How to safely discontinue Plaquenil (hydroxychloroquine)?

From the Guidelines

To safely discontinue Plaquenil (hydroxychloroquine), patients should be at target (low disease activity or remission) for at least 6 months prior to tapering, and the dose should be gradually reduced over time under the direct supervision of a healthcare provider. This approach is based on the recommendations from the 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis 1. The guideline suggests that continuation of all DMARDs at their current dose is conditionally recommended over a dose reduction of a DMARD, and gradual discontinuation is conditionally recommended over abrupt discontinuation of a DMARD.

Some key points to consider when discontinuing Plaquenil include:

• Patients should not stop taking Plaquenil suddenly on their own, as this can lead to disease flares and other complications.
• The tapering schedule should be individualized based on the patient's condition and how long they've been taking the medication.
• Regular follow-up appointments should be scheduled to monitor symptoms and disease activity.
• Blood tests may be ordered to check for signs of disease activity.
• Patients should report any new or worsening symptoms immediately.

The gradual discontinuation of Plaquenil is necessary due to its long half-life in the body, which means it takes time to be fully eliminated, and the body needs time to adjust to decreasing levels of the medication 1. Some patients may need to transition to alternative medications before completely stopping Plaquenil to maintain disease control. The 2021 guideline also notes that gradual discontinuation of sulfasalazine is conditionally recommended over gradual discontinuation of hydroxychloroquine for patients taking triple therapy who wish to discontinue a DMARD 1.

Overall, the decision to discontinue Plaquenil should be made in consultation with a healthcare provider, taking into account the individual patient's needs and circumstances, and based on the most recent and highest quality evidence available 1.

From the FDA Drug Label

Discontinue hydroxychloroquine sulfate if cardiotoxicity is suspected or demonstrated by tissue biopsy. If ocular toxicity is suspected, discontinue hydroxychloroquine sulfate and monitor the patient closely given that retinal changes and visual disturbances may progress even after cessation of therapy. Discontinue hydroxychloroquine sulfate if these severe reactions occur. Discontinue the drug if the patient develops myelosuppression which cannot be attributable to the disease. Discontinue hydroxychloroquine sulfate if muscle or nerve toxicity is suspected or demonstrated by tissue biopsy. Discontinue hydroxychloroquine sulfate if renal toxicity is suspected or demonstrated by tissue biopsy.

To safely discontinue Plaquenil (hydroxychloroquine), the following steps should be taken:

• Monitor for adverse reactions: Closely monitor the patient for signs and symptoms of adverse reactions, such as cardiotoxicity, ocular toxicity, severe skin reactions, myelosuppression, muscle or nerve toxicity, and renal toxicity.
• Gradual discontinuation: There is no specific guidance on gradual discontinuation, but given the long half-life of the drug, some patients may require several weeks off drug for symptoms to partially or fully abate.
• Follow-up care: Patients should be advised to seek medical attention promptly if they experience new or worsening symptoms, such as depression, suicidal thoughts or behavior, or mood changes.
• Consider alternative treatments: The risks and benefits of continued treatment with hydroxychloroquine sulfate should be assessed for patients who develop adverse reactions, and alternative treatments should be considered if necessary 2, 2.

From the Research

Discontinuing Plaquenil (Hydroxychloroquine) Safely

To safely discontinue Plaquenil (hydroxychloroquine), several factors should be considered:

• The available evidence does not provide a specific method for tapering hydroxychloroquine 3, 4, 5.
• However, studies on tapering other medications, such as antipsychotics and SSRIs, suggest that a gradual tapering process may minimize the risk of relapse or withdrawal symptoms 6, 7.
• A hyperbolic tapering approach, where the dose is reduced by a fixed percentage at regular intervals, may be effective in reducing the risk of relapse or withdrawal symptoms 6, 7.
• The tapering process should be individualized and titrated to the patient's tolerance, with dose reductions becoming smaller and smaller as the total dose decreases 6, 7.

Key Considerations

• There is no established protocol for discontinuing hydroxychloroquine, and the decision to stop treatment should be made on a case-by-case basis 3, 4, 5.
• Patients should be closely monitored for any adverse effects or relapse of their underlying condition during the tapering process 3, 4, 5.
• The available evidence suggests that hydroxychloroquine is generally well-tolerated and safe for long-term use, but the risk of certain adverse effects, such as long QT syndrome, may increase with prolonged treatment 5.