What is the optimal dose of Plaquenil (hydroxychloroquine) for treating rheumatoid arthritis and lupus?

From the Guidelines

The optimal dose of Plaquenil (hydroxychloroquine) for treating rheumatoid arthritis and lupus should not exceed 5 mg/kg real body weight, as recommended by the most recent guidelines 1.

Key Considerations for Dosing

• The dose should be based on real body weight rather than ideal body weight to minimize toxicity risks.
• For patients with renal insufficiency, the dose should be reduced by 25% if the estimated glomerular filtration rate (eGFR) is less than 30 ml/min per 1.73 m² 1.
• Doses of 2–3 mg/kg/d may not achieve adequate blood levels and could be associated with higher flare rates.

Monitoring and Safety

• Regular eye examinations are essential during Plaquenil therapy, typically recommended every 6-12 months, as the medication can cause retinal toxicity with long-term use 1.
• The risk of retinal damage increases with higher doses and longer duration of treatment.
• Patients with a history of glucose-6-phosphate dehydrogenase (G6PD) deficiency should be monitored for the risk of hemolysis before starting hydroxychloroquine.

Clinical Application

• Plaquenil should be taken with food or milk to reduce stomach irritation.
• The medication takes 4-12 weeks to show full therapeutic effects, so patience is necessary when beginning treatment.
• Plaquenil works by modulating immune system activity and reducing inflammation, making it effective for autoimmune conditions like rheumatoid arthritis and lupus.

Evidence-Based Practice

• The most recent guidelines from the European League Against Rheumatism and the Kidney Disease: Improving Global Outcomes (KDIGO) clinical practice guideline support the use of hydroxychloroquine in patients with lupus, with a focus on minimizing toxicity risks and monitoring for adverse effects 1.

From the FDA Drug Label

2.3 Dosage for Rheumatoid Arthritis in Adults The recommended dosage is: Initial dosage: 400 mg to 600 mg daily as a single daily dose or two divided doses. The action of hydroxychloroquine is cumulative and may require weeks to months for maximum therapeutic effect Daily doses exceeding 5 mg/kg (actual weight) of hydroxychloroquine sulfate increase the incidence of retinopathy [see Warnings and Precautions (5.2)]. Chronic dosage: 200 mg once daily to 400 mg daily, as a single dose or two divided doses.

2.4 Dosage for Systemic Lupus Erythematosus in Adults The recommended dosage is 200 mg given once daily, or 400 mg given once daily or in two divided doses.

The optimal dose of Plaquenil (hydroxychloroquine) for treating rheumatoid arthritis is:

• Initial dosage: 400 mg to 600 mg daily
• Chronic dosage: 200 mg to 400 mg daily The optimal dose of Plaquenil (hydroxychloroquine) for treating lupus is:
• 200 mg to 400 mg daily 2

From the Research

Optimal Dose of Plaquenil for Treating Rheumatoid Arthritis and Lupus

The optimal dose of Plaquenil (hydroxychloroquine) for treating rheumatoid arthritis and lupus is a matter of debate. However, based on the available evidence, the following points can be made:

• The daily dose associated with the best compromise between efficacy and safety is generally considered to be ≤5 mg/kg/day actual body weight 3.
• A study found that lower HCQ weight-based dose (≤5 vs >5 mg/kg/day) and non-weight-based dose (<400 vs 400 mg/day) were each associated with increased hospitalizations for active SLE 4.
• Another study suggested that HCQ therapy was found not only to be beneficial in slowing the disease progression in RA patients but enhanced the effects of methotrexate in treating RA as well 5.
• The concern regarding retinal toxicity rather than proper efficacy data is the one that dictated the daily dosage of ⩽5 mg/kg/day actual body weight currently agreed upon 3.

Key Considerations

Some key considerations when determining the optimal dose of Plaquenil include:

• The risk of retinal toxicity, which can be minimized by close attention to the dose and regular retinal examinations 6, 3.
• The potential benefits of HCQ in reducing atherosclerosis and risks of cardiovascular disease in rheumatic patients 6.
• The importance of balancing the short-term and cumulative risks of increased SLE activity with the long-term risk of HCQ retinopathy 4.

Dosage Regimens

Some possible dosage regimens for Plaquenil include:

• 800 mg loading dose followed by 400 mg twice or 3 times weekly for pre-exposure prophylaxis 7.
• 800 mg loading dose followed in 6 hours by 600 mg, then 600 mg daily for 4 more days for post-exposure prophylaxis 7.
• ≤5 mg/kg/day actual body weight for the treatment of rheumatoid arthritis and lupus 3, 4.