Hydroxychloroquine sulfate

1.1 Malaria

Hydroxychloroquine sulfate tablet in indicated in adult and pediatric patients for the:
• Treatment of uncomplicated malaria due to Plasmodium falciparum, Plasmodium malariae, Plasmodium vivax,
and Plasmodium ovale .
• Prophylaxis of malaria in geographic areas where chloroquine resistance is not reported.

Limitations of Use:

Hydroxychloroquine sulfate tablet is not recommended for:
• Treatment of complicated malaria.
• Treatment of malaria by chloroquine or hydroxychloroquine-resistant strains of Plasmodium species [see
Microbiology (12.4)].
• Treatment of malaria acquired in geographic areas where chloroquine resistance occurs or when the
Plasmodium species has not been identified.
• Prophylaxis of malaria in geographic areas where chloroquine resistance occurs.
• Prevention of relapses of P. vivax or P. ovale because it is not active against the hypnozoite liver stage forms of
these parasites. For radical cure of P. vivax and P. ovale infections, concomitant therapy with an 8-aminoquinoline drug is necessary [see Microbiology (12.4)].
For the most current information about drug resistance, refer to the latest recommendations from the Center for Disease
Control and Prevention 1.

1.2 Rheumatoid Arthritis

Hydroxychloroquine sulfate tablet is indicated for the treatment of acute and chronic rheumatoid arthritis in adults.

1.3 Systemic Lupus Erythematosus

Hydroxychloroquine sulfate tablet is indicated for the treatment of systemic lupus erythematosus in adults.

1.4 Chronic Discoid Lupus Erythematosus

Hydroxychloroquine sulfate tablet is indicated for the treatment of chronic discoid lupus erythematosus in adults.

2.1 Important Administration Instructions

Administer hydroxychloroquine sulfate tablet orally with food or milk. Do not crush or divide the tablets.

2.2 Dosage for Malaria in Adult and Pediatric Patients

Hydroxychloroquine sulfate is not recommended in pediatric patients less than 31 kg because the lowest available
strength (200 mg) exceeds the recommended dose for these patients and it cannot be divided.

Prophylaxis

Treatment must start 2 weeks before travel to an endemic area. Advise the patient to take the prophylaxis dosage once
a week, staring 2 weeks prior to travel to the endemic area, on the same day every week, continuing the same weekly
dose while in the endemic area, and for 4 weeks after leaving the endemic area. The recommended prophylaxis
dosage is:
• Adult patients: 400 mg once a week
• Pediatric patients ≥ 31kg: 6.5 mg/kg actual body weight (up to 400 mg) once a week

Treatment of Uncomplicated Malaria

The dosages for the treatment of uncomplicated malaria are:
• Adult patients: Administer 800 mg initially; subsequently administer 400 mg at 6 hours, 24 hours, and 48 hours
after the initial dose (total dosage = 2,000 mg).
• Pediatric patients ≥ 31 kg: Administer 13 mg/kg (up to 800 mg) initially; subsequently administer 6.5 mg/kg (up

to 400 mg) at 6 hours, 24 hours, and 48 hours after the initial dose (total dosage = 31 mg/kg - up to 2,000 mg).
For radical cure of P. vivax and P. ovale infections, concomitant therapy with an 8-aminoquinoline drug is necessary
[see Microbiology (12.4)].

2.3 Dosage for Rheumatoid Arthritis in Adults

The recommended dosage is:
• Initial dosage: 400 mg to 600 mg daily as a single daily dose or two divided doses. The action of
hydroxychloroquine is cumulative and may require weeks to months for maximum therapeutic effect. Daily
doses exceeding 5 mg/kg (actual weight) of hydroxychloroquine sulfate increase the incidence of retinopathy
[see Warnings and Precautions (5.2)].
• Chronic dosage: 200 mg once daily to 400 mg daily, as a single dose or two divided doses.
Corticosteroids, salicylates, and other antirheumatic agents may be used concomitantly with hydroxychloroquine
sulfate.

2.4 Dosage for Systemic Lupus Erythematosus in Adults

The recommended dosage is 200 mg given once daily, or 400 mg given once daily or in two divided doses.

2.5 Dosage for Chronic Discoid Lupus Erythematosus in Adults

The recommended dosage is 200 mg given once daily, or 400 mg given once daily or in two divided doses.

Tablets: 200 mg of hydroxychloroquine sulfate, white to off-white, capsule-shaped, biconvex, film-coated tablets
debossed with “ZC38” on one side and plain on other side.

Hydroxychloroquine sulfate is contraindicated in patients with known hypersensitivity to 4-aminoquinoline compounds.

5.1 Cardiomyopathy and Ventricular Arrhythmias

Fatal and life-threatening cases of cardiotoxicity, including cardiomyopathy, have been reported in patients treated with
hydroxychloroquine sulfate. Signs and symptoms of cardiac compromise have occurred during acute and chronic
hydroxychloroquine sulfate treatment. In multiple cases, endomyocardial biopsy showed association of the
cardiomyopathy with phospholipidosis in the absence of inflammation, infiltration, or necrosis. Drug-induced
phospholipidosis may occur in other organ systems [see Warnings and Precautions (5.8, 5.11)].

Patients may present with ventricular hypertrophy, pulmonary hypertension and conduction disorders including sick
sinus syndrome. ECG findings include atrioventricular, right or left bundle branch block.

Hydroxychloroquine sulfate has a potential to prolong the QT interval. Ventricular arrhythmias (including torsades de
pointes) have been reported in hydroxychloroquine sulfate-treated patients. The magnitude of QT prolongation may
increase with increasing concentrations of the drug. Therefore, the recommended dose should not be exceeded [see
Adverse Reactions (6), Overdosage (10)]. Avoid hydroxychloroquine sulfate administration in patients with congenital or
documented acquired QT prolongation and/or known risk factors for prolongation of the QT interval such as:
• Cardiac disease, e.g., heart failure, myocardial infarction.
• Proarrhythmic conditions, e.g., bradycardia (< 50 bpm).
• History of ventricular dysrhythmias
• Uncorrected hypokalemia and/or hypomagnesemia.
• Concomitant administration with QT interval prolonging agents as this may lead to an increased risk for ventricular
arrhythmias [see Drug Interactions (7.1)].
Therefore, hydroxychloroquine sulfate is not recommended in patients taking other drugs that have the potential to
prolong the QT interval. Correct electrolyte imbalances prior to use. Monitor cardiac function as clinically indicated
during hydroxychloroquine sulfate therapy. Discontinue hydroxychloroquine sulfate if cardiotoxicity is suspected or
demonstrated by tissue biopsy.

5.2 Retinal Toxicity

Irreversible retinal damage was observed in some patients treated with hydroxychloroquine sulfate and it is related to
cumulative dosage and treatment duration. In patients of Asian descent, retinal toxicity may first be noticed outside the
macula.
Risk factors for retinal damage include daily hydroxychloroquine sulfate dosages ≥5 mg/kg of actual body weight,

durations of use greater than five years, renal impairment, use of concomitant drug products such as tamoxifen citrate,
and concurrent macular disease.
Within the first year of starting hydroxychloroquine sulfate, a baseline ocular examination is recommended including
best corrected distance visual acuity (BCVA), an automated threshold visual field (VF) of the central 10 degrees (with
retesting if an abnormality is noted), and spectral domain ocular coherence tomography (SD-OCT). For patients at
higher risk of retinal damage, monitoring should include annual examinations which include BCVA, VF and SD-OCT. For
patients without significant risk factors, annual retinal exams can usually be deferred until five years of treatment. In
patients of Asian descent, it is recommended that visual field testing be performed in the central 24 degrees instead of
the central 10 degrees.
If ocular toxicity is suspected, discontinue hydroxychloroquine sulfate and monitor the patient closely given that retinal
changes and visual disturbances may progress even after cessation of therapy.

5.3 Serious Skin Reactions

Serious adverse reactions have been reported with the use of hydroxychloroquine sulfate including Stevens- Johnson
syndrome (SJS), toxic epidermal necrolysis (TEN), drug reaction with eosinophilia and systemic symptoms (DRESS
syndrome), acute generalized exanthematous pustulosis (AGEP). Monitor for serious skin reactions, especially in
patients receiving a drug that may also induce dermatitis. Advise patients to seek medical attention promptly if they
experience signs and symptoms of serious skin reactions such as blisters on the skin, eyes, lips or in the mouth,
itching or burning, with or without fever [see Warnings and Precautions (5.4), Adverse Reactions (6)]. Discontinue
hydroxychloroquine sulfate if these severe reactions occur.

5.4 Worsening of Psoriasis

Administration of hydroxychloroquine sulfate to patients with psoriasis may precipitate a severe flare-up of psoriasis.
Avoid hydroxychloroquine sulfate in patients with psoriasis, unless the benefit to the patient outweighs the possible risk.

5.5 Risks Associated with Use in Porphyria

Administration of hydroxychloroquine sulfate to patients with porphyria may exacerbate porphyria. Avoid hydroxychloroquine sulfate in patients with porphyria.

Hepatotoxicity Associated with Porphyria Cutanea Tarda

Cases of hepatotoxicity have been reported when hydroxychloroquine was used in patients with porphyria cutanea tarda
(PCT). Patients received dosages ranging from 200 mg twice weekly to 400 mg daily. Most of the PCT-related cases
presented with marked elevations in transaminases (>20 times upper limit of the reference range) within days to a
month of hydroxychloroquine initiation. In some cases, PCT was diagnosed only after the occurrence of
treatment-induced liver injury, when hydroxychloroquine was prescribed for an approved indication. Some of the cases
were associated with other risk factors for hepatic injury (e.g., alcohol use, concomitant hepatotoxic medications).

Measure liver tests promptly in patients who report symptoms that may indicate liver injury, such as fatigue, rash,
nausea, dark urine, or jaundice. In this clinical context, if the patient is found to have abnormal serum liver tests (e.g.,
ALT level greater than three times the upper limit of the reference range, total bilirubin greater than two times the upper
limit of the reference range), interrupt treatment with hydroxychloroquine sulfate, and investigate further to establish the
probable cause.

The safety and effectiveness of hydroxychloroquine sulfate for the treatment of PCT have not been established and
hydroxychloroquine sulfate is not approved for this use.

5.6 Hematologic Toxicity

Hydroxychloroquine sulfate may cause myelosuppression including aplastic anemia, agranulocytosis, leukopenia, or
thrombocytopenia. Monitor blood cell counts periodically in patients on prolonged hydroxychloroquine sulfate therapy.
If the patient develops myelosuppression which cannot be attributable to the disease, discontinue the drug.

5.7 Hemolytic Anemia Associated with G6PD Deficiency

Hemolysis has been reported in patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency. Monitor for
hemolytic anemia as this can occur, particularly in association with other drugs that cause hemolysis.

5.8 Skeletal Muscle Myopathy or Neuropathy

Skeletal muscle myopathy or neuropathy leading to progressive weakness and atrophy of proximal muscle groups,
depressed tendon reflexes, and abnormal nerve conduction, have been reported. Muscle and nerve biopsies have shown
associated phospholipidosis. Drug-induced phospholipidosis may occur in other organ systems [see Warnings and
Precautions (5.1, 5.11)].
Assess muscle strength and deep tendon reflexes periodically in patients on long-term therapy with hydroxychloroquine
sulfate. Discontinue hydroxychloroquine sulfate if muscle or nerve toxicity is suspected or demonstrated by tissue
biopsy.

5.9 Neuropsychiatric Reactions Including Suicidality

Suicidal behavior, suicidal ideation, and other neuropsychiatric adverse reactions have been reported in patients treated
with hydroxychloroquine sulfate [see Adverse Reactions (6)]. Neuropsychiatric adverse reactions typically occurred
within the first month after the start of treatment with hydroxychloroquine and have been reported in patients with and
without a prior history of psychiatric disorders.

The risks and benefits of continued treatment with hydroxychloroquine sulfate should be assessed for patients who
develop these symptoms. Given the long half-life of the drug, some patients may require several weeks off drug for
symptoms to partially or fully abate.
Advise patients to contact their healthcare provider promptly if they experience new or worsening neuropsychiatric
symptoms such as depression, suicidal thoughts or behavior, or mood changes.

5.10 Hypoglycemia

Hydroxychloroquine sulfate can cause severe and potentially life-threatening hypoglycemia, in the presence or
absence of antidiabetic agents [see Drug Interactions (7)]. Measure blood glucose in patients presenting with clinical
symptoms suggestive of hypoglycemia and as adjust the antidiabetic treatment as necessary. Warn
hydroxychloroquine sulfate-treated patients about the risk of hypoglycemia and educate them on the signs and
symptoms of hypoglycemia; diabetic patients should monitor their blood sugar levels. Advise patients to seek medical
attention if they develop any signs and symptoms of hypoglycemia.

5.11 Renal Toxicity

Proteinuria with or without moderate reduction in glomerular filtration rate have been reported with the use of
hydroxychloroquine sulfate.
Renal biopsy showed phospholipidosis without immune deposits, inflammation, and/or increased cellularity. Physicians
should consider phospholipidosis as a possible cause of renal injury in patients with underlying connective tissue
disorders who are receiving hydroxychloroquine sulfate. Drug induced phospholipidosis may occur in other organ
systems [see Warnings and Precautions (5.1, 5.8)]. Discontinue hydroxychloroquine sulfate if renal toxicity is suspected
or demonstrated by tissue biopsy.

The following adverse reactions are described in greater detail in other sections:
• Cardiomyopathy and Ventricular Arrhythmias [see Warnings and Precautions (5.1)]
• Retinal Toxicity [see Warnings and Precautions (5.2)]
• Serious Skin Reactions [see Warnings and Precautions (5.3)]
• Worsening of Psoriasis [see Warnings and Precautions (5.4)]

• Risks Associated with Use in Porphyria [see Warnings and Precautions (5.5)]​

• Hematologic Toxicity [see Warnings and Precautions (5.6)]
• Hemolytic Anemia Associated with G6PD [see Warnings and Precautions (5.7)]
• Skeletal Muscle Myopathy or Neuropathy [see Warnings and Precautions (5.8)]
• Neuropsychiatric Reactions Including Suicidality [see Warnings and Precautions (5.9)]
• Hypoglycemia [see Warnings and Precautions (5.10)]

• Renal Toxicity [see Warnings and Precautions (5.11)]
The following adverse reactions have been identified during post-approval use of 4-aminoquinoline drugs, including
hydroxychloroquine sulfate. Because these reactions are reported voluntarily from a population of uncertain size, it is
not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure:
- Blood and lymphatic system disorders: Bone marrow depression, anemia, aplastic anemia, agranulocytosis,
leukopenia, thrombocytopenia
- Cardiac disorders: Cardiomyopathy, cardiac failure, QT-interval prolongation, ventricular tachycardia, torsades de
pointes, atrioventricular block, bundle branch block, sick sinus syndrome, pulmonary hypertension
- Ear and labyrinth disorders: Vertigo, tinnitus, nystagmus, sensorineural hearing loss
- Eye disorders: Retinopathy, retinal pigmentation changes (typically bull’s eye appearance), visual field defects
(paracentral scotomas), macular degeneration, corneal edema, corneal opacities, decreased dark adaptation
- Gastrointestinal disorders: Nausea, vomiting, diarrhea, abdominal pain
- General disorders: Fatigue
- Hepatobiliary disorders: Abnormal liver function tests, fulminant hepatic failure
- Immune system disorders: Urticaria, angioedema, bronchospasm
- Metabolism and nutrition disorders: Anorexia, hypoglycemia, weight loss
- Musculoskeletal and connective tissue disorders: Proximal myopathy, depressed tendon reflexes, abnormal
nerve conduction
- Nervous system disorders: Ataxia, dizziness, headache, seizure, extrapyramidal disorders (dystonia, dyskinesia,
tremor)
- Neuropsychiatric disorders: Affect/emotional lability, irritability, nervousness, psychosis, suicidal ideation, suicidal
behavior, depression, hallucinations, anxiety, agitation, confusion, delusions, paranoia, mania and sleep disorders
(insomnia, night terrors, nightmares)
- Skin and subcutaneous tissue disorders: Alopecia, hair color changes, rash, pruritus, photosensitivity, psoriasis
exacerbation, hyperpigmentation, exfoliative dermatitis, erythema multiforme, acute generalized exanthematous
pustulosis, Drug Rash with Eosinophilia and Systemic Symptoms (DRESS syndrome), Stevens-Johnson
syndrome (SJS), toxic epidermal necrolysis (TEN)

7.1 Drugs Prolonging QT Interval and Other Arrhythmogenic Drugs

Hydroxychloroquine sulfate prolongs the QT interval. There may be an increased risk of inducing ventricular
arrhythmias if hydroxychloroquine sulfate is used concomitantly with other arrhythmogenic drugs. Therefore,
hydroxychloroquine sulfate is not recommended in patients taking other drugs that have the potential to prolong the QT
interval or are arrhythmogenic [see Warnings and Precautions (5.1].

7.2 Insulin or Other Antidiabetic Drugs

Hydroxychloroquine sulfate may enhance the effects of insulin and antidiabetic drugs, and consequently increase the
hypoglycemic risk. Therefore, a decrease in dosage of insulin and other antidiabetic drugs may be necessary [see
Warnings and Precautions (5.10)] .

7.3 Drugs that Lower the Seizure Threshold

Hydroxychloroquine sulfate can lower the seizure threshold. Co-administration of hydroxychloroquine sulfate with other
antimalarials known to lower the seizure threshold (e.g., mefloquine) may increase the risk of seizures.

7.4 Antiepileptics

The activity of antiepileptic drugs might be impaired if co-administered with hydroxychloroquine sulfate.

7.5 Methotrexate

Concomitant use of hydroxychloroquine sulfate and methotrexate may increase the incidence of adverse reactions.

7.6 Cyclosporine

An increased plasma cyclosporin level was reported when cyclosporin and hydroxychloroquine sulfate were
co-administered. Monitor serum cyclosporine levels closely in patients receiving combined therapy.

7.7 Digoxin

Concomitant hydroxychloroquine sulfate and digoxin therapy may result in increased serum digoxin levels. Monitor
serum digoxin levels closely in patients receiving combined therapy.

7.8 Cimetidine

Concomitant use of cimetidine resulted in a 2-fold increase of exposure of chloroquine, which is structurally related to
hydroxychloroquine. Interaction of cimetidine with hydroxychloroquine cannot be ruled out. Avoid concomitant use of
cimetidine.

7.9 Rifampicin

Lack of efficacy of hydroxychloroquine was reported when rifampicin was concomitantly administered. Avoid
concomitant use of rifampicin.

7.10 Praziquantel

Chloroquine has been reported to reduce the bioavailability of praziquantel. Interaction of praziquantel with
hydroxychloroquine cannot be ruled out.

7.11 Antacids and kaolin

Antacids and kaolin can reduce absorption of chloroquine; an interval of at least 4 hours between intake of these
agents and chloroquine should be observed. Interaction of antacids and kaolin with hydroxychloroquine cannot be
ruled out.

7.12 Ampicillin

In a study of healthy volunteers, chloroquine significantly reduced the bioavailability of ampicillin. Interaction of
ampicillin with hydroxychloroquine cannot be ruled out.

8.1 Pregnancy

Pregnancy Exposure Registry

There is a pregnancy exposure registry that monitors pregnancy outcomes in women exposed to hydroxychloroquine
sulfate during pregnancy. Encourage patients to register by contacting 1-877-311-8972.

Risk Summary

Prolonged clinical experience over decades of use and available data from published epidemiologic and clinical studies
with hydroxychloroquine sulfate use in pregnant women have not identified a drug-associated risk of major birth
defects, miscarriage, or adverse maternal, or fetal outcomes (see Data). There are risks to the mother and fetus
associated with untreated or increased disease activity from malaria, rheumatoid arthritis, and systemic lupus
erythematosus in pregnancy (see Clinical Considerations). Animal reproduction studies were not conducted with
hydroxychloroquine.
The estimated background risk of major birth defects and miscarriage for the indicated populations is unknown. All
pregnancies have a background risk of birth defect, loss, or other adverse outcomes. In the US general population, the
estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2% to 4% and
15% to 20%, respectively.

Clinical Considerations

Disease-Associated Maternal and/or Embryo-Fetal Risk

Malaria: Malaria during pregnancy increases the risk for adverse pregnancy outcomes, including maternal anemia,
prematurity, spontaneous abortion, and stillbirth.
Rheumatoid Arthritis: Published data suggest that increased disease activity is associated with the risk of developing
adverse pregnancy outcomes in women with rheumatoid arthritis Adverse pregnancy outcomes include preterm
delivery (before 37 weeks of gestation), low birth weight (less than 2,500 g) infants, and small for gestational age at
birth.
Systemic Lupus Erythematosus: Pregnant women with systemic lupus erythematosus, especially those with increased
disease activity, are at increased risk of adverse pregnancy outcomes, including spontaneous abortion, fetal death,
preeclampsia, preterm birth, and intrauterine growth restriction. Passage of maternal auto-antibodies across the
placenta may result in neonatal illness, including neonatal lupus and congenital heart block.

Data

Human Data

Data from published epidemiologic and clinical studies have not established an association with hydroxychloroquine
sulfate use during pregnancy and major birth defects, miscarriage, or adverse maternal or fetal outcomes.
Hydroxychloroquine readily crosses the placenta with cord blood levels corresponding to maternal plasma levels. No
retinal toxicity, ototoxicity, cardiotoxicity, or growth and developmental abnormalities have been observed in children
who were exposed to hydroxychloroquine in utero. Available epidemiologic and clinical studies have methodological
limitations including small sample size and study design.

8.2 Lactation

Risk Summary

Published lactation data report that hydroxychloroquine is present in human milk at low levels. No adverse reactions
have been reported in breastfed infants. No retinal toxicity, ototoxicity, cardiotoxicity, or growth and developmental
abnormalities have been observed in children who were exposed to hydroxychloroquine through breastmilk. There is
no information on the effect of hydroxychloroquine on milk production. The developmental and health benefits of
breastfeeding should be considered along with the mother’s clinical need for hydroxychloroquine sulfate and any
potential adverse effects on the breastfed child from hydroxychloroquine sulfate or from the underlying maternal
condition.

8.4 Pediatric Use

The safety and effectiveness of hydroxychloroquine sulfate have been established in pediatric patients for the
treatment of uncomplicated malaria due to P. falciparum, P. malariae, P. vivax, and P. ovale, as well as for the
prophylaxis of malaria in geographic areas where chloroquine resistance is not reported. However, this product cannot
be directly administered to pediatric patients weighing less than 31 kg because the film-coated tablets cannot be
crushed or divided [see Dosage and Administration (2.1, 2.2)].
The safety and effectiveness of hydroxychloroquine sulfate have not been established in pediatric patients for the
treatment of rheumatoid arthritis, chronic discoid lupus erythematosus, or systemic lupus erythematosus.

8.5 Geriatric Use

Clinical trials of hydroxychloroquine sulfate did not include sufficient numbers of patients 65 years of age and older to
determine whether they respond differently from younger adult patients. Nevertheless, this drug is known to be
substantially excreted by the kidney, and the risk of toxic reactions to this drug may be greater in patients with
impaired renal function. In general, dose selection in geriatric patients should start with the lowest recommended
dose, taking into consideration the greater frequency of decreased hepatic, renal or cardiac function, and of
concomitant disease or other drug therapy.

8.6 Patients with Renal or Hepatic Disease

A reduction in the dosage of hydroxychloroquine sulfate may be necessary in patients with hepatic or renal disease.

Hydroxychloroquine sulfate overdosage symptoms have an onset within 1 hour to 3 hours of ingestion. The following
have been reported with hydroxychloroquine sulfate overdosage:
• Cardiovascular toxicity, including QRS or QTc prolongation, ventricular tachycardia, ventricular fibrillation,
torsade de pointes, atrioventricular block, cardiac arrest and death.
• Life-threatening hypotension is common.
• Severe hypokalemia secondary to an intracellular shift is common in severe toxicity.
• Central nervous system (CNS) depression, seizures, visual disturbances, transient blindness, and coma may occur.
Gastrointestinal decontamination procedures warrant consideration in patients that present within the first hour
post-ingestion. If the level of consciousness rapidly deteriorates in severe poisoning, consider intubation before
gastrointestinal decontamination procedures. Monitor plasma potassium levels and manage accordingly.
Hemofiltration, hemodialysis, and hemoperfusion are not of benefit.
Consider contacting a poison center (1-800-221-2222) or a medical toxicologist for overdosage management
recommendations.

Hydroxychloroquine sulfate tablet, USP is an antimalarial and antirheumatic drug, chemically described as
2-[[4-[(7-Chloro-4-quinolyl) amino]pentyl] ethylamino] ethanol sulfate (1:1) with the molecular formula
C18H26ClN3O•H2SO4. The molecular weight of hydroxychloroquine sulfate is 433.95. Its structural formula is:

Hydroxychloroquine Tablet

Hydroxychloroquine sulfate is a white or practically white, crystalline powder, freely soluble in water; practically
insoluble in alcohol, chloroform, and in ether.
Each hydroxychloroquine sulfate tablet intended for oral administration contains 200 mg of hydroxychloroquine sulfate,
USP equivalent to 155 mg base. In addition, each tablet contains the following inactive ingredients: dibasic calcium
phosphate dihydrate, magnesium stearate, pregelatinized starch, polyethylene glycol, polyvinyl alcohol, starch, talc and
titanium dioxide.

12.1 Mechanism of Action

Malaria
Hydroxychloroquine is a 4-aminoquinoline antimalarial [see Microbiology (12.4)] and antirheumatic agent.

Rheumatoid Arthritis, Systemic Lupus Erythematosus and Chronic Discoid Lupus
Erythematosus

The mechanisms underlying the anti-inflammatory and immunomodulatory effects of hydroxychloroquine sulfate in the
treatment of rheumatoid arthritis, chronic discoid lupus erythematosus and systemic lupus erythematosus are not fully
known.

12.2 Pharmacodynamics

The exposure-response relationship and time course of pharmacodynamic response for the safety and effectiveness of
hydroxychloroquine have not been fully characterized.

12.3 Pharmacokinetics

Following oral administration, the whole blood concentration of hydroxychloroquine at steady state is dose proportional
over a dose range from 200 mg daily to 400 mg daily of hydroxychloroquine in rheumatoid arthritis and lupus patients.

Absorption

Following a single 200 mg oral dose of hydroxychloroquine sulfate to healthy male volunteers, whole blood
hydroxychloroquine C was 129.6 ng/mL (plasma C was 50.3 ng/mL) with T of 3.3 hours (plasma T 3.7 hours). Peak
blood concentrations of metabolites were observed at the same time as peak levels of hydroxychloroquine. Mean
absolute oral bioavailability is 79% (SD: 12%) in fasting conditions.

Peak blood concentrations ranged from 1,161 ng/mL to 2,436 ng/mL (mean 1,918 ng/mL) following a single dose of
155 mg intravenous infusion and from 2290 ng/mL to 4,211 ng/mL (mean 3,312 ng/mL) following a single dose of
310 mg intravenous infusion in healthy subjects. Pharmacokinetic parameters were not significantly different over the
therapeutic dose range of 155 mg and 310 mg, indicating linear kinetics.

In patients with rheumatoid arthritis, there was large variability as to the fraction of the dose absorbed (i.e. 30% to
100%), and mean hydroxychloroquine levels were significantly higher in patients with less disease activity.

Distribution

Hydroxychloroquine sulfate is extensively distributed to tissues and has a large volume of distribution. Approximately
50% of hydroxychloroquine is bound to plasma proteins.

Metabolism

Significant levels of three metabolites, desethylhydroxychloroquine (DHCQ), desethylchloroquine (DCQ), and
bidesethylhydroxychloroquine (BDCQ) were found in plasma and blood, with DHCQ being the major metabolite. In vitro,
hydroxychloroquine is metabolized mainly by CYP2C8, CYP3A4 and CYP2D6 as well as by FMO-1 and MAO-A

Elimination/Excretion

Renal clearance in patients with rheumatoid arthritis treated with hydroxychloroquine sulfate for at least 6 months was similar to that in single dose studies in healthy volunteers, suggesting that no change in clearance occurred with chronic dosing. Renal clearance of unchanged hydroxychloroquine was approximately 16% to 30% of the dose after oral and IV administration. Results following a single oral dose of a 200 mg tablet demonstrated a half-life of hydroxychloroquine about 40 days in whole blood. Following chronic oral administration of hydroxychloroquine, the absorption half-life of hydroxychloroquine was approximately 3 to 4 hours and the terminal half-life ranged from 40 to 50 days in whole blood. The effective half-life of hydroxychloroquine is likely to be shorter and steady state is achieved by 6 weeks following 400 mg daily oral administration in rheumatoid arthritis patients.

Drug Interaction Studies

In vitro study suggested that hydroxychloroquine has a potential to inhibit CYP2D6, CYP3A4, P- glycoproteins (P-gp),
MATE1 and MATE2-K.

In vitro study suggested that hydroxychloroquine has no significant potential to inhibit CYP1A2, CYP2B6, CYP2C8,
CYP2C9, CYP2C19, and the main transporters OATP1B1, OATP1B3, OAT1, OAT3, OCT1, and OCT2. In vitro,
hydroxychloroquine has no significant potential to induce CYP1A2, CYP2B6 and CYP3A4.

12.4 Microbiology

Mechanism of Action in Malaria

The precise mechanism by which hydroxychloroquine exhibits activity against Plasmodium is not known.
Hydroxychloroquine is a weak base and may exert its effect by concentrating in the acid vesicles of the parasite and
inhibiting polymerization of heme. It can also inhibit certain enzymes by its interaction with DNA.

Antimicrobial Activity

Hydroxychloroquine is active against the erythrocytic forms of chloroquine sensitive strains of P. falciparum, P.
malariae, P. vivax, and P. ovale. Hydroxychloroquine is not active against the gametocytes and exoerythrocytic forms
including the hypnozoite liver stage forms of P. vivax and P. ovale.

Drug Resistance

P. falciparum strains exhibiting reduced susceptibility to chloroquine also show reduced susceptibility to
hydroxychloroquine. Resistance of Plasmodium parasites to chloroquine is widespread [see Indications and Usage
(1.1)].

13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility

No carcinogenicity or genotoxicity studies have been conducted with hydroxychloroquine. No animal studies have been
performed to evaluate the potential effects of hydroxychloroquine on reproduction or development, or to determine
potential effects on fertility in males or females.

¹ Center for Disease Control and Prevention. Malaria.
www.cdc.gov/parasites/malaria/index.html

16.1 How Supplied

Hydroxychloroquine sulfate Tablets, USP contain 200 mg of hydroxychloroquine sulfate, USP (equivalent to 155 mg
base). White to off-white, capsule-shaped, biconvex, film-coated tablets debossed with “ZC38” on one side and plain
on other side, and are supplied as follows:
• Boxes of 10 x 10 UD 100 NDC 63739-777-10

16.2 Storage

Store at 20° to 25°C (68° to 77°F) [See USP Controlled Room Temperature].
Dispense in a tight, light-resistant container as defined in the USP/NF. Keep out of the reach of children.

Important Administration Instructions

Advise the patient to take hydroxychloroquine sulfate tablet with food or milk and not to crush or divide the tablet.

Cardiomyopathy and Ventricular Arrhythmias

Inform the patient that serious cardiac effects, life-threatening and fatal cases have been reported with use of
hydroxychloroquine sulfate. Advise patients to seek medical attention immediately if they experience any symptoms of
heart rhythm changes including fast or irregular heartbeat, lightheadedness, dizziness, or syncope [see Warnings and
Precautions (5.1)].

Retinal Toxicity

Inform the patient that irreversible retinal damage has been observed in some patients with the use of
hydroxychloroquine sulfate. Advise patients of the importance of the ophthalmology visits for monitoring their eyes.
Instruct patients to seek medical attention promptly if they experience decreased vision or decreased dark adaptation
[see Warnings and Precautions (5.2)].

Serious Skin Reactions

Inform the patient that severe, life-threatening skin reactions have been reported with the use of hydroxychloroquine
sulfate. Advise the patient to seek medical attention immediately if experiencing any of the following signs and
symptoms: blisters on the skin, eyes, lips or in the mouth, itching or burning, with or without fever [see Warnings and
Precautions (5.3)].

Hepatotoxicity Associated with Porphyria Cutanea Tarda

Inform the patient that liver toxicity has been reported in when hydroxychloroquine sulfate was used in patients with
porphyria cutanea tarda. In some cases, PCT was diagnosed only after the occurrence of liver injury, when
hydroxychloroquine sulfate was prescribed for an approved indication. Advise the patient to seek medical attention if
experiencing fatigue, rash, nausea, dark urine, or jaundice [see Warnings and Precautions (5.5)].

Skeletal Muscle Myopathy or Neuropathy

Inform the patient that muscle weakness and atrophy has been reported with hydroxychloroquine sulfate use Advise
patients to report to the physician symptoms of muscle weakness [see Warnings and Precautions (5.8)].

Neuropsychiatric Reactions Including Suicidality

Alert patients to seek medical attention immediately if they experience new or worsening depression, suicidal
thoughts, or other mood changes [see Warnings and Precautions (5.9)].

Hypoglycemia

Inform the patient that hydroxychloroquine sulfate has been associated with severe hypoglycemia. Advise the patient
to monitor blood sugar levels if possible and to seek medical attention if experiencing any of the signs and symptoms
of hypoglycemia such as sweating, shakiness, weakness, dizziness, tachycardia, nausea, blurred vision, confusion,
fainting, or loss of consciousness [see Warnings and Precautions (5.10)].

Pregnancy

Inform the patient that there is a pregnancy registry that monitors pregnancy outcomes in women exposed to
hydroxychloroquine sulfate during pregnancy. Encourage patients to register by contacting 1-877-311-8972 [see Use
in Specific Populations (8.1)].

Manufactured by:
Zydus Lifesciences Ltd.
India

Distributed by:
McKesson Corporation dba SKY Packaging
Memphis, TN 38141

February 2024
21415-2

HYDROXYCHLOROQUINE 200MG