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Commentary

The Risks of Prescribing Hydroxychloroquine in COVID-19-Infected Patients With Schizophrenia

The Risks of Prescribing Hydroxychloroquine in COVID-19-Infected Patients With Schizophrenia

In the desperate attempt to find effective treatments for coronavirus disease 2019 (COVID-19), the antimalarial drugs hydroxychloroquine and chloroquine have recently entered the spotlight due to their antiviral activity against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).1 Although current data supporting the use of hydroxychloroquine and chloroquine for COVID-19 are limited and inconclusive, these drugs are recommended for treatment of hospitalized COVID-19 patients in several countries including the United States. Moreover, the US Food and Drug Administration has designated hydroxychloroquine for off-label, compassionate use in the treatment of COVID-19 patients.2

Schizophrenia is a chronic and debilitating psychiatric illness that affects 1% of the population in all cultures.3 Patients with schizophrenia may be much more susceptible to COVID-19 infection for multiple reasons. Research has shown that patients with schizophrenia have a higher risk of physical illness including pneumonia and are reported to have poorer treatment outcomes due to lack of proper health care, unequal access to physical health care resources, and increased risk of complications.4 Moreover, due to cognitive and social impairment, they may not have a thorough understanding about the risk of COVID-19 infection and may not properly practice disinfection and social distancing.5 Furthermore, inpatients in psychiatric hospitals are at higher risk of infection due to the confined conditions.5

When infected with COVID-19, patients with schizophrenia may have more severe symptoms compared to others, as a significant proportion are heavy smokers and have at least 1 medical comorbidity, which has already been associated with severity of COVID-19 infection.6 In such a scenario, many of these individuals will need hospitalization and medications including hydroxychloroquine.

Prescribing of hydroxychloroquine in patients with schizophrenia could be a challenging clinical situation. Hydroxychloroquine is known to cause a spectrum of psychiatric adverse effects, including agitation, depression, mania, confusion, insomnia, hallucinations, catatonia, and suicidal ideation.7 Hypoglycemia, idiosyncratic hypersensitivity reactions, and drug-drug interactions have also been reported with hydroxychloroquine use, and many of these adverse effects can be dose related.7 There are also multiple reports of psychosis induced by hydroxychloroquine in patients with no past history of psychosis.7 Patients with schizophrenia can have exacerbations of psychotic symptoms during hydroxychloroquine therapy. Moreover, most patients with schizophrenia are on long-term antipsychotic medications, many of which carry the risk of QTc interval prolongation, and in combination with hydroxychloroquine could theoretically increase the risk of torsades de pointes.8 Furthermore, adding azithromycin as recommended by various countries including the United States will compound this risk. Considering the current weak evidence base for use of hydroxychloroquine in the treatment of COVID-19 infection and the significant risk of psychotic exacerbation and QTc prolongation, it would be prudent to avoid hydroxychloroquine in patients with schizophrenia. When the situation demands its use, the treating physician should collaborate with the treating psychiatrist to closely monitor for any exacerbations in psychiatric symptoms and should minimize cardiac risk by switching antipsychotic medication with a high risk of QTc prolongation to a safer agent.

Received: April 14, 2020.

Published online: April 30, 2020.

Potential conflicts of interest: None.

Funding/support: None.

REFERENCES

1.Yazdany J, Kim AHJ. Use of hydroxychloroquine and chloroquine during the COVID-19 pandemic: what every clinician should know [published online ahead of print March 31, 2020]. Ann Intern Med. PubMed CrossRef

2.Owens B. Excitement around hydroxychloroquine for treating COVID-19 causes challenges for rheumatology [published online ahead of print April 1, 2020]. Lancet Rheumatology. 2020. CrossRef

3.Karam CS, Ballon JS, Bivens NM, et al. Signaling pathways in schizophrenia: emerging targets and therapeutic strategies. Trends Pharmacol Sci. 2010;31(8):381-390. PubMed CrossRef

4.Haga T, Ito K, Sakashita K, et al. Risk factors for pneumonia in patients with schizophrenia. Neuropsychopharmacol Rep. 2018;38(4):204-209. PubMed CrossRef

5.Yao H, Chen JH, Xu YF. Patients with mental health disorders in the COVID-19 epidemic. Lancet Psychiatry. 2020;7(4):e21. PubMed CrossRef

6.Fonseca L, Diniz E, Mendonça G, et al. Schizophrenia and COVID-19: risks and recommendations [published online ahead of print April 9, 2020]. Br J Psychiatry. PubMed CrossRef

7.Juurlink DN. Safety considerations with chloroquine, hydroxychloroquine and azithromycin in the management of SARS-CoV-2 infection [published online ahead of print]. CMAJ. PubMed CrossRef

8.Vieweg WV. New generation antipsychotic drugs and QTc interval prolongation. Prim Care Companion J Clin Psychiatry. 2003;5(5):205-215. PubMed CrossRef

aDepartment of Psychiatry, Iqraa International Hospital and Research Centre, Calicut, Kerala, India

*Corresponding author: N. A. Uvais, MBBS, DPM, Iqraa International Hospital and Research Centre, Calicut, Kerala, India (druvaisna@gmail.com).

Prim Care Companion CNS Disord 2020;22(3):20com02635

To cite: Uvais NA. The risks of prescribing hydroxychloroquine in COVID-19-infected patients with schizophrenia. Prim Care Companion CNS Disord. 2020;22(3):20com02635.

To share: https://doi.org/10.4088/PCC.20com02635

© Copyright 2020 Physicians Postgraduate Press, Inc.

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