TherapeuticsTreatment of hydroxychloroquine overdose☆,☆☆
Section snippets
Case report
A 16-year-old girl presented to the emergency department (ED) with a blood pressure of 63 mm Hg by palpation, pulse of 110 beats/min, slurred speech, and drowsiness. History revealed she had taken a handful of her hydroxychloroquine (200 mg), levothyroxine, aspirin, and ibuprofen, 30 minutes before presentation. Fluid boluses brought her blood pressure to 76/32 mm Hg and dopamine was begun at 10 mcg/kg/min. Naloxone 2 mg IV was given without response. She was gastrically lavaged with evidence
Discussion
Hydroxychloroquine overdoses are rarely reported despite the frequent use of this drug. A literature search found only 7 acute overdose reports in the English medical literature.2, 3, 4, 5, 6, 7, 8
The lethal dose is not well established. Twelve grams in a 2-year-old child caused convulsions, cardiorespiratory arrest, and death.5 Twelve grams in a 16-year-old boy was lethal.2 Four grams in a 29-year-old man caused ventricular tachycardia that responded to lidocaine and bretylium. Twelve grams in
Treatment and treatment controversies
Because there is little experience with hydroxychloroquine, the treatment of toxicity is modeled after the treatment for chloroquine (see Table 2).1. Early intubation and mechanical ventilation in patients with signi .cant ingestions or symptoms. 2. Cardiovascular monitoring 3. Epinephrine for hypotension, dysrhythmias, QRS widening, circulatory collapse 4. Diazepam for seizures,dysrhythmias, QRS widening, hypotension, circulatory collapse. LD of 2 mg/kg IV over 30
Conclusion
Hydroxychloroquine overdoses are rare, but very serious. Life-threatening symptoms may occur within 30 minutes with very rapid progression to death within a few hours. The symptoms are similar to chloroquine overdoses. Treatment must be implemented quickly and should be modeled after experience with chloroquine overdoses. Treatment modalities however need further study.
After reviewing the medical literature on hydroxychloroquine and chloroquine overdoses, the following treatment approaches are
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Cited by (73)
Massive Nonfatal Hydroxychloroquine Ingestion in a Pediatric Patient
2022, Journal of Emergency MedicineCitation Excerpt :As mentioned, treatment of hydroxychloroquine toxicity follows that for chloroquine and consists of high-dose epinephrine and high-dose diazepam infusions in addition to potassium supplementation. Epinephrine is the vasopressor of choice for treatment of hypotension resulting from vasodilation and myocardial depression due to its inotropic and vasoconstriction action (2,12). The use of high-dose diazepam was adopted from animal studies in which animals poisoned with chloroquine demonstrated improved hemodynamic functioning and enhanced urinary excretion of chloroquine, as well as decreased mortality after administration of high-dose diazepam (13,14).
Utility of Hypertonic Saline and Diazepam in COVID-19–Related Hydroxychloroquine Toxicity
2021, Journal of Emergency MedicineCitation Excerpt :Once the above treatments have been initiated, clinicians should monitor QRS and QTc intervals with frequent ECGs and follow serum potassium levels every 1 to 2 h, targeting a value of ≥4.0 mEq/L. We recommend close ECG and serum potassium monitoring for 36 h to include the expected window of HCQ toxicity (24 h) and assess for rebound hyperkalemia after toxicity resolves (19,25). If serum potassium concentrations begin to decrease, consider decreasing the sodium bicarbonate infusion rate or changing to hypertonic sodium chloride boluses.
Acute chloroquine and hydroxychloroquine toxicity: A review for emergency clinicians
2020, American Journal of Emergency MedicineCitation Excerpt :Refractory cases with intractable hypoglycemia (glucose <50 mg/dL) can be managed similar to sulfonylurea toxicity with 50 μg subcutaneous octreotide every 6 h [95,99]. Hypokalemia is a marker of severity of toxicity in acute poisoning and must be carefully monitored and managed as intracellular shifts can reverse as acute toxicity resolves, with rapid onset of hyperkalemia [11]. Potassium may be repleted cautiously in severe hypokalemia (<1.9 mEq/L), and monitoring of potassium levels should occur regularly.
Chloroquine/hydroxychloroquine overdose
2020, Visual Journal of Emergency MedicineThe effects of hydroxychloroquine and its promising use in refractory obstetric antiphospholipid syndrome
2024, Rheumatology InternationalWhole blood drug levels do not correlate with QTc intervals in hydroxychloroquine-treated systemic lupus erythematosus patients
2023, Rheumatology (United Kingdom)
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Address reprint requests to Kathy Marquardt, Pharm D, DABAT, California Poison Control System, Sacramento Division, University of California, Davis Medical Center, 2315 Stockton Blvd, Sacramento, CA 95817.
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