What are the indications for hydroxychloroquine (HCQ)?

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Hydroxychloroquine Indications

Hydroxychloroquine is FDA-approved for the treatment of uncomplicated malaria, prophylaxis of malaria in non-resistant areas, rheumatoid arthritis, systemic lupus erythematosus, and chronic discoid lupus erythematosus. 1

FDA-Approved Indications

Malaria

  • Treatment of uncomplicated malaria caused by:
    • Plasmodium falciparum
    • Plasmodium malariae
    • Plasmodium ovale
    • Plasmodium vivax 1
  • Prophylaxis of malaria in geographic areas where chloroquine resistance is not reported 1
    • Begin weekly doses 2 weeks prior to travel
    • Continue weekly doses while in endemic area
    • Continue for 4 weeks after leaving endemic area

Rheumatologic Conditions

  • Rheumatoid arthritis in adults 1
  • Systemic lupus erythematosus (SLE) in adults 1
    • The American College of Rheumatology recommends hydroxychloroquine for all SLE patients regardless of disease activity or severity 2
    • The European League Against Rheumatism also strongly recommends hydroxychloroquine for SLE patients 2
  • Chronic discoid lupus erythematosus in adults 1

Dermatologic Applications

  • Cutaneous lupus erythematosus (CLE) - effective at 400 mg/day with low incidence of retinopathy 3

Important Limitations of Use

Malaria Limitations

Hydroxychloroquine is NOT recommended for:

  • Treatment of complicated malaria 1
  • Treatment of chloroquine or hydroxychloroquine-resistant strains 1
  • Treatment of malaria acquired in areas with chloroquine resistance 1
  • Prophylaxis in geographic areas where chloroquine resistance occurs 1
  • Prevention of relapses of P. vivax or P. ovale (not active against hypnozoite liver stage forms) 1

COVID-19

  • NOT recommended for COVID-19 treatment based on high-certainty evidence showing no mortality benefit and increased risk of adverse effects 2

Dosing Considerations and Safety

Dosing

  • Maximum recommended dose: ≤5.0 mg/kg based on actual body weight to minimize retinal toxicity risk 2
  • Rheumatoid arthritis: Initial 400-600 mg daily; maintenance 200-400 mg daily 1
  • SLE and discoid lupus: 200-400 mg daily (single or divided doses) 1

Safety Monitoring

  • Retinal toxicity: The most significant dose-limiting toxicity 2

    • Risk factors: daily dose >5 mg/kg, duration >10 years, age >65 years, renal disease, concurrent tamoxifen use 2
    • Ophthalmologic examination should start after 5 years of use (or after 1 year if additional risk factors exist), then every 6-12 months 2

  • Dose adjustment: Reduce dose by 25% for eGFR <30 ml/min per 1.73 m² 2

  • Pregnancy: Considered safe if clinically indicated 2

Common Pitfalls and Caveats

  • Retinopathy risk increases with higher doses and longer duration of treatment
  • Failure to adjust dose based on ideal body weight can increase toxicity risk
  • Inappropriate use for COVID-19 despite evidence against its effectiveness
  • Overlooking the need for regular ophthalmologic monitoring in long-term users
  • Not recognizing potential cardiac adverse effects including cardiomyopathy and ventricular arrhythmias 1

References

2
Guideline

Hydroxychloroquine Treatment Guidelines

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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