Hydroxychloroquine Does NOT Need to Be Stopped When Taking Renal-Dosed Paxlovid
You should continue hydroxychloroquine for inflammatory arthritis when taking renal-dosed Paxlovid (nirmatrelvir/ritonavir), as there are no clinically significant drug-drug interactions that require discontinuation, and stopping hydroxychloroquine risks disease flare. 1, 2
Drug-Drug Interaction Assessment
No Contraindication Exists
- There is no absolute contraindication to combining hydroxychloroquine with ritonavir-containing regimens based on available drug interaction data 3
- Unlike protease inhibitor-containing hepatitis C regimens (which are contraindicated with lopinavir/ritonavir due to OATP1B inhibition), hydroxychloroquine does not share this interaction profile 3
- Chloroquine and hydroxychloroquine are generally safe with COVID-19 therapies from a drug-drug interaction standpoint 3
Ritonavir Boosting Considerations
- Ritonavir in Paxlovid acts as a pharmacokinetic booster for nirmatrelvir, not as the primary antiviral 3
- The renal-adjusted dose already accounts for altered drug clearance, and hydroxychloroquine does not significantly interfere with this 3
- No dose adjustment of hydroxychloroquine is required when co-administered with ritonavir-containing regimens 3
Risk of Stopping Hydroxychloroquine
Disease Flare Risk
- Patients on chronic hydroxychloroquine therapy should continue their medication during acute infections, including COVID-19, due to immunomodulatory benefits and the substantial risk of disease flares 1, 2
- Discontinuation of hydroxychloroquine is associated with exacerbation of inflammatory arthritis 4
- The immunomodulatory effects of hydroxychloroquine may actually be beneficial during acute viral infections 2, 5
Clinical Evidence
- Studies demonstrate that stopping disease-modifying antirheumatic drugs (DMARDs) like hydroxychloroquine leads to increased disease activity 4
- Hydroxychloroquine has a significantly higher probability of long-term continuation in inflammatory conditions when maintained consistently 4
Practical Management Algorithm
Continue Hydroxychloroquine at Standard Dose
- Maintain the usual dose of 200-400 mg daily (maximum 5 mg/kg actual body weight) 1, 2
- No dose adjustment is needed specifically for the Paxlovid interaction 3
Monitor for Additive Effects
- Watch for gastrointestinal side effects, as both medications can cause GI upset 1
- Monitor renal function if the patient is on renal-dosed Paxlovid, but this is for Paxlovid monitoring, not hydroxychloroquine interaction 3
Ensure Appropriate Paxlovid Dosing
- Renal-dosed Paxlovid (nirmatrelvir 150 mg/ritonavir 100 mg twice daily for eGFR 30-60 mL/min) does not require hydroxychloroquine adjustment 3
- The lower ritonavir exposure in renal dosing further reduces any theoretical interaction risk 3
Common Pitfalls to Avoid
Do Not Confuse with COVID-19 Treatment Recommendations
- While hydroxychloroquine is not recommended for COVID-19 treatment or prophylaxis 3, 2, this does not mean it should be stopped in patients already taking it for inflammatory arthritis 1, 2
- The recommendation against hydroxychloroquine for COVID-19 is about initiating it as antiviral therapy, not about continuing established DMARD therapy 3, 2
Do Not Stop Without Rheumatology Input
- Abrupt discontinuation of DMARDs can lead to irreversible disease progression 3
- If there were a true contraindication (which there is not), consultation with rheumatology would be essential before stopping 3