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Hydroxychloroquine

Hydroxychloroquine was first used as a treatment for malaria. It has an effect on the messaging system between cells in the immune system and can interrupt the inflammatory response.

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Background

Chloroquine was developed in the 1930s as a treatment for malaria, but can cause serious side effects. Hydroxychloroquine was developed in the 1970s from chloroquine to have fewer side effects.

Hydroxychloroquine is used widely for the treatment of lupus (SLE) but is also an established medicine for the treatment of RA. It is often used in combination with one or two other disease modifying anti-rheumatic drugs (DMARDs), particularly methotrexate.

How does it work?

The exact way hydroxychloroquine works is not well understood at present. Hydroxychloroquine is available as 200mg and 300mg tablets. It can take up to three months for hydroxychloroquine to start working to improve symptoms of RA.

Blood tests for hydroxychloroquine are checked before treatment starts and then as frequently as the specialist advises, usually at clinic visits. When it is prescribed alongside other DMARDs the frequency of blood tests may be more regular, depending on the recommendations for the other DMARD(s).

Most commonly reported side effects

As with any medication, hydroxychloroquine has a number of possible side effects, although it is important to remember that these are only potential side effects and they may not occur at all. Side effects may include:

• Loss of appetite, anorexia
• Headache
• Skin reactions – rash, itching, photosensitivity (increased sensitivity to sunlight)
• Visual changes – blurring*
• Abdominal pain, cramps, nausea
• Diarrhoea, vomiting
• Blood disorders
• An increased risk of episodes of low blood sugar in people who have diabetes and are taking certain medicines to treat it.

Eyes

People who take hydroxychloroquine for more than 5 years may be at risk of developing changes in the retina (the back of the eye). However, with regular eye check-ups, any issues can usually be detected early and managed effectively. For this reason, once you have been on hydroxychloroquine for 5 years you will need an eye exam (this may happen sooner, if you have additional risk factors). You will then have annual eye health checks while on this medication, so that any problems with the eye can be caught as early as possible. 

You may have to pay privately for these tests, which are available at many local/ high street opticians. Before making an appointment, you should check that the clinic can perform the following tests:

1. Optical Coherence Tomography (OCT) scan.

2. Fundus autofluorescence scan

For these tests, you will be asked to place your chin on a support, to keep your head still and to look directly into the machine that will scan your eye. You may be asked not to drive to your appointment, as drops may be given to dilate (widen) the pupils, which can made vision blurry for some time afterwards.

If you notice any changes to your vision while you are taking hydroxychloroquine you should contact your GP or specialist team.

Hydroxychloroquine can be very dangerous if an overdose is taken, or if it is accidentally taken by someone who it is not prescribed for. Children are particularly at risk if they accidentally take hydroxychloroquine so it must be stored out of the sight and reach of children (as should all medicines). More information on side effects can be found in the patient information leaflet for hydroxychloroquine that comes with your medicine. Remember to report any concerns about possible side effects to your doctor, your pharmacist or nurse.

Hydroxychloroquine with other medicines

Hydroxychloroquine can sometimes cause serious problems if it is taken with some other medicines (particularly those used for other health conditions).

Your healthcare team can advise you of any known interactions with your medication, so it is important to let them know about all the medicines you are taking, whether they are prescribed or over-the-counter. You should also let them know if you are taking any supplements or herbal medicines as these can also interact with medicines.

If you start taking any new medicines, check with a doctor, nurse or pharmacist that they are safe to take with any medicines you are currently taking.

Hydroxychloroquine during pregnancy and breast-feeding

Hydroxychloroquine can safely be taken through all stages of pregnancy and while breastfeeding.

Men and women can take hydroxychloroquine while trying to conceive.

Pregnancy information in this booklet is based on British Society for Rheumatology (BSR) guidelines on prescribing medicines in pregnancy and breastfeeding.

Before starting a family it is recommended that you get advice from your consultant or clinical nurse specialist about when to start a pregnancy.

Hydroxychloroquine and alcohol

As hydroxychloroquine is often prescribed alongside other DMARDs it is really important that you follow any advice given to you about drinking alcohol with your other medicines. This is particularly the case when you are taking hydroxychloroquine with methotrexate, sulfasalazine or leflunomide.

Please see the separate entries on other RA medications.

If you are taking hydroxychloroquine alone, then you can drink alcohol provided that you follow the current UK guidelines.

Hydroxychloroquine and immunisation/vaccination

If you are taking hydroxychloroquine on its own, it would be safe for you to have any vaccinations, whether they are live or not. This may not be the case if you are taking other medicines in combination with hydroxychloroquine, so it is important to check that all of your RA medicines are safe with live vaccines. For example, live vaccines are not recommended for people taking methotrexate, leflunomide or biologic medicines, but non-live vaccines can be used safely.

Annual flu vaccine is strongly recommended. It is available in two forms: an injection for adults and a nasal spray for children. The injectable vaccine is not a live vaccine and is generally given to adults. The nasal spray is a live vaccine and is generally given
to children. You can have a flu vaccination at your GP surgery or local pharmacy.

Annual ‘Pneumovax’ vaccination (which protects against pneumococcal pneumonia) is not live and is strongly recommended.

Shingles (Herpes zoster) vaccine is recommended for all adults turning 65, those aged 70 to 79 and those aged 50 and over with a severely weakened immune system. The
vaccination is given as two doses, two months apart. at your GP surgery. It is available as a live or non-live vaccine.

Covid-19 vaccines and boosters are not live and are generally recommended for people with RA.

Your GP can advise if you are eligible for free flu, Pneumovax, shingles and Covid vaccinations, depending on the medications you are taking and their doses.

Hints and tips

Hydroxychloroquine can sometimes make your skin more sensitive to sunlight, so you could get sunburnt more quickly. If you are going out in the sun, you should:

• Remember to use sunscreen as well as wearing a t-shirt and hat
• Re-apply sunscreen often, as recommended on the packaging

Medicines in rheumatoid arthritis

We believe it is essential that people living with RA understand why certain medicines are used, when they are used and how they work to manage the condition.

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Updated: 01/09/2020

Next review: 01/06/2023