Anti-inflammatory effects are thought to result through a variety of pathways reducing the cascade of cytokine production and including actions related to an increase in lysosome pH. This causes:. These lysosomotropic effects occur in macrophages , dendritic cells , and lymphocytes. Hydroxychloroquine has a two-fold impact on T cells.
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The combined effect is a beneficial action in autoimmunity without a penalty of increased opportunistic infections. Antiproliferative and immunomodulatory effects are mediated by decreasing lymphocyte proliferation , interference with natural killer cell activity, and possibly the alteration of auto- antibody production. The photoprotective effects of hydroxychloroquine are not entirely understood.
Current theories include that the:. Antimalarial medications prevent platelet aggregation and act as prostaglandin antagonists due to the inhibition of phospholipase A2. Therefore, hydroxychloroquine may be used as a life-long therapy for patients with systemic lupus who are at an increased risk of cardiovascular disease. Hydroxychloroquine should be taken with a meal or a glass of milk to minimise the gastrointestinal side effects.
Alternate-day dosing can be used. If a therapeutic response is not achieved with hydroxychloroquine alone, adding quinacrine may improve the therapeutic effect.
For the treatment of cutaneous lupus erythematosus , the usual dose range is — mg daily until a therapeutic response is achieved. Although maximum doses were previously calculated on the patient's ideal body weight and advised not to exceed 6. To minimise the cumulative dose, which is also believed to be of some importance in the development of retinal toxicity, the dose should be reduced as tolerated over the winter months. Initial higher doses may lead to hepatotoxicity as a result of rapid mobilisation of hepatic porphyrin stores. The high affinity for melanin-containing cells such as those found in the retinal pigment epithelium is hypothesised to be the cause.
The risk of retinal toxicity is dependent on several factors:. In , with new scientific data, the American Academy of Ophthalmology revised the screening recommendations for patients being commenced on long-term hydroxychloroquine therapy. A fundus examination alone is insufficient for screening, and further tests are required including at least automated visual field testing and spectral-domain optical coherence tomography.
Every patient should undergo a baseline ophthalmic examination within the first year of commencing hydroxychloroquine if long-term use is anticipated. In the absence of risk factors listed above, annual screening should then be performed after five years. Patients with hydroxychloroquine-induced retinal toxicity will not have any visual symptoms in the early stages, and will only develop clinical symptoms with severe end-stage damage.
Therefore, it is essential that the screening recommendations outlined above are followed, and hydroxychloroquine should be ceased if there are signs of definite retinopathy. The retinopathy does not reverse, but the progression is rare after hydroxychloroquine is discontinued. Visual symptoms may present as paracentral scotomas islands of vision loss when reading.
If blurring or vision changes occur, hydroxychloroquine should be ceased, and a careful eye examination conducted.
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Nausea, vomiting, and diarrhoea are common side effects, but are usually transient or resolve on the reduction of the dose. They can be minimised by taking the hydroxychloroquine with food. Transverse pigmented nail bands and mucosal pigmentation have also been reported.
If a rash appears, hydroxychloroquine should be withdrawn and may be restarted at a lower dose. Haematological side effects are rare. Haemolysis in patients with glucosephosphate dehydrogenase G6PD deficiency, aplastic anaemia , and leukopenia has been reported. The most extensive study to date evaluating G6PD deficiency with concurrent use of hydroxychloroquine reported no episodes of haemolysis in over months of exposure among the 11 studied patients with G6PD deficiency.
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Routine screening for G6PD deficiency is no longer recommended for hydroxychloroquine. Hydroxychloroquine does cross the placenta and is considered Category D in pregnancy see DermNet NZ's pages on Safety of medicines taken during pregnancy and on Lactation and the skin. However, in multiple studies, hydroxychloroquine use has not been associated with congenital disabilities, stillbirth, prematurity, low birth weight, fetal death, or retinopathy following maternal intake at recommended doses.
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International experts currently recommend that hydroxychloroquine can continue during pregnancy and breastfeeding. Hydroxychloroquine is regarded as safer than chloroquine if required in women planning a pregnancy or breastfeeding. The amount of monitoring with hydroxychloroquine varies from centre to centre. More frequent surveillance is needed if laboratory values are abnormal or with high-risk patients.
UK bans parallel export and hoarding of three Covid drugs
Hydroxychloroquine levels can be measured in the blood. This can potentially be used for monitoring the patient's adherence to treatment and where the response has been inadequate. No standardised effective reference level has been validated. See smartphone apps to check your skin. DermNet NZ does not provide an online consultation service. If you have any concerns with your skin or its treatment, see a dermatologist for advice. Hydroxychloroquine — codes and concepts open. Hydroxychloroquine sulphate. Treatment or procedure. New Zealand approved datasheets are the official source of information for prescription medicines, including approved uses and risk information.
Check the individual New Zealand datasheet on the Medsafe website. References Browning DJ. Pharmacology of chloroquine and hydroxychloroquine. Juurlink said a vaccine is a year or 18 months away but that data gathered worldwide could point to safe and effective treatments within a month or two.
We will look back a year from now and marvel at how much was done in such a short time, but we are just at the beginning of it all. The key right now is preventing and slowing the spread of the virus to give researchers and clinicians the time to develop treatments to minimize symptoms and get people out of hospital faster. Drug-maker Novartis has vowed to donate up to million doses of hydroxychloroquine to support the global pandemic response. Teva Pharmaceutical Industries said it plans to donate more than 10 million tablets of hydroxychloroquine to hospitals in the U.
Bayer also said it would donate three million tablets of its chloroquine phosphate drug, sold under the name Resochin. Concerned about a run on the drugs amid shortages reported in the U. For those living with lupus, a chronic autoimmune disease, hydroxychloroquine is proven to reduce mortality by 50 per cent, prevent disease flares and cardiovascular complications, and reduce the need for hospitalization, according to a press release from Lupus Canada. More coronavirus coverage Interactive. Coronavirus in Canada. Map: Tracking the spread around the world.
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