HYDROXYCHLOROQUINE 200MG

4 CONTRAINDICATIONS

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

6 ADVERSE REACTIONS

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 DRUG INTERACTIONS

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.

15 REFERENCES

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

RECENT MAJOR CHANGES

Warnings and Precautions, Risks Associated with Use in Porphyria (5.5) 07/2023
Warnings and Precautions, Neuropsychiatric Reactions Including Suicidality (5.9) 07/2023

2 DOSAGE AND ADMINISTRATION

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.

3 DOSAGE FORMS AND STRENGTHS

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.

8 USE IN SPECIFIC POPULATIONS

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.

10 OVERDOSAGE

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.

11 DESCRIPTION

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 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 CLINICAL PHARMACOLOGY

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 NONCLINICAL TOXICOLOGY

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.

16 HOW SUPPLIED/STORAGE AND HANDLING

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.

17 PATIENT COUNSELING INFORMATION

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