Brief Review of Chloroquine and Hydroxychloroquine Toxicity and Management

Jacob A. Lebin, MD; Kathy T. LeSaint, MD

Disclosures

Western J Emerg Med. 2020;21(4):760-763. 

In This Article

Clinical Management

Aggressive symptomatic and supportive care is the mainstay of treatment for both CQ and HCQ overdose. In addition to stabilization of the airway, breathing, and circulation, the patient should receive intravenous (IV) access as well as continuous cardiac monitoring. Serial ECGs should be obtained to monitor for QRS and QT interval prolongation. CQ and HCQ are well absorbed by activated charcoal, and thus should be administered if the risk for aspiration is low. Additionally, given the life-threatening nature of CQ and HCQ poisoning, decontamination with gastric lavage can be considered in cases of a large overdose and if the patient presents soon after ingestion. A medical toxicologist or poison control center should be contacted to assist with management.

Boluses of sodium bicarbonate (1–2 milliequivalents per kilogram [kg] IV) should be provided for QRS interval prolongation to counteract the effects of sodium channel blockade. Of note, the serum alkalinization that results from sodium bicarbonate administration may exacerbate the pre-existing hypokalemia seen from toxicity, which can contribute to further dysrhythmias. However, several reports have suggested that hypokalemia may be protective in severe CQ poisoning.[18–20] Therefore, replacement of potassium is controversial in the setting of acute toxicity, although we believe it would be reasonable to treat severe hypokalemia (i.e., < 2 mmol/L). Cases of rebound hyperkalemia have been reported once toxicity resolves; therefore, serial potassium levels should be obtained.[8,19]

Both diazepam and epinephrine have been suggested as specific treatments for CQ and HCQ toxicity. In observational studies, patients with mixed overdoses of diazepam and chloroquine had less toxic effects than those who ingested chloroquine alone.[11,19] Diazepam is believed to decrease CQ and HCQ induced-vasodilation and have central antagonistic, anticonvulsant, and antidysrhythmic effects.[10] We recommend that patients with severe CQ and HCQ symptoms receive high-dose diazepam therapy (2 milligrams/kg IV over 30 minutes). Because high-dose IV epinephrine (0.25 micrograms/kg per minutes [mcg/kg/min], increasing by 0.25mcg/kg/min until adequate systolic blood pressure) has been the most extensively studied in cases of CQand HCQ-induced hypotension, epinephrine is the vasopressor of choice in these specific ingestions.[16,21] Additionally, combining high-dose diazepam and high-dose epinephrine has shown a potential mortality benefit when compared to controls.[16] Like sodium bicarbonate, high-dose epinephrine may worsen pre-existing hypokalemia. Finally, a trial of 20% IV fat emulsion (Intralipid) may be indicated in refractory cases, but extracorporeal membrane oxygenation will provide greater benefit if available.[22,23]

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