Hydroxychloroquine Use in Patients with Rheumatoid Arthritis or Systemic Lupus Erythematosus
Rationale for Continuing Hydroxychloroquine
- Hydroxychloroquine discontinuation significantly increases flare risk in both RA and SLE, with patients who stop treatment having a 2.5-fold higher risk of disease flares 1
- The American College of Rheumatology recommends indefinite (lifelong) continuation of hydroxychloroquine in SLE patients due to its profound beneficial effects 1
- Hydroxychloroquine reduces renal flares, cardiovascular events, thrombotic complications, organ damage accumulation, and overall mortality in SLE 1
Perioperative Guidelines Support Continuation
- The 2022 ACR/AAHKS guideline for perioperative management conditionally recommends continuing hydroxychloroquine through surgery for patients with RA and SLE undergoing total joint arthro bargroplasty 2
- If hydroxychloroquine can be safely continued through major orthopedic surgery, it should certainly be continued during a 5-day course of antibiotics for pneumonia 2
COVID-19 Pandemic Experience
- During the COVID-19 pandemic, the ACR task force endorsed continued use of hydroxychloroquine in SLE patients even in the setting of active SARS-CoV-2 infection, recognizing its favorable risk/benefit profile 3
Managing the Drug Interaction
- The primary concern with hydroxychloroquine plus azithromycin is QT interval prolongation, which can predispose to ventricular arrhythmias 3
- Obtain baseline ECG before starting azithromycin if feasible, particularly in patients with pre-existing cardiac disease, electrolyte abnormalities, or those on other QT-prolonging medications 3
- Check and correct electrolytes (potassium, magnesium) before initiating azithromycin 3
- Avoid other QT-prolonging medications during the 5-day azithromycin course when possible 3
- Consider telemetry or repeat ECG if the patient is hospitalized or has risk factors for arrhythmia 3
- If QTc exceeds 500 msec or increases >60 msec from baseline, consider alternative antibiotic therapy 3
Common Pitfalls to Avoid
- Do not forget that rescue corticosteroids for disease flares carry their own infection risks, potentially worsening the pneumonia 3