodynamic support 5
- Electrolyte correction, including aggressive potassium replacement 3, 5
- Seizure prevention 5
- Early orotracheal intubation and intravenous diazepam boluses 4
- High-dose diazepam infusion or intermittent intravenous bolus strategy 4