Can Plaquenil (hydroxychloroquine) be started in patients with liver cancer?

Hydroxychloroquine (Plaquenil) in Patients with Liver Cancer

Hydroxychloroquine should not be started in patients with liver cancer due to the risk of hepatotoxicity and potential for fulminant hepatic failure.

Rationale for Contraindication

Hepatotoxicity Risk

• Hydroxychloroquine has been documented to cause serious hepatotoxicity, including cases of fulminant hepatic failure requiring liver transplantation 1
• Symptoms of liver disease can develop rapidly within two weeks of starting hydroxychloroquine treatment 1
• Patients with pre-existing liver conditions like hepatocellular carcinoma are at particularly high risk for drug-induced liver injury

Pain Management Alternatives for Liver Cancer Patients

Patients with liver cancer often require pain management, and safer alternatives exist:

• First-line for mild pain: Acetaminophen at reduced doses (2000-3000 mg/day) with regular liver function monitoring 2
• For moderate pain: Low-dose tramadol (maximum 50 mg every 12 hours) with careful monitoring 2
• For severe pain: Fentanyl is the preferred opioid due to minimal hepatic metabolism, available in multiple formulations (patch, sublingual, IV) 2

Treatment Options for Liver Cancer

Instead of focusing on hydroxychloroquine, patients with liver cancer should receive appropriate cancer-directed therapy:

1. Early-stage HCC:

   • Surgical resection for solitary tumors with preserved liver function 3
   • Liver transplantation for patients with decompensated cirrhosis and HCC within accepted criteria 3
   • Thermal ablation for selected patients with solitary <2 cm HCC in compensated cirrhosis 3

2. Advanced HCC:

   • Atezolizumab plus bevacizumab is recommended as first-line systemic therapy for patients with preserved liver function 3
   • Sorafenib or lenvatinib can be considered for patients who are not candidates for atezolizumab plus bevacizumab 3
   • Second-line options include cabozantinib, pembrolizumab, ramucirumab, or regorafenib 3

Important Considerations

Potential Research Interest vs. Clinical Safety

While some preclinical research suggests chloroquine compounds might have anti-tumor effects in HCC 4, 5, these findings are preliminary and do not outweigh the documented risks of hepatotoxicity in patients with liver disease.

Monitoring Requirements

If hydroxychloroquine must be used for a compelling reason (such as co-existing autoimmune disease with no alternatives):

• Regular liver function tests should be performed (weekly for the first month)
• Immediate discontinuation if signs of liver dysfunction develop
• Ophthalmologic monitoring is also required due to risk of retinopathy 6

Drug Interactions

Hydroxychloroquine may interact with many medications used in liver cancer treatment, potentially affecting efficacy or increasing toxicity.

Conclusion

Given the availability of safer and more effective treatments specifically for liver cancer, and the documented risk of hepatotoxicity, hydroxychloroquine should be avoided in patients with liver cancer. Treatment should focus on established liver cancer therapies and appropriate pain management strategies specifically designed for patients with liver disease.