Hydroxychloroquine prescribing habits and impact of the COVID-19 pandemic
Authors: Drew Kuraitis, Andrea Murina
Journal: Journal of the American Academy of Dermatology (2020)

To the Editor: COVID-19 clinical trials and media attention have led to public familiarity with hydroxychloroquine (HCQ). Attention has been drawn to rare HCQ adverse effects, such as severe arrhythmia and cardiomyopathy.1Kuraitis D. Murina A. Facts, not fear: safety of hydroxychloroquine.Am J Med Sci. 2020; 360: 199-200Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar Anecdotally, patients have contacted us regarding such adverse effects, despite being on long-term HCQ without issue. The purposes of this study were to characterize dermatologists' HCQ practice habits and to determine if the COVID-19 pandemic has affected these habits. An institutional review board–exempt survey was distributed via the Association of Professors of Dermatology e-mail distribution list. Sixty dermatologists completed the survey. Eighteen respondents (30%) reported being contacted by patients regarding HCQ shortages, and 14 (23%) were contacted by patients regarding adverse effects they had seen in the media but had not personally experienced. Twenty respondents (33%) were contacted by nondermatology physician colleagues regarding adverse effects or laboratory monitoring. The COVID-19 pandemic has not changed how most dermatologists (57; 95%) will use HCQ in practice. Most respondents (53; 88%) were "very comfortable" with prescribing HCQ for indications approved by the US Food and Drug Administration, and fewer respondents (44; 73%) were "very comfortable" with off-label use. Screening and monitoring habits are presented in Supplemental Table I (available via Mendeley at http://doi.org/10.17632/f526xz9p7v.1), and counseling habits and adverse effects experiences are presented in Supplemental Table II (available via Mendeley at http://doi.org/10.17632/f526xz9p7v.1). HCQ laboratory habits vary greatly, with 18% of respondents not obtaining baseline studies, and 25% obtaining a glucose 6-phosphate dehydrogenase (G6PD) assay before initiation. There are no reports of HCQ-induced hemolysis, and antimalarial monotherapy is thought to be safe in glucose 6-phosphate dehydrogenase–deficient patients.2Afra T.P. Vasudevan Nampoothiri R. Razmi T.M. Doubtful precipitation of hemolysis by hydroxychloroquine in glucose-6-phosphate dehydrogenase-deficient patient with COVID-19 infection.Eur J Haematol. 2020; 105: 512-513Crossref PubMed Scopus (11) Google Scholar This practice gap is likely based on theoretical concerns. Most HCQ adverse effects are symptomatic in nature, but regular screening laboratories can detect hepatotoxicity and/or blood dyscrasia, although the interval at which these tests should be performed is not well defined.3O'Laughlin J.P. Mehta P.H. Wong B.C. Life threatening severe QTc prolongation in patient with systemic lupus erythematosus due to hydroxychloroquine.Case Rep Cardiol. 2016; 2016: 4626279PubMed Google Scholar Reflecting this, respondents performed screening tests at varying intervals, with 22% not performing any such tests. Although formal guidelines do not exist for dermatologists, The American College of Rheumatology recommends only baseline blood counts and liver transaminase and creatinine levels before HCQ initiation and does not recommend surveillance blood testing.4Saag K.G. Teng G.G. Patkar N.M. et al.American College of Rheumatology 2008 recommendations for the use of nonbiologic and biologic disease-modifying antirheumatic drugs in rheumatoid arthritis.Arthritis Rheum. 2008; 59: 762-784Crossref PubMed Scopus (1250) Google Scholar Ophthalmologic screening habits also vary among dermatologists despite formal retinopathy screening guidelines existing, which include a baseline examination and then annual examinations after 5 years, if there are no other retinopathy risk factors.5Marmor M.F. Kellner U. Lai T.Y. Melles R.B. Mieler W.F. American Academy of OphthalmologyRecommendations on screening for chloroquine and hydroxychloroquine retinopathy (2016 revision).Ophthalmology. 2016; 123: 1386-1394Abstract Full Text Full Text PDF PubMed Scopus (794) Google Scholar Cardiac adverse effect concerns were second only to retinopathy concerns, although most respondents do not take a cardiac history before starting HCQ. Regarding coadministration of qTC-prolonging medication, respondents were most concerned about azithromycin, likely influenced by ongoing attention to this combination. During COVID-19 trials, HCQ discontinuation was rarely required because of qTC prolongation, even with azithromycin coadministration.6Saleh M. Gabriels J. Chang D. et al.Effect of chloroquine, hydroxychloroquine, and azithromycin on the corrected QT interval in patients with SARS-CoV-2 infection.Circ Arrhythm Electrophysiol. 2020; 13: e008662Crossref PubMed Scopus (241) Google Scholar Long-term HCQ use may actually protect against conduction abnormalities, and HCQ-induced cardiomyopathy is not seen acutely, with a diagnosis after a median of 22 years of HCQ therapy.1Kuraitis D. Murina A. Facts, not fear: safety of hydroxychloroquine.Am J Med Sci. 2020; 360: 199-200Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar Limitations include the number of respondents reached via the e-mail distribution list and selection bias. This study shows the impact that the ongoing COVID-19 pandemic has had on dermatology practice, in addition to highlighting the variability of practice habits and real-time concerns of dermatologists. The lack of standardized practice habits highlights a need for formal task force guidelines regarding HCQ use and also provides an opportunity for quality improvement.