Should rheumatoid arthritis medications like Plaquenil (hydroxychloroquine) be stopped in a hospitalized patient?

Management of Rheumatologic Medications During Hospitalization

For hospitalized patients with rheumatic disease, hydroxychloroquine (Plaquenil) may be continued, but other DMARDs such as methotrexate, leflunomide, sulfasalazine, immunosuppressants, biologics, and JAK inhibitors should be temporarily withheld during the hospital stay. 1

Decision Algorithm for Rheumatologic Medications in Hospitalized Patients

Hydroxychloroquine (Plaquenil)

• Continue hydroxychloroquine in most hospitalized patients
• Exception: If patient has COVID-19, temporarily withhold hydroxychloroquine due to potential cardiac risks (QT prolongation) that may be heightened in the context of COVID-19 and other QT-prolonging medications commonly used in hospitalized patients 1
• Rationale: Hydroxychloroquine has a relatively favorable risk/benefit profile with low infection risk, and abrupt discontinuation could lead to disease flares, particularly in SLE patients 1

Other csDMARDs (Methotrexate, Leflunomide, Sulfasalazine)

• Temporarily withhold during hospitalization
• Rationale: These medications may mask symptoms of infection or complicate the clinical picture during acute illness 1
• Sulfasalazine's side effects (GI upset, diarrhea, hepatitis, cytopenias) could be confused with other conditions 1

Biologics and JAK Inhibitors

• Temporarily withhold during hospitalization
• Rationale: These medications are associated with increased risk of serious infections 1
• For patients with COVID-19, these medications should be stopped regardless of COVID-19 severity 1

Immunosuppressants (Tacrolimus, Cyclosporine, Mycophenolate, Azathioprine)

• Temporarily withhold during hospitalization
• Rationale: Increased risk of infection and potential drug interactions with hospital medications 1

Special Considerations

COVID-19 Specific Management

• If patient has COVID-19, all DMARDs except hydroxychloroquine should be withheld 1
• For patients with severe COVID-19 respiratory symptoms, NSAIDs should also be stopped 1
• In select circumstances, IL-6 receptor inhibitors may be continued as part of shared decision-making, as they may have potential benefits in COVID-19 cytokine storm 1

Resumption of Medications After Hospitalization

• For patients with uncomplicated hospital stays, consider restarting DMARDs within 7-14 days after resolution of the acute illness 1
• For patients recovering from severe illness, decisions regarding restarting medications should be made on a case-by-case basis 1

Common Pitfalls to Avoid

1. Don't stop hydroxychloroquine unnecessarily: Abrupt discontinuation in SLE patients can lead to disease flares and increased morbidity 1

2. Don't continue biologics/immunosuppressants during active infection: These significantly increase infection risk and can mask symptoms of worsening infection 1

3. Don't forget to consider Pneumocystis jiroveci pneumonia prophylaxis: For patients on cyclophosphamide or high-dose glucocorticoids 1

4. Don't restart all medications simultaneously after hospitalization: Stagger reintroduction to better monitor for adverse effects and disease activity 1

By following this algorithm, clinicians can appropriately manage rheumatologic medications during hospitalization while minimizing both infection risk and the risk of disease flares, ultimately optimizing patient outcomes in terms of morbidity, mortality, and quality of life.