Hydroxychloroquine overdose: case report and recommendations for management

Wong, Anna Ling Ngan; Cheung, Ian Tsz Fung; Graham, Colin A.

doi:10.1097/mej.0b013e3280adcb56

Cited by 19 publications

(12 citation statements)

References 15 publications

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“…The minimum fatal dose of hydroxychloroquine is not well defined. The minimum dose reported to elicit severe symptoms (hypotension, hypokalemia, and ventricular dysrhythmias) is 4 g [31]. One case report from 1965 (for which the full text is not available) describes a 16 year old who died after reportedly ingesting 12 g of hydroxychloroquine [32].…”

Section: Chloroquine and Hydroxychloroquinementioning

confidence: 99%

COVID-19: Therapeutics and Their Toxicities

et al. 2020

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SARS-CoV-2 is a novel coronavirus that emerged in 2019 and is causing the COVID-19 pandemic. There is no current standard of care. Clinicians need to be mindful of the toxicity of a wide variety of possibly unfamiliar substances being tested or repurposed to treat COVID-19. The United States Food and Drug Administration (FDA) has provided emergency authorization for the use of chloroquine and hydroxychloroquine. These two medications may precipitate ventricular dysrhythmias, necessitating cardiac and electrolyte monitoring, and in severe cases, treatment with epinephrine and high-doses of diazepam. Recombinant protein therapeutics may cause serum sickness or immune complex deposition. Nucleic acid vaccines may introduce mutations into the human genome. ACE inhibitors and ibuprofen have been suggested to exacerbate the pathogenesis of COVID-19. Here, we review the use, mechanism of action, and toxicity of proposed COVID-19 therapeutics.

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Section: Chloroquine and Hydroxychloroquinementioning

confidence: 99%

COVID-19: Therapeutics and Their Toxicities

et al. 2020

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“…Overdose of chloroquine and hydroxychloroquine has been a clinical challenge for decades, with cases of poisoning first reported in the 1950s [145,146]. Often chloroquine has been used in these self-poisoning attempts [147][148][149][150][151][152][153][154][155][156] or as an abortifacient [157], particularly in developing countries [158], due to its narrow therapeutic index. One case series from Zimbabwe [158] reported 80% of chloroquine overdoses were deliberate with a nearly 6% mortality rate that was significantly higher than poisonings from other drugs.…”

Section: Toxicity In Overdosementioning

confidence: 99%

Toxicity of chloroquine and hydroxychloroquine following therapeutic use or overdose

Doyno

Sobieraj

Baker

2020

Clinical Toxicology

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Introduction: While chloroquine, a derivative of quinine, has been used as an antimalarial for 70 years, hydroxychloroquine is now used to treat conditions such as rheumatoid arthritis and systemic lupus erythematosus. In 2020, hydroxychloroquine (and to a lesser extent chloroquine) also received attention as a possible treatment for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). During investigation for treating coronavirus disease 2019 (COVID-19) caused by SARS-CoV-2, concerns for serious adverse events arose. Objective: We review the toxicity associated with hydroxychloroquine and chloroquine use both short-term and long-term and in overdose. Methods: Medline (via OVID) was searched from its inception through June 7 2020 using the following as either MeSH or keyword terms: ("Chloroquine/" or "Hydroxychloroquine/") AND ("Adverse Drug Event/" or "Toxicities, Drug/" or "Toxic.mp." or "Toxicity.mp." or "Overdose.mp."). We limited resultant articles to those published in English and reporting on Human subjects. This search yielded 330 articles, of which 57 were included. Articles were excluded due to lack of relevance, not reporting desired outcomes, or being duplicative in their content. Twenty-five additional articles were identified through screening references of included articles. To identify toxicities in individuals treated with hydroxychloroquine or chloroquine with COVID-19, we searched PubMed on June 10th, 2020: ("Chloroquine" or "Hydroxychloroquine") AND ("Coronavirus" or "COVID-19" or "SARS-CoV-2"). This search resulted in 638 articles. We reviewed articles for reporting of adverse events or toxicities. Most citations were excluded because they did not include original investigations or extrapolated data from subjects that did not have COVID-19; 34 citations were relevant. For the drug-interactions section, relevant classes and agents were identified through a screen of the https://www.covid19-druginteractions. org/ website. We then conducted targeted searches of PubMed up to June 7th 2020 combining "chloroquine" and "hydroxychloroquine" with terms for specific drug classes and drugs identified from the drug-interaction site as potentially relevant. We found 29 relevant articles. Toxicity with short-term use: Gastrointestinal: Gastrointestinal toxicities are the most common to occur following initiation of chloroquine or hydroxychloroquine. Nausea, vomiting, and diarrhea account for most reported intolerances. Glucose abnormalities: Alterations in blood glucose concentrations may occur with hydroxychloroquine but are rare with standard therapeutic use. Cardiotoxicity: Short-term use can produce conduction abnormalities. Evidence from COVID-19 treatment suggests QT/QTc prolongation is of concern, particularly when used in combination with azithromycin, although disagreement exists across studies. Dermatologic: Drug eruptions or rashes, followed by cutaneous hyperpigmentation, pruritis, Stevens-Johnson syndrome, and toxic epidermal necrolysis, may occur within days to weeks of exposure but ...

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“…In a protocol together with highdose diazepam and early mechanical ventilation, epinephrine was proven to improve outcome in severe chloroquine toxicity [7]. Although formal evidence of the benefit of epinephrine in hydroxychloroquine toxicity is lacking, its use is mentioned in several case reports with good outcomes [1,[20][21][22][25][26][27]. In the case presented above, norepinephrine was used with success.…”

Section: Discussionmentioning

confidence: 99%

Nearly Fatal Hydroxychloroquine Overdose Successfully Treated with Midazolam, Propofol, Sodium Bicarbonate, Norepinephrine, and Intravenous Lipid Emulsion

Onsia

Bots

2021

Case Reports in Emergency Medicine

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Background. In the context of the current COVID-19 pandemic, there has been renewed interest in the drug hydroxychloroquine. However, clinicians should be aware of the dangers of hydroxychloroquine intoxication, an insufficiently studied condition. Case Report. We present a case of autointoxication with 20 g hydroxychloroquine in a 35-year-old woman. Cardiac monitoring showed ventricular arrhythmias for which high-dose midazolam and propofol were initiated, resulting in a brief normalization of the cardiac rhythm. Because of the reoccurrence of these arrhythmias, intravenous lipid emulsion was administered with fast cardiac stabilization. Treatment with continuous norepinephrine, potassium chloride/phosphate, and sodium bicarbonate was initiated. On day 6, she was extubated and after 11 days, she was discharged from the hospital without complications. Conclusion. Since high-quality scientific evidence is lacking, treatment options are based on experience in chloroquine toxicity. Activated charcoal is advised if the patient presents early. Sedation with diazepam, early ventilation, and continuous epinephrine infusion are considered effective in treating severe intoxication. Caution is advised when substituting potassium. Despite the lack of formal evidence, sodium bicarbonate appears to be useful and safe in case of QRS widening. Intravenous lipid emulsion, with or without hemodialysis, remains controversial but appears to be safe. As a last resort, extracorporeal life support might be considered in case of persisting hemodynamic instability.

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Hydroxychloroquine overdose: case report and recommendations for management

Cited by 19 publications

References 15 publications

COVID-19: Therapeutics and Their Toxicities

COVID-19: Therapeutics and Their Toxicities

Toxicity of chloroquine and hydroxychloroquine following therapeutic use or overdose

Nearly Fatal Hydroxychloroquine Overdose Successfully Treated with Midazolam, Propofol, Sodium Bicarbonate, Norepinephrine, and Intravenous Lipid Emulsion

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