Is hydroxychloroquine used to treat rheumatoid arthritis?

Hydroxychloroquine in Rheumatoid Arthritis Treatment

Yes, hydroxychloroquine is used for treating rheumatoid arthritis, though it has limited efficacy compared to other disease-modifying antirheumatic drugs (DMARDs) and is primarily reserved for patients with mild disease activity.

Role in Rheumatoid Arthritis Management

• Hydroxychloroquine (HCQ) is classified as a conventional synthetic disease-modifying antirheumatic drug (csDMARD) for rheumatoid arthritis (RA) treatment 1
• It is most commonly used as part of combination therapy, particularly in the frequently used triple therapy regimen consisting of methotrexate, sulfasalazine, and hydroxychloroquine 1
• According to the 2019 EULAR recommendations, hydroxychloroquine has shown only weak clinical efficacy and no structural efficacy in RA treatment based on historic studies 1

Efficacy and Position in Treatment Algorithm

• Hydroxychloroquine has demonstrated effectiveness in treating RA in various placebo-controlled and open studies, though its efficacy is considered moderate compared to other DMARDs 2, 3
• The HERA Study, a randomized trial in early RA, showed that hydroxychloroquine produced statistically significant improvements in joint symptoms, pain, and physical function compared to placebo over 36 weeks 4
• Current guidelines position hydroxychloroquine as having a limited place in RA treatment, mainly reserved for patients with mild disease activity 1
• The 2019 EULAR recommendations focus more on sulfasalazine and leflunomide as preferred csDMARDs due to their superior efficacy 1

Dosing and Administration

• The FDA-approved dosing for hydroxychloroquine in rheumatoid arthritis is typically 200-400 mg daily 5
• A randomized controlled trial comparing 200 mg and 400 mg daily doses found both regimens effective in reducing disease activity, but the 400 mg dose was associated with three times more side effects 6
• The American College of Rheumatology recommends a maximum daily dose of 5 mg/kg based on actual body weight to minimize retinal toxicity risk 7

Combination Therapy

• Hydroxychloroquine is often more effective when combined with other DMARDs 3, 8
• The most frequently used combination consists of methotrexate, sulfasalazine, and hydroxychloroquine 1
• Studies indicate that combining hydroxychloroquine with other DMARDs can provide clinical improvement in patients with inadequate response to previous csDMARD therapy 3

Safety Considerations

• Hydroxychloroquine has a relatively favorable safety profile compared to other DMARDs 6, 8
• The main safety concern is retinal toxicity, which is dose and duration dependent 7, 5
• Dose reduction may be necessary in patients with hepatic or renal disease 5
• Monitoring recommendations include baseline ophthalmologic examination and annual screening after 5 years of therapy for low-risk patients 7

Special Populations

• In geriatric patients, dose selection should start with the lowest recommended dose due to the greater frequency of decreased renal function 5
• For patients with impaired renal or hepatic function, dose reduction may be necessary 5

Clinical Decision Making

• When choosing between hydroxychloroquine and other DMARDs, consider:
  • Disease severity (hydroxychloroquine is more appropriate for mild disease) 1
  • Patient comorbidities (hydroxychloroquine may have beneficial effects on metabolic and cardiovascular outcomes) 3, 8
  • Risk of adverse effects (hydroxychloroquine has fewer serious adverse effects than some other DMARDs) 6

In conclusion, while hydroxychloroquine is used in rheumatoid arthritis treatment, current guidelines suggest it has a limited role primarily for patients with mild disease activity, with greater emphasis placed on other DMARDs like methotrexate, sulfasalazine, and leflunomide for most patients with RA.