Consumer medicine information

Hequinel Tablets 200 mg

Hydroxychloroquine sulfate

BRAND INFORMATION

Brand name

Hequinel

Active ingredient

Hydroxychloroquine sulfate

Schedule

S4

 

Consumer medicine information (CMI) leaflet

Please read this leaflet carefully before you start using Hequinel Tablets 200 mg.

What is in this leaflet

This leaflet answers some common questions about hydroxychloroquine. It does not contain all the available information.

It does not take the place to talking to your doctor or pharmacist.

All medicines have risks and benefits. Your doctor has weighed the risks of you using hydroxychloroquine against the benefits they expect it will have for you.

If you have any concerns about using this medicine, ask your doctor or pharmacist.

This medicine has been prescribed for you only. Do not pass it on to others. It may harm them, even if their signs of illness are the same as yours.

If you get any side effects talk to your doctor or pharmacist. This includes any possible side effects not listed in this leaflet.

Read this leaflet carefully before you start using this medicine because it contains important information for you.

Keep this leaflet. You may need to read it again.

What HEQUINEL is used for

The name of your medicine is Hequinel Tablets 200 mg. It contains the active ingredient hydroxychloroquine sulfate.

It may be used for any of the following conditions:

Rheumatoid Arthritis
Rheumatoid arthritis is a form of arthritis with inflammation of the joints, characterized by stiffness, swelling and pain.

Hydroxychloroquine may be used for short or long-term rheumatoid arthritis treatment.

In treating rheumatoid arthritis, hydroxychloroquine may slow down the process of joint damage and relieve the symptoms of the disease.

Systemic Lupus Erythematous (SLE)
SLE is a disease in which a person's normal immunity is upset. The body produces an excess of blood proteins called antibodies and these antibodies may cause problems in any organ of the body.

These antibodies may end up, for example, in the skin causing a variety of skin rashes or deposit in the kidney, brain, lung and joints causing injury.

Discoid Lupus Erythematous (DLE)
DLE is similar to SLE except it only affects the skin and is characterized by a scaling, red rash.

Malaria (treatment and control of symptoms)
Malaria is an infectious disease caused by the presence of parasites in red blood cells.

The disease is characterized by chills, fever and sweats. In malaria, hydroxychloroquine destroys the harmful parasite which causes the illness.

Your doctor may have prescribed hydroxychloroquine for another reason.

Ask your doctor if you have any questions about why this medicine has been prescribed for you. Hydroxychloroquine is not addictive. This medicine is available only with a doctor's prescription.

Before you use HEQUINEL

When you must not use it

Do not take this medicine if you have had an allergic reaction to hydroxychloroquine, chloroquine or related products or any of the ingredients listed at the end of this leaflet.

If you are uncertain whether you have had an allergic reaction to a related product ask your doctor or pharmacist. Symptoms of an allergic reaction may include an asthma attack, facial swelling, skin rash or hay fever.

Ask your doctor about the risks and benefits of taking this medicine while you are pregnant. When hequinel is taken for long periods of time, there is an increased risk to the unborn child. It may cause problems with brain function, hearing, balance and vision.

Ask your doctor about the risks and benefits of taking hequinel while you are breastfeeding.

Do not take this medicine if you have previously experienced changes in your eyesight when taking medicines for rheumatoid arthritis or malaria.

Hydroxychloroquine should not be used in children under 6 years.

Hydroxychloroquine should not be used in children over 6 years for long periods.

Do not take this medicine after the expiry date (EXP) printed on the pack. It may have no effect at all, or worse, an entirely unexpected effect if you take it after the expiry date.

Do not take this medicine if the packaging is torn, shows signs of tampering or if it does not look quite right.

Do not take this medicine to treat any other complaint unless your doctor says it is safe.

Do not give this medicine to anyone else.

Before you start to use HEQUINEL

You must tell your doctor if:

  1. You are allergic to quinine.
  2. You have allergies to any ingredients listed under "Product Description" at the end of this leaflet.
  3. You have any pre-existing eye disorders
  4. You have experienced low blood sugar levels (hypoglycaemia – a "hypo"). Hydroxychloroquine may increase the risk of you having a hypo.
  5. You have or have had any of these medical conditions:
  • Chloroquine-resistant malaria
  • Liver or kidney problems
  • Diabetes
  • Stomach, brain or blood disorders
  • Disease of the heart muscle
  • Skin diseases, in particular psoriasis which is a kind of itchy rash
  • Glucose-6-phosphate dehydrogenase (G-6-PD) deficiency which is a lack of a chemical substance which causes the breakdown of sugar in the body.
  • Porphyria, which is a rare disease of blood pigments.
  1. You plan to become pregnant or breast-feed.

If you have not told your doctor about any of the above, tell them before you start taking this medicine.

Taking other medicines

Tell your doctor or pharmacist if you are taking any other medicines, including any that you buy without a prescription from your pharmacy, supermarket or health food shop.

Some medicines and hydroxychloroquine may interfere with each other. These include:

  • Any medicine to treat depression
  • Digoxin - a medicine used to treat heart disease
  • Medicines to treat diabetes
  • Medicines used to suppress the immune system such as cyclosporine
  • Antiarrythmic drugs such as amiodarone
  • Other antimalarial drugs
  • Medicines to treat epilepsy
  • Tamoxifen (a medicine used to treat breast cancer)
  • Anti-infective medicines

These medicines may be affected by hydroxychloroquine or may affect how well it works.

Your doctor and pharmacist can tell you if you are taking any of these medicines.

How To Take HEQUINEL

Follow all directions given to you by your doctor or pharmacist carefully.

Swallow tablets whole with a little water or other liquid. It is best to take it at meal times.

How much to take

Your doctor or pharmacist will tell you how many tablets you will need to take. This depends on your condition and whether or not you are taking any other medicines.

The dosage will depend on why you are being treated with hydroxychloroquine.

The usual doses are:

Rheumatoid arthritis

Adults
2-3 tablets daily. Your doctor may later reduce this to 1-2 tablets daily.

SLE and DLE

Adults
2-4 tablets daily. Your doctor may later reduce this to 1-2 tablets daily.

Control of Malaria Symptoms

Adults
2 tablets once a week. The tablets should be taken on exactly the same day of each week.

For example, if your first dose is taken on a Monday, then each weekly dose should be taken on a Monday.

Treatment of Malaria

Adults
The starting dose is 4 tablets. Take another 2 tablets six to eight hours later and two further tablets on each of the next 2 days.

Always follow the instructions given to you by your doctor.

Dosages for children are calculated according to the child's body weight. Your doctor will work out the correct dose for you.

Hydroxychloroquine should not be used in children for long periods. Your doctor may ask you to take a different dose. You should follow the instructions on the label.

If you are unsure what dose to take ask your pharmacist or doctor.

How long to take it for

Continue taking your medicine for as long as your doctor tells you. Make sure you have enough to last over weekends and holidays.

If you forget to take it

If you are being given hydroxychloroquine for rheumatoid arthritis or SLE or DLE, do not take a double dose to make up for the dose missed. Just continue with the appropriate dose on the next day.

If you are being given hydroxychloroquine for suppression or treatment of malaria, you should take your tablets as soon as you remember, and go back to taking it as you would normally.

If you have trouble remembering when to take your medicine, ask your pharmacist for some hints.

If you take too much (overdose)

Immediately telephone your doctor or the Poisons Information Centre (Tel: 13 11 26 for Australia) for advice, or go to the Accident and Emergency Department at the nearest hospital, if you think that you or anyone else may have taken too much hydroxychloroquine.

Do this even if there are no signs of discomfort or poisoning. You may need urgent medical attention.

If you take too much hydroxychloroquine, you may experience headaches, drowsiness, visual disturbances or fits.

These symptoms may occur within 30 minutes of overdose.

While You Are Taking HEQUINEL

If you are about to start taking any new medicines, tell your doctor and pharmacist that you are taking hydroxychloroquine.

Tell all doctors, dentists and pharmacists who are treating you that you are taking hydroxychloroquine.

Tell your doctor if you experience any of the following symptoms including; weakness, trembling or shaking, sweating, light-headedness, headache, dizziness, lack of concentration, tearfulness or crying, irritability, hunger and numbness around the lips and fingers. These symptoms may be associated with hypoglycaemia. If you experience any of the symptoms of hypoglycaemia, you need to raise your blood glucose urgently. You can do this by taking one of the following:

  • 5-7 jelly beans
  • 3 teaspoons of sugar or honey
  • 1/2 can of ordinary (non-diet) soft drink
  • 2-3 concentrated glucose tablets unless you are within 10 to 15 minutes of your next meal or snack, follow up with extra carbohydrates e.g. plain biscuits, fruit or milk - when over the initial symptoms. Taking this extra carbohydrate will prevent a second drop in your blood glucose level.

Make sure you, your friends, family and work colleagues can recognize the symptoms of hypoglycaemia and know how to treat them. Your doctor will need to perform the following tests during treatment with hydroxychloroquine:

Eye Tests
Your doctor will need to perform some eye tests every few months to check that your eyesight is not changing.

In extremely rare cases, hydroxychloroquine has been associated with blindness. This can be avoided by having regular eye tests.

It is recommended you wear sunglasses when out in the sun.

Blood Tests
Your doctor will need to perform occasional blood tests to check for any blood reactions.

Your doctor may monitor your blood sugar levels if you have experienced hypoglycaemia while taking hydroxychloroquine.

Driving/Operating Machinery
Be careful driving or operating machinery until you know how Hydroxychloroquine affects you. Hydroxychloroquine may cause problems with the eyesight of some people. Make sure you know how you react to hydroxychloroquine before you drive a car, operate machinery, or do anything else that could be dangerous with blurred vision.

Things you must do

Tell any other doctors, dentists, and pharmacists who are treating you that you are taking Hydroxychloroquine.

Tell your doctor immediately if you become pregnant.

If you are about to have any blood tests, tell your doctor that you are taking this medicine.

Go to your doctor regularly for a check-up.

Your doctor may occasionally do tests to make sure the medicine is working and to prevent side effects.

Things you must not do

Do not give this medicine to anyone else, even if their symptoms seem similar to yours.

Do not take your medicine to treat any other complaints unless your doctor or pharmacist tells you to.

Do not stop taking your medicine, or change the dosage, without checking with your doctor.

Things to be careful of

Be careful while driving or operating machinery until you know how hydroxychloroquine affects you.

Hydroxychloroquine may cause problems with the eyesight of some people. Make sure you know how you react to hydroxychloroquine before you drive a car, operate machinery, or do anything else that could be dangerous with blurred vision.

Side Effects of HEQUINEL

All medicines may have some unwanted side effects. Sometimes they are serious, but most of the time, they are not. Your doctor has weighed the risks of using this medicine against the benefits they expect it will have for you.

Tell your doctor or pharmacist as soon as possible if you do not feel well while you are taking hydroxychloroquine. Hydroxychloroquine helps most people with rheumatoid arthritis, SLE, DLE, treatment of malaria and the control of malaria symptoms, but it may have unwanted side effects in a few people.

You may need medical treatment if you get some of the side effects.

Ask your doctor or pharmacist to answer any questions you may have.

Following is a list of possible side effects. Do not be alarmed by this list. You may not experience any of them.

Tell your doctor or pharmacist if you notice any of the following and they worry you:

Less serious side effects

Stomach problems such as:

  • Nausea
  • Vomiting
  • Diarrhoea
  • Abdominal cramps

Other problems such as:

  • Loss of appetite
  • Muscle weakness
  • Dizziness
  • Ringing in the ears
  • Headache
  • Nervousness
  • Skin rash and itching
  • Hair loss

If you already have psoriasis, you are more likely to experience skin reactions than other people when taking hydroxychloroquine.

More serious side effects

Tell your doctor if you notice any of the following:

  • Visual disturbances
  • Any hearing loss
  • Suicidal behavior
  • Frequent fevers, severe chills, bruising, sore throat or mouth ulcers (these may be signs of blood reactions)
  • Changes in the way your heart beats
  • More severe symptoms of hypoglycaemia, including:
    - disorientation
    - seizures, fits or convulsions
    - loss of consciousness

These are serious side effects. You may need medical attention.

Serious side effects are rare. Other side effects not listed above may occur in some patients.

Tell your doctor or pharmacist if you notice anything that is making you feel unwell

Some people may get other side effects while taking hydroxychloroquine.

After Using HEQUINEL

Storage

Keep your medicine in its original packaging until it is time to take it.

If you take your medicine out of its original packaging it may not keep well.

Keep your medicine in a cool dry place where the temperature will stay below 25°C.

Heat and dampness can destroy some medicines. Do not leave hydroxychloroquine in the car on hot days.

Do not store your medicine, or any other medicine, in the bathroom or near a sink.

Do not leave it on a window sill or in the car.

Heat, sunlight and dampness can destroy some medicines.

Keep it where children cannot reach it.

Children are particularly sensitive to the unwanted effects of hydroxychloroquine.

A locked cupboard at least one and a-half metre above the ground is a good place to store medicines.

Disposal

If your doctor or pharmacist tells you to stop taking this medicine or it has passed its expiry date, ask your pharmacist what to do with any medicine that is left over.

Where to go for further information

Pharmaceutical companies are not in a position to give people an individual diagnosis or medical advice. Your doctor or pharmacist is the best person to give you advice on the treatment of your condition.

Product Description

What Hequinel Tablets looks like?

White to off-white, capsule-shaped tablets, embossed "HCQS" on one side, plain on the other side.

Packaged in bottles of 100 tablets.

Ingredients

Each tablet contains 200 mg of hydroxychloroquine sulfate as the active ingredient (equivalent to 155 mg hydroxychloroquine).

It also contains the following inactive ingredients:

  • anhydrous calcium hydrogen phosphate
  • pregelatinised maize starch
  • hypromellose
  • magnesium stearate
  • polysorbate 80
  • colloidal anhydrous silica
  • Opadry II White 85F18422.

This medicine is gluten-free, lactose free and free of other azo dyes.

Sponsor

Arrow Pharma Pty Ltd
15 – 17 Chapel street
VIC 3121
www.arrowpharma.com.au

This leaflet was last updated in December 2019

Australian Registration Number: AUST R 223696

Published by MIMS March 2020

BRAND INFORMATION

Brand name

Hequinel

Active ingredient

Hydroxychloroquine sulfate

Schedule

S4

 

1 Name of Medicine

Hydroxychloroquine sulfate.

6.7 Physicochemical Properties

Hydroxychloroquine sulfate is a colourless crystalline solid, soluble in water to at least 20%.

Chemical structure.

Chemical name: (RS)-2-N-[4-(7-chloro-4-quinolylamino) pentyl]-N-ethylaminoethanol sulfate.
Molecular formula: C18H26ClN3O.H2SO4.
Molecular weight of 433.95.

CAS number.

Cas No.: 747-36-4.

2 Qualitative and Quantitative Composition

Each tablet contains 200 mg hydroxychloroquine sulfate, which is equivalent to 155 mg base.
For the full list of excipients, see Section 6.1 List of Excipients.

3 Pharmaceutical Form

White to off-white, capsule-shaped tablets, embossed "HCQS" on one side, plain on the other side.

5 Pharmacological Properties

5.1 Pharmacodynamic Properties

Mechanism of action.

Hydroxychloroquine is an anti-malarial. It also exerts a beneficial effect in mild systemic and discoid lupus erythematosus and rheumatoid arthritis. The precise mechanism of action is not known.

Malaria.

Like chloroquine phosphate, hydroxychloroquine is highly active against the erythrocytic forms of Plasmodium vivax and P. malariae and most strains of P. falciparum (but not the gametocytes of P. falciparum).
Hydroxychloroquine does not prevent relapses in patients with vivax or malariae malaria because it is not effective against exo-erythrocytic forms of the parasite, nor will it prevent vivax or malariae infection when administered as a prophylactic. It is highly effective as a suppressive agent in patients with vivax or malariae malaria, in terminating acute attacks and significantly lengthening the interval between treatment and relapse. In patients with falciparum malaria, it abolishes the acute attack and effects complete cure of the infection, unless due to a resistant strain of P. falciparum.

Clinical trials.

No data available.

5.2 Pharmacokinetic Properties

No data available.

5.3 Preclinical Safety Data

Genotoxicity.

There are limited data on hydroxychloroquine genotoxicity. Chloroquine is reported in the literature to elicit both gene mutations and chromosomal/DNA breaks in some in vitro systems but not others and in in vivo studies using rodents when dosed via the intraperitoneal route. Chromosomal effects were not observed in vivo when chloroquine was administered orally.

Carcinogenicity.

No carcinogenicity studies are available on hydroxychloroquine. A dietary carcinogenicity study in rats with the parent drug chloroquine was negative. No other carcinogenicity study was conducted in mice or other species. In the absence of sufficient human and animal data an increased risk of cancer in patients receiving long term treatment cannot be ruled out.

4 Clinical Particulars

4.1 Therapeutic Indications

Rheumatoid arthritis; mild systemic and discoid lupus erythematosus; the suppression and treatment of malaria.

4.3 Contraindications

Hydroxychloroquine is contraindicated in:
patients with pre-existing maculopathy of the eye;
patients with known hypersensitivity to 4-aminoquinoline compounds;
long-term therapy in children;
children under 6 years of age.

4.4 Special Warnings and Precautions for Use

Hydroxychloroquine is not effective against chloroquine-resistant strains of P. falciparum.
Patients should be warned to keep hydroxychloroquine out of the reach of children, as small children are particularly sensitive to 4-aminoquinolines.
Hydroxychloroquine should be used with caution, or not at all, in patients with severe gastrointestinal, neurological or blood disorders. If such severe disorders occur during therapy, hydroxychloroquine should be stopped. Periodic blood counts are advised.
When used in patients with porphyria or psoriasis, these conditions may be exacerbated. Hydroxychloroquine should not be used in these conditions unless in the judgement of the physician, the benefit to the patient outweighs the possible risk.

Chronic cardiac toxicity.

Cases of cardiomyopathy resulting in cardiac failure, in some cases with fatal outcome, have been reported in patients treated with hydroxychloroquine. Clinical monitoring for signs and symptoms of cardiomyopathy is advised and hydroxychloroquine should be discontinued if cardiomyopathy develops. Chronic toxicity should be considered when conduction disorders (bundle branch block/ atrio-ventricular heart block) as well as biventricular hypertrophy are diagnosed.

Hypoglycaemia.

Hydroxychloroquine has been shown to cause severe hypoglycaemia including loss of consciousness that could be life threatening in patients treated with and without anti-diabetic medications. Patients treated with hydroxychloroquine should be warned about the risk of hypoglycaemia and the associated clinical signs and symptoms. Patients presenting with clinical symptoms suggestive of hypoglycaemia during treatment with hydroxychloroquine should have their blood glucose level checked and treatment reviewed as necessary.

QT interval prolongation.

Hydroxychloroquine prolongs the QTc interval and should not be used in patients receiving drugs known to prolong the QT interval, e.g. class IA and III antiarrhythmics, tricyclic antidepressants, antipsychotics, some anti-infectives due to increased risk of ventricular arrhythmia (see Section 4.5 Interactions with Other Medicines and Other Forms of Interactions; Section 4.9 Overdose).
Hydroxychloroquine should be used with caution 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);
a history of ventricular dysrhythmias;
uncorrected hypokalaemia and/or hypomagnesaemia.
The magnitude of QT prolongation may increase with increasing concentrations of the drug. Therefore, the recommended dose should not be exceeded (see Section 4.5 Interactions with Other Medicines and Other Forms of Interactions; Section 4.8 Adverse Effects (Undesirable Effects)).

Ophthalmological.

Irreversible retinal damage has been observed in some patients who had received long-term or high dosage 4-aminoquinolone therapy for discoid and systemic lupus erythematosus or rheumatoid arthritis. Retinopathy has been reported to be dose related. Exceeding the recommended daily dose sharply increases the risk of retinal toxicity.
If there is any indication of abnormality in the visual field or retinal macular areas (such as pigmentary changes, loss of foveal reflex), or any visual symptoms (such as light flashes and streaks) which are not fully explainable by difficulties of accommodation or corneal opacities, hydroxychloroquine should be discontinued immediately and the patient closely observed for possible progression. Retinal changes (and visual disturbances) may progress after cessation of therapy (see Section 4.8 Adverse Effects (Undesirable Effects)).
Concomitant use of hydroxychloroquine with drugs known to induce retinal toxicity, such as tamoxifen, is not recommended.
Before starting treatment with hydroxychloroquine, all patients should have a careful complete examination of both eyes which includes slit lamp microscopy for corneal changes, fundoscopy, visual acuity, central visual field and colour vision. A complete eye examination before treatment will determine the presence of any visual abnormalities, either coincidental or due to the disease and establish a baseline for further assessment of the patient's vision.
Ophthalmological testing should be conducted at 6 monthly intervals in patients receiving hydroxychloroquine at a dose of not more than 6 mg per kg body weight per day.
Ophthalmological testing should be conducted at 3-4 monthly intervals in the following circumstances: dose exceeds 6 mg/kg ideal (lean) body weight per day. Using absolute body weight, as a guide to dosage, could result in an over dosage in the obese; significant renal impairment; significant hepatic impairment; elderly; complaints of visual disturbances; duration of treatment exceeds 8 years.
Corneal changes often subside on reducing the dose or on interrupting therapy for a short period of time, but any suggestion of retinal change or restriction in the visual field is an indication for complete withdrawal of the drug.
The use of sunglasses in patients exposed to strong sunlight is recommended, as this may be an amplifying factor in retinopathy.

Skin reactions.

Pleomorphic skin eruptions (morbilliform, lichenoid, purpuric), itching, dryness and increased pigmentation sometimes appear after a few months of therapy. The rash is usually mild and transient. If a rash appears, hydroxychloroquine should be withdrawn and only started again at a lower dose.
Patients with psoriasis appear to be more susceptible to severe skin reactions than other patients.

Other monitoring on long term treatments.

Patients on long-term therapy should have periodic full blood counts. If evidence of abnormalities such as agranulocytosis, aplastic anaemia, thrombocytopenia or leukopenia becomes apparent, and cannot be attributed to the disease being treated, hydroxychloroquine should be discontinued.
All patients on long-term therapy with this preparation should be questioned and examined periodically, including the testing of knee and ankle reflexes, to detect any evidence of muscular weakness. If weakness occurs discontinue the drug.

Miscellaneous.

Gastrointestinal disturbances such as nausea, anorexia, abdominal cramps or rarely vomiting, occur in some patients. The symptoms usually stop on reducing the dose or temporarily stopping the drug.
Muscle weakness, vertigo, tinnitus, nerve deafness, headache and nervousness have been reported less frequently.
In the treatment of rheumatoid arthritis, if objective improvement (such as reduced joint swelling, increased mobility) does not occur within six months, hydroxychloroquine should be discontinued. Safe use of hydroxychloroquine in the treatment of juvenile rheumatoid arthritis has not been established.
Suicidal behaviour has been reported in very rare cases in patients treated with hydroxychloroquine.
Extrapyramidal disorders may occur with hydroxychloroquine.
Observe caution in patients with hepatic or renal disease, in whom a reduction in dosage may be necessary, as well as in those taking medicines known to affect these organs. Also observe caution in patients with gastrointestinal, neurological, or blood disorders, in those with a sensitivity to quinine, and in glucose-6-phosphate dehydrogenase deficiency.

Use in hepatic and renal impairment.

Observe caution in patients with hepatic or renal disease, in whom a reduction in dosage may be necessary, as well as in those taking medicines known to affect these organs.

Use in the elderly.

See Section 4.4 Special Warnings and Precautions for Use, Ophthalmological.

Paediatric use.

See Section 4.2 Dose and Method of Administration.

Effects on laboratory tests.

No data available.

4.5 Interactions with Other Medicines and Other Forms of Interactions

It has been suggested that 4-aminoquinolines are pharmacologically incompatible with monoamine oxidase inhibitors.
Concomitant hydroxychloroquine and digoxin therapy may result in increased serum digoxin concentrations. Consequently, serum digoxin concentrations should be closely monitored in patients receiving combination therapy.
As hydroxychloroquine may enhance the effects of a hypoglycaemic treatment, a decrease in doses of insulin or antidiabetic drugs may be required.
Drugs known to prolong QT interval/ with potential to induce cardiac arrhythmia:
Hydroxychloroquine should not be used in patients receiving drugs known to prolong the QT interval and should not be administered with other drugs that have the potential to induce cardiac arrhythmias, including halofantrine e.g. Class IA and III antiarrhythmics, tricyclic antidepressants, antipsychotics, some anti-infectives due to increased risk of ventricular arrhythmia. Also, there may be an increased risk of inducing ventricular arrhythmias if hydroxychloroquine is used concomitantly with other arrhythmogenic drugs, such as amiodarone and moxifloxacin.
Increased plasma cyclosporin level has been reported when cyclosporin and hydroxychloroquine are co-administered.
Hydroxychloroquine can lower the convulsive threshold. Co-administration of hydroxychloroquine with other antimalarials known to lower the convulsion threshold (e.g. mefloquine) may increase the risk of convulsions.
The activity of antiepileptic drugs might be impaired if co-administered with hydroxychloroquine.
In a single-dose interaction study, chloroquine has been reported to reduce the bioavailability of praziquantel. It is not known if there is a similar effect when hydroxychloroquine and praziquantel are co-administered. Per extrapolation, due to the similarities in structure and pharmacokinetic parameters between hydroxychloroquine and chloroquine, a similar effect may be expected for hydroxychloroquine.
There is a theoretical risk of inhibition of intra-cellular α-galactosidase activity when hydroxychloroquine is co-administered with agalsidase.

4.6 Fertility, Pregnancy and Lactation

Effects on fertility.

There are no animal data on hydroxychloroquine action on fertility. A study in male rats after 30 days of oral treatment at 5 mg/day of chloroquine showed a decrease in fertility rate, and in testosterone levels, weight of testes, epididymis, seminal vesicles and prostate.
There are no data in humans.
(Category D)
Hydroxychloroquine crosses the placenta. Data are limited regarding the use of hydroxychloroquine during pregnancy. It should be noted that 4-aminoquinolines in therapeutic doses have been associated with central nervous system damage, including ototoxicity (auditory and vestibular toxicity, congenital deafness), retinal haemorrhages and abnormal retinal pigmentation. Hydroxychloroquine should be avoided in pregnancy except when, in the judgement of the physician, the potential benefits outweigh the potential hazards.
The use of this drug in the treatment of malaria or suppression of malaria in high risk situations may be justified if the treating physician considers the risk to the foetus is outweighed by the benefits to the mother and foetus.
Nursing mothers: careful consideration should be given to using hydroxychloroquine during lactation, since it has been known to be excreted in small amounts in human breast milk and it is known that infants are extremely sensitive to the toxic effects of 4-aminoquinones.
Although hydroxychloroquine is excreted in breast milk, the amount is insufficient to confer any protection against malaria to the infant. Separate chemoprophylaxis for the infant is required.
There are very limited data on the safety in the breastfed infant during long-term hydroxychloroquine treatment; the prescriber should assess the potential risks and benefits of use during breastfeeding, according to indication and duration of treatment.

4.8 Adverse Effects (Undesirable Effects)

Very common ≥ 1/10 (≥ 10%); common ≥ 1/100 and < 1/10 (≥ 1% and < 10%); uncommon ≥ 1/1000 and < 1/100 (≥ 0.1% and < 1.0%); rare ≥ 1/10,000 and < 1/1000 (≥ 0.01% and < 0.1%); very rare < 1/10,000 (< 0.01%); not known, frequency cannot be estimated from available data.

Blood and lymphatic system disorders.

Rare: bone marrow depression, anaemia, aplastic anaemia, leucopenia, thrombocytopenia.
Very rare: agranulocytosis.

Immune system disorders.

Not known: urticaria, angioedema, bronchospasm.

Metabolism and nutrition disorders.

Common: anorexia.
Not known: hypoglycaemia.
Hydroxychloroquine may exacerbate porphyria.

Psychiatric disorders.

Common: affect lability.
Very rare: psychosis, suicidal behavior, nightmares.

Nervous system disorders.

Common: headache.
Uncommon: dizziness, nerve deafness, nervousness.
Rare: convulsions, neuromyopathy.
Very rare: nystagmus, ataxia.
Not known: extrapyramidal disorders such as dystonia, dyskinesia, tremor.

Eye disorders.

Common: blurring of vision.
Uncommon: corneal changes, retinal changes, retinopathy with changes in pigmentation and visual field defects. In its early form, it appears reversible on discontinuation of hydroxychloroquine. If allowed to develop, there may be a risk of progression even after treatment withdrawal.
Patients with retinal changes may be asymptomatic initially, or may even have scotomatous vision with paracentral, pericentral ring types, temporal scotomas and abnormal colour visions.
Corneal changes including oedema and opacities have occurred from three weeks (infrequently) to some years after the beginning of therapy. They are either symptomless or may cause disturbances such as halos, blurring of vision or photophobia. They may be transient or are reversible on stopping treatment. Should these types of corneal changes occur with hydroxychloroquine, it should be either stopped or temporarily withdrawn.
Not known: Cases of maculopathies and macular degeneration have been reported and may be irreversible.
Reversible extra-ocular muscle palsies and temporary blurring of vision due to interference with accommodation have also been noted.
Retinal changes such as abnormal macular pigmentation and depigmentation (sometimes described as a "bull's eye"), pallor of the optic disc, optic atrophy and narrowing of the retinal arterioles have been reported.
Originally, the condition was thought to be progressive and irreversible, but more recent evidence suggests that routine ophthalmological examinations may detect retinal changes, especially pigmentation, at an early and reversible stage when there is no apparent visual disturbance.
Much evidence suggests that there is a threshold of dosage above which retinopathy appears. These results seem to correlate more with daily dosage than with a cumulative dose, although the risk increases with increased duration of treatment.
Before starting treatment with hydroxychloroquine, all patients should have a careful complete examination of both eyes which included slit lamp microscopy for corneal changes, fundoscopy, visual acuity, central visual field and colour vision, repeated at six month intervals during therapy (see Section 4.4 Special Warnings and Precautions for Use, Ophthalmological). Any adverse changes in the ocular findings or the appearance of scotoma, night blindness or other retinal changes require immediate discontinuation of hydroxychloroquine; these patients should not subsequently receive any pharmacologically similar drugs.

Ear and labyrinth disorders.

Uncommon: vertigo, tinnitus.
Not known: hearing loss.

Cardiac disorders.

Rare: cardiomyopathy which may result in cardiac failure, and in some cases a fatal outcome (see Section 4.4 Special Warnings and Precautions for Use).
Chronic toxicity should be considered when conduction disorders (bundle branch block/ atrio-ventricular heart block) as well as biventricular hypertrophy are diagnosed.
Not known: QT interval prolongation in patients with specific risk factors, which may lead to arrhythmia (torsade de pointes, ventricular tachycardia) (see Section 4.4 Special Warnings and Precautions for Use; Section 4.5 Interactions with Other Medicines and Other Forms of Interactions).

Gastrointestinal disorders.

Very common: abdominal pain, nausea.
Common: diarrhoea, vomiting.

Hepatobiliary disorders.

Uncommon: abnormal liver function tests.
Very rare: fulminant hepatitis.

Skin and subcutaneous tissue disorders.

Common: skin rashes, alopecia, pruritus.
Uncommon: pigmentary changes, bleaching of hair.
Very rare: bullous eruptions such as acute generalized exanthematous pustulosis (AGEP), exfoliative dermatitis and erythema multiforme, Stevens-Johnson syndrome, drug rash with eosinophilia and systemic symptoms (DRESS syndrome), toxic epidermal necrolysis, photosensitivity.

Musculoskeletal and connective tissue disorders.

Uncommon: sensory-motor disorders.
Not known: absent or hypoactive deep tendon reflexes, muscle weakness or neuromyopathy leading to progressive weakness and atrophy of proximal muscle groups (muscle weakness may be reversible after drug discontinuation, but recovery may take many months). Depression of tendon reflexes and abnormal nerve conduction studies.
Very rare: extraocular muscle palsies.

Miscellaneous.

Rare: exacerbation or precipitation of porphyria and attacks of psoriasis.
Very rare: weight loss, lassitude.

Reporting suspected adverse effects.

Reporting suspected adverse reactions after registration of the medicinal product is important. It allows continued monitoring of the benefit-risk balance of medicinal product. Healthcare professionals are asked to report any suspected adverse reactions at https://www.tga.gov.au/reporting-problems.

4.2 Dose and Method of Administration

Hequinel tablets 200 mg are intended for oral administration.

Rheumatoid arthritis.

Hydroxychloroquine is cumulative in action and will require several weeks to exert its beneficial therapeutic effects, whereas minor side effects may occur relatively early. Several months of therapy may be required before maximum effects can be obtained.

Initial dosage.

In adults, a suitable initial dosage is from 400-600 mg daily, preferably taken at meal times. In a few patients the side effects may require temporary reduction of the initial dosage. Generally, after 5-10 days the dose may be gradually increased to the optimum response level, frequently without return of side effects.

Maintenance dosage.

When a good response is obtained (usually in 4-12 weeks) the dose can be reduced to 200-400 mg daily (but should not exceed 6 mg/kg per day) and can be continued as maintenance treatment. The minimum effective maintenance dose should be employed. The incidence of retinopathy has been reported to be higher when the maintenance dose is exceeded.
If objective improvement (such as reduced joint swelling or increased mobility) does not occur within six months the drug should be discontinued.
If a relapse occurs after medication is withdrawn, therapy may be resumed or continued on an intermittent schedule if there are no ocular contraindications.
Safe use of hydroxychloroquine for the treatment of juvenile rheumatoid arthritis has not been established.

Use in combination therapy.

Hydroxychloroquine may be used safely and effectively in combination with corticosteroids, salicylates, NSAIDs and methotrexate and other second line therapeutic agents. Corticosteroids and salicylates can generally be decreased gradually in dosage or eliminated after hydroxychloroquine has been used for several weeks. When gradual reduction of steroid dosage is suggested, it may be done by reducing every 4-5 days the dose of cortisone by no more than 5-15 mg; of methylprednisolone from 1-2 mg and dexamethasone from 0.25-0.5 mg. Treatment regimens using agents other than corticosteroids and NSAIDs are under development. No definitive dose combinations have been established.

Lupus erythematosus.

In mild systemic and discoid cases, antimalarials are the drugs of choice.
The dose of hydroxychloroquine depends on the severity of the disease and the patient's response to treatment. For adults, an initial dose of 400-800 mg daily is recommended. This level can be maintained for several weeks and then reduced to a maintenance dose of 200-400 mg daily.

Malaria.

Hydroxychloroquine is active against the erythrocytic forms of P. vivax and P. malariae and most strains of P. falciparum (but not the gametocytes of P. falciparum).
Hydroxychloroquine does not prevent relapses in patients with vivax or malariae malaria because it is not effective against exo-erythrocytic forms, nor will it prevent vivax or malariae infection when administered as a prophylactic.
It is effective as a suppressive agent in patients with vivax or malariae malaria, in terminating acute attacks and significantly lengthening the interval between treatment and relapse. In patients with falciparum malaria it abolishes the acute attack and effects complete cure of the infection, unless due to a resistant strain of P. falciparum.

Malaria suppression.

Suppressive therapy should begin two weeks prior to exposure. Failing this, in adults an initial loading dose of 800 mg (620 mg base), or in children 10 mg base per kg, may be taken in two divided doses, six hours apart. The suppressive therapy should be continued for eight weeks after leaving the endemic area.

Adults.

400 mg (310 mg base) on exactly the same day of each week.

Children.

The weekly suppressive dose is 5 mg (base) per kg bodyweight, but should not exceed the adult dose regardless of weight.

Treatment of the acute attack.

Adults.

An initial dose of 800 mg followed by 400 mg 6-8 hours later and then 400 mg on each of two consecutive days (total dose of 2 g or 1.55 g base). A single dose of 800 mg (620 mg base) has also proved effective.

Children.

The dosage is calculated on the basis of bodyweight (total dose of 25 mg base per kg).
First dose: 10 mg base per kg (not exceeding a single dose of 620 mg base).
Second dose: 5 mg base per kg (not exceeding 310 mg base), six hours after first dose.
Third dose: 5 mg base per kg eighteen hours after second dose.
Fourth dose: 5 mg base per kg twenty four hours after third dose.
For radical cure of vivax and malariae malaria, concomitant therapy with an 8-aminoquinoline is necessary.

4.7 Effects on Ability to Drive and Use Machines

Patients should be warned about driving and operating machinery since hydroxychloroquine can impair visual accommodation and cause blurring of vision. If the condition is not self-limiting, the dosage may need to be temporarily reduced.

4.9 Overdose

Overdosage with 4-aminoquinolines is dangerous. Children are particularly sensitive to these compounds and a number of fatalities have been reported following the accidental ingestion of chloroquine, sometimes in relatively small doses (0.75 or 1 gram in one 3 year old child).
The 4-aminoquinolines are very rapidly and completely absorbed after ingestion and toxic symptoms following overdosage may occur within 30 minutes. Toxic symptoms consist of headache, drowsiness, visual disturbances, hypokalaemia, cardiovascular collapse and convulsions followed by sudden and early respiratory and cardiac arrest. The ECG may reveal atrial standstill, nodal rhythm, prolonged intraventricular conduction time, including QT prolongation, torsade de pointes, ventricular tachycardia and progressive bradycardia leading to ventricular fibrillation and/or cardiac arrest. Immediate medical attention is required as these effects may appear shortly after the overdose.
Treatment is symptomatic and must be prompt. Emesis is not recommended because of the potential for CNS depression, convulsions and cardiovascular instability. Activated charcoal should be administered. The dose of activated charcoal should be at least five times the estimated amount of hydroxychloroquine ingested.
Consideration should be given to using diazepam parentally as there have been reports that it may decrease cardiotoxicity.
Respiratory support and management of shock should be instituted as necessary.
For information on the management of overdose, contact the Poisons Information Centre on 13 11 26 (Australia).

7 Medicine Schedule (Poisons Standard)

S4.

6 Pharmaceutical Particulars

6.1 List of Excipients

Hequinel tablets contains the following excipients: anhydrous calcium hydrogen phosphate, pregelatinised maize starch, hypromellose, magnesium stearate, polysorbate 80, colloidal anhydrous silica and Proprietary Ingredient Opadry II White 85F18422.

6.2 Incompatibilities

Incompatibilities were either not assessed or not identified as part of the registration of this medicine.

6.3 Shelf Life

In Australia, information on the shelf-life can be found on the public summary of the Australian Register of Therapeutic Goods (ARTG). The expiry date can be found on the packaging.

6.4 Special Precautions for Storage

Store below 25°C. Protect from light.

6.5 Nature and Contents of Container

200 mg: Packaged in HDPE bottles of 100 tablets.

6.6 Special Precautions for Disposal

In Australia, any unused medicine or waste material should be disposed of by taking to your local pharmacy.

Summary Table of Changes