What is the typical dose of Plaquenil (hydroxychloroquine) for various conditions?

Plaquenil (Hydroxychloroquine) Dosing by Indication

Systemic Lupus Erythematosus and Lupus Nephritis

For SLE and lupus nephritis, hydroxychloroquine should be dosed at approximately 5 mg/kg/day based on actual body weight, not to exceed this threshold. 1

• The starting dose is around 5 mg/kg/day (typically 400 mg daily for most adults), with doses of 2-3 mg/kg/day potentially insufficient to achieve adequate blood levels and associated with higher flare rates 1
• Blood hydroxychloroquine levels above 0.6 mg/L may be associated with lower risk of lupus nephritis flare 1
• In patients with eGFR <30 mL/min per 1.73 m², reduce the dose by 25% 1
• The 2012 EULAR/ERA-EDTA guidelines recommend 6.5 mg/kg/day or 400 mg/day (whichever is lower) for patients with normal baseline ophthalmologic examination 1
• Keeping daily dosage <5.0 mg/kg actual body weight minimizes retinopathy risk while maintaining therapeutic efficacy 1

Rheumatoid Arthritis and Other Inflammatory Conditions

The standard dose for rheumatoid arthritis is 400 mg daily (200 mg twice daily), calculated to remain ≤5.0 mg/kg actual body weight. 1

• For patients of short stature, calculate dose based on actual body weight to avoid overdosage 1
• A loading dose of 600 mg/day may be used initially, with maintenance dosage calculated to remain below 6.5 mg/kg/day 2

Dermatomyositis and Juvenile Dermatomyositis

Hydroxychloroquine is administered at 200 mg twice daily (5 mg/kg) primarily for cutaneous manifestations. 1

• This dosing applies to both adult dermatomyositis and juvenile dermatomyositis 1
• For non-responders to hydroxychloroquine, chloroquine can be substituted at 250-500 mg/day 1

Malaria Treatment

For uncomplicated P. vivax or P. ovale malaria, give 4 tablets (800 mg salt) initially, then 2 tablets (400 mg salt) at 6,24, and 48 hours. 1

• This regimen is first-line treatment for chloroquine-sensitive malaria 1
• For chloroquine-resistant P. vivax, use artemisinin-based combination therapies instead 1

Critical Dosing Considerations

Renal Impairment

• Hydroxychloroquine is cleared primarily by the kidney, making renal disease a major risk factor for toxicity 1
• Reduce dose by 25% when eGFR <30 mL/min per 1.73 m² 1
• Patients with renal insufficiency require lower doses and closer monitoring 1

Body Weight Calculations

• Always use actual body weight, not ideal body weight, for dose calculations 1
• The risk of retinopathy is statistically similar across BMI groups ranging from 15-35 kg/m² when dosed by actual body weight 1
• Using ideal body weight formulas results in overdosage in thin individuals 1

Retinopathy Risk Stratification

• Doses >5.0 mg/kg dramatically increase both population risk and annual incremental risk of retinopathy 1
• At recommended doses ≤5.0 mg/kg, retinopathy risk is <2% during the first 10 years and increases to approximately 4% after 20 years 1
• Doses of 6-8 mg/kg carry substantially higher risk, with 21.6% cumulative incidence at 15 years for doses >6 mg/kg versus 2.7% for doses ≤5 mg/kg 3

Monitoring Requirements

• Baseline ophthalmologic examination is no longer required before initiating treatment 1
• Annual ophthalmologic screening should begin after 1 year in patients with risk factors (concomitant tamoxifen, eGFR <60 mL/min, dose >5 mg/kg/day, chloroquine use) or after 5 years otherwise 1
• G6PD testing is preferred in men of African, Asian, or Middle Eastern origin before starting treatment, though hemolysis risk appears low 1

Drug Interactions and Contraindications

• Concomitant tamoxifen use increases retinopathy risk and requires earlier screening 1
• Antimalarials may rarely cause cardiotoxicity (cardiomyopathy or conduction abnormalities) with high cumulative exposure 1
• Avoid in patients with pre-existing maculopathy that would interfere with screening tests 1