Hydroxychloroquine for children and young people

JIA artwork

Picture by Isabella Davis, age 13

Hydroxychloroquine explained

Hydroxychloroquine is not prescribed frequently for the treatment of juvenile idiopathic arthritis (JIA), but may be used as part of a treatment programme alongside one or two other disease modifying anti-rheumatic drugs (DMARDs).

The overactive immune system in JIA causes swelling, pain, heat and redness. Hydroxychloroquine dampens down this process. Hydroxychloroquine has an effect on the messaging between cells and it is this mechanism that is beneficial in both RA and JIA, by interrupting the inflammatory response.

Background 

  • Hydroxychloroquine was first developed as the drug ‘chloroquine’ to treat malaria 
  • Chloroquine was modified to hydroxychloroquine to significantly reduce the possible side effects that were causing eye problems

How does it work? 

  • Hydroxychloroquine is only available as a 200mg tablet, therefore it is only suitable for children and young people who are able to swallow tablets 
  • The action of hydroxychloroquine is not fully understood and it is a cumulative effect over several weeks before any benefit is seen 
  • Initial blood tests are required before treatment is started and then as advised by the specialist. 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). 

Possible 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 
  • Headache 
  • Skin reactions – rash, itching, photosensitivity (increased sensitivity to sunlight) 
  • Visual changes – blurring * 
  • Abdominal pain, cramps, nausea 
  • Diarrhoea, vomiting 
  • Blood disorders 

”The British Society for Paediatric and Adolescent Rheumatology (BSPAR) recommends that children should have their vision tested before long term treatment with hydroxychloroquine and have an annual review of visual acuity [sharpness of vision]. Children should be referred to an ophthalmologist if there is visual impairment, changes in visual acuity, or blurred vision. The Royal College of Ophthalmologists has recommended that a locally agreed protocol between the prescribing doctor and ophthalmologist be established to monitor the vision of these children” 

(Taken from the British National Formulary for Children 2014/15 p.512) 

Please Note: over dosage is very dangerous, particularly in infants 

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 

There are some significant potential drug interactions between hydroxychloroquine and some other medications (particularly treatments used for other health conditions) and these risks can be minor or major. It is therefore particularly important that a full and complete medical history is given to the prescribing doctor. 

Remember to take care when using any other medications or complementary therapies (even if bought ‘over the counter’ for colds or flu and importantly, any antacids for indigestion). Remember to check with a doctor, nurse or pharmacist that they are safe to take with hydroxychloroquine and any other medication taken. 

Hydroxychloroquine and Pregnancy 

It is not necessary to stop treatment with hydroxychloroquine during pregnancy, if the JIA is well controlled but this is usually a decision made by the specialist consultant. 

Hydroxychloroquine must be stopped during the weeks or months of breast feeding as it is transferred in breast milk. 

Hydroxychloroquine and Alcohol 

As hydroxychloroquine is nearly always prescribed alongside other DMARDs it is really important that any advice that relates to another DMARD must be acknowledged and used as the guide for this drug. This is particularly the case with methotrexate and sulfasalazine. 

For those over 18 years there is no reason to avoid moderate alcohol consumption whilst on hydroxychloroquine (though advice on alcohol intake will depend on the advice for any other drugs being taken). Please see our separate articles on other JIA medications. 

Hydroxychloroquine and immunisation/vaccination

Live vaccines [measles, mumps, rubella (MMR), chickenpox, oral polio (NOT injectable polio), BCG, oral typhoid and yellow fever] cannot be given to anyone already taking hydroxychloroquine. If hydroxychloroquine has not yet been started it is important to seek advice on how long a gap to leave after having a live vaccine.

  • The annual ’flu vaccination and ‘pneumovax’ protection against pneumonia is permitted 
  • If possible have ‘pneumovax’ protection before starting hydroxycloroquine 

Flu vaccine is now available in two forms, an injection and a nasal spray. Unlike the injection, the nasal spray is a live vaccine. There is limited research evidence around live vaccines in people with a lowered immune system (due to their medication). It is therefore important to discuss with the healthcare team which of these options would be best. 

Vaccination of close family members can help to protect someone with a lowered immune system. 

Protection from sunburn 

Hydroxychloroquine can make skin more sensitive to sunlight. The following tips can help with this:

  • Remember to use sunscreen before going into the sun, as well as a t-shirt and hat 
  • Reapply sunscreen frequently as recommended 

Table summary

Drug name How the drug is taken How it works Blood tests mandatory?
Hydroxychloroquine (HCQ) Tablet Reduces over activity of the immune system Yes - infrequently

References available on request

By retired rheumatology clinical nurse specialist Nicky Kennedy BSc RN QN HV
Original article: 09/12/2015
Reviewed: N/A
Next review due: 09/12/2018