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Talarico F, Chakravarty S, Liu YS, Greenshaw AJ, Passos IC, Cao B. Systematic Review of Psychiatric Adverse Effects Induced by Chloroquine and Hydroxychloroquine: Case Reports and Population Studies. Ann Pharmacother 2023; 57:463-479. [PMID: 35927939 DOI: 10.1177/10600280221113572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To perform a systematic review on the psychiatric adverse effects of chloroquine (CQ) and hydroxychloroquine (HCQ); to summarize what is known about psychiatric adverse effects of these drugs; to compare clinical trials, populational studies, and case report studies; and to increase awareness of the potential psychiatric adverse effects of these drugs. DATA SOURCES A literature search of PubMed, Scopus, and Web of Science was performed to identify manuscripts published between December 1962 and June 2022. Search terms included CQ, HCQ, psychiatry, psychosis, depression, anxiety, bipolar disorder, delirium, and psychotic disorders. STUDY SELECTION AND DATA EXTRACTION Relevant studies included reports of adverse effects after CQ or HCQ ingestion. DATA SYNTHESIS The current literature presents evidence for a risk of short-term psychiatric adverse effects induced by either CQ or HCQ. However, the populational-level studies presented some limitations regarding the voluntary response in survey data, self-report adverse effects, and placebo group reporting similar symptoms to the case group. Thus, populational-level studies addressing the discussed limitations and the nature and extent of possible psychiatric adverse effects are needed. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE Most of the patients who developed such adverse effects did not report a family history of psychiatric disease. The frequency of psychiatric adverse effects depends on the patient's biological sex, age, and body mass index, but not on the drug dosage. CONCLUSIONS Based on clinical trials and case reports, the current literature presents evidence for a risk of short-term psychiatric adverse effects induced by either drug.
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Affiliation(s)
- Fernanda Talarico
- Department of Psychiatry, University of Alberta, Edmonton, AB, Canada
| | | | - Yang S Liu
- Department of Psychiatry, University of Alberta, Edmonton, AB, Canada
| | | | - Ives Cavalcante Passos
- Programa de Pós-Graduação em Psiquiatria e Ciências do Comportamento, Laboratory of Molecular Psychiatry and Bipolar Disorder Program, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Bo Cao
- Department of Psychiatry, University of Alberta, Edmonton, AB, Canada
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Lane JCE, Weaver J, Kostka K, Duarte-Salles T, Abrahao MTF, Alghoul H, Alser O, Alshammari TM, Areia C, Biedermann P, Banda JM, Burn E, Casajust P, Fister K, Hardin J, Hester L, Hripcsak G, Kaas-Hansen BS, Khosla S, Kolovos S, Lynch KE, Makadia R, Mehta PP, Morales DR, Morgan-Stewart H, Mosseveld M, Newby D, Nyberg F, Ostropolets A, Woong Park R, Prats-Uribe A, Rao GA, Reich C, Rijnbeek P, Sena AG, Shoaibi A, Spotnitz M, Subbian V, Suchard MA, Vizcaya D, Wen H, de Wilde M, Xie J, You SC, Zhang L, Lovestone S, Ryan P, Prieto-Alhambra D. Risk of depression, suicide and psychosis with hydroxychloroquine treatment for rheumatoid arthritis: a multinational network cohort study. Rheumatology (Oxford) 2021; 60:3222-3234. [PMID: 33367863 PMCID: PMC7798671 DOI: 10.1093/rheumatology/keaa771] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 10/19/2020] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES Concern has been raised in the rheumatology community regarding recent regulatory warnings that HCQ used in the coronavirus disease 2019 pandemic could cause acute psychiatric events. We aimed to study whether there is risk of incident depression, suicidal ideation or psychosis associated with HCQ as used for RA. METHODS We performed a new-user cohort study using claims and electronic medical records from 10 sources and 3 countries (Germany, UK and USA). RA patients ≥18 years of age and initiating HCQ were compared with those initiating SSZ (active comparator) and followed up in the short (30 days) and long term (on treatment). Study outcomes included depression, suicide/suicidal ideation and hospitalization for psychosis. Propensity score stratification and calibration using negative control outcomes were used to address confounding. Cox models were fitted to estimate database-specific calibrated hazard ratios (HRs), with estimates pooled where I2 <40%. RESULTS A total of 918 144 and 290 383 users of HCQ and SSZ, respectively, were included. No consistent risk of psychiatric events was observed with short-term HCQ (compared with SSZ) use, with meta-analytic HRs of 0.96 (95% CI 0.79, 1.16) for depression, 0.94 (95% CI 0.49, 1.77) for suicide/suicidal ideation and 1.03 (95% CI 0.66, 1.60) for psychosis. No consistent long-term risk was seen, with meta-analytic HRs of 0.94 (95% CI 0.71, 1.26) for depression, 0.77 (95% CI 0.56, 1.07) for suicide/suicidal ideation and 0.99 (95% CI 0.72, 1.35) for psychosis. CONCLUSION HCQ as used to treat RA does not appear to increase the risk of depression, suicide/suicidal ideation or psychosis compared with SSZ. No effects were seen in the short or long term. Use at a higher dose or for different indications needs further investigation. TRIAL REGISTRATION Registered with EU PAS (reference no. EUPAS34497; http://www.encepp.eu/encepp/viewResource.htm? id=34498). The full study protocol and analysis source code can be found at https://github.com/ohdsi-studies/Covid19EstimationHydroxychloroquine2.
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Affiliation(s)
- Jennifer C E Lane
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | - James Weaver
- Janssen Research and Development, Titusville, NJ, USA
| | | | - Talita Duarte-Salles
- Fundació Institut Universitari per a la recerca a l’Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
| | | | - Heba Alghoul
- Faculty of Medicine, Islamic University of Gaza, Gaza, Palestine
| | - Osaid Alser
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Thamir M Alshammari
- Medication Safety Research Chair, King Saud University, Riyadh, Saudi Arabia
| | - Carlos Areia
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | | | | | - Edward Burn
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
- Fundació Institut Universitari per a la recerca a l’Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
| | - Paula Casajust
- Real-World Evidence, Trial Form Support, Barcelona,Spain
| | - Kristina Fister
- School of Medicine, Andrija Štampar School of Public Health, University of Zagreb, Zagreb, Croatia
| | - Jill Hardin
- Janssen Research and Development, Titusville, NJ, USA
| | - Laura Hester
- Janssen Research and Development, Titusville, NJ, USA
| | - George Hripcsak
- Department of Biomedical Informatics, Columbia University Irving Medical Center, New York, NY, USA
- New York-Presbyterian Hospital, New York, NY, USA
| | - Benjamin Skov Kaas-Hansen
- Clinical Pharmacology Unit, Zealand University Hospital, Roskilde, Denmark
- NNF Centre for Protein Research, University of Copenhagen, Copenhagen, Denmark
| | - Sajan Khosla
- Real World Science & Digital, AstraZeneca, Cambridge, UK
| | - Spyros Kolovos
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | - Kristine E Lynch
- Department of Veterans Affairs, Salt Lake City, UT, USA
- University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Rupa Makadia
- Janssen Research and Development, Titusville, NJ, USA
| | - Paras P Mehta
- College of Medicine, University of Arizona, Tucson, AZ, USA
| | - Daniel R Morales
- Division of Population Health and Genomics, University of Dundee, Dundee, UK
| | | | - Mees Mosseveld
- Department of Medical Informatics, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Danielle Newby
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Fredrik Nyberg
- School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Anna Ostropolets
- Department of Biomedical Informatics, Columbia University Irving Medical Center, New York, NY, USA
| | - Rae Woong Park
- Department of Biomedical Informatics, Ajou University School of Medicine, Suwon-si, Gyeonggi-do, South Korea
| | - Albert Prats-Uribe
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | - Gowtham A Rao
- Janssen Research and Development, Titusville, NJ, USA
| | | | - Peter Rijnbeek
- Department of Medical Informatics, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Anthony G Sena
- Janssen Research and Development, Titusville, NJ, USA
- Department of Medical Informatics, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Azza Shoaibi
- Janssen Research and Development, Titusville, NJ, USA
| | - Matthew Spotnitz
- Department of Biomedical Informatics, Columbia University Irving Medical Center, New York, NY, USA
| | - Vignesh Subbian
- College of Engineering, University of Arizona, Tucson, AZ, USA
| | - Marc A Suchard
- Departments of Biomathematics and Human Genetics David Geffen School of Medicine at UCLA, and Department of Biostatistics, UCLA School of Public Health, South Los Angeles, CA, USA
| | - David Vizcaya
- Bayer Pharmaceuticals, Sant Joan Despi, Barcelona, Spain
| | - Haini Wen
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, P.R. China
| | - Marcel de Wilde
- Department of Medical Informatics, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Junqing Xie
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | - Seng Chan You
- Department of Biomedical Informatics, Ajou University School of Medicine, Suwon-si, Gyeonggi-do, South Korea
| | - Lin Zhang
- School of Public Health, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, P.R. China
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Simon Lovestone
- Janssen-Cilag, 50-100 Holmers Farm Way, High Wycombe HP12 4EG, UK
| | - Patrick Ryan
- Janssen Research and Development, Titusville, NJ, USA
- Department of Biomedical Informatics, Columbia University Irving Medical Center, New York, NY, USA
| | - Daniel Prieto-Alhambra
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
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Garcia P, Revet A, Yrondi A, Rousseau V, Degboe Y, Montastruc F. Psychiatric Disorders and Hydroxychloroquine for Coronavirus Disease 2019 (COVID-19): A VigiBase Study. Drug Saf 2020; 43:1315-1322. [PMID: 33078372 PMCID: PMC7571787 DOI: 10.1007/s40264-020-01013-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2020] [Indexed: 12/13/2022]
Abstract
INTRODUCTION In the stressful context of the coronavirus disease 2019 (COVID-19) pandemic, some reports have raised concerns regarding psychiatric disorders with the use of hydroxychloroquine. In this study, we reviewed all psychiatric adverse effects with hydroxychloroquine in COVID-19 patients, as well as in other indications, reported in VigiBase, the World Health Organization's (WHO) global database of individual case safety reports. METHODS First, we analyzed all psychiatric adverse effects, including suicide, of hydroxychloroquine in COVID-19 patients reported to 16 June 2020. We also performed disproportionality analysis to investigate the risk of reporting psychiatric disorders with hydroxychloroquine compared with remdesivir, tocilizumab, or lopinavir/ritonavir prescribed in COVID-19 patients. We used reporting odds ratios (RORs) and their 95% confidence intervals (CIs) to calculate disproportionality. Second, we sought to examine the psychiatric safety profile of hydroxychloroquine in other indications (before 2020). RESULTS Among the 1754 reports with hydroxychloroquine in COVID-19 patients, we found 56 psychiatric adverse effects. Half of these adverse effects were serious, including four completed suicides, three cases of intentional self-injury, and 12 cases of psychotic disorders with hallucinations. Compared with remdesivir, tocilizumab, or lopinavir/ritonavir, the use of hydroxychloroquine was associated with an increased risk of reporting psychiatric disorders (ROR 6.27, 95% CI 2.74-14.35). Before 2020, suicide was the main cause of death among all adverse drug reactions reported with hydroxychloroquine, followed by cardiac adverse effects (cardiomyopathy) and respiratory failure. CONCLUSIONS This pharmacovigilance analysis suggests that COVID-19 patients exposed to hydroxychloroquine experienced serious psychiatric disorders, and, among these patients, some committed suicide. Further real-world studies are needed to quantify the psychiatric risk associated with hydroxychloroquine during the COVID-19 pandemic.
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Affiliation(s)
- Philippe Garcia
- Department of Medical and Clinical Pharmacology, Centre of PharmacoVigilance and Pharmacoepidemiology, Faculty of Medicine, Toulouse University Hospital (CHU), 37 Allées Jules Guesde, 31000, Toulouse, France
| | - Alexis Revet
- Department of Child and Adolescent Psychiatry, Faculty of Medicine, Toulouse University Hospital (CHU), Toulouse, France
- UMR 1027 Pharmacoepidemiology, Assessment of Drug Utilization and Drug Safety, INSERM, CIC 1426, University Paul Sabatier Toulouse, Toulouse, France
| | - Antoine Yrondi
- Department of Medical Psychiatry, Toulouse University Hospital (CHU), Faculty of Medicine, Treatment Resistant Depression Expert Center, FondaMental, ToNIC Toulouse NeuroImaging Center, University Paul Sabatier Toulouse, INSERM, Toulouse, France
| | - Vanessa Rousseau
- Department of Medical and Clinical Pharmacology, Centre of PharmacoVigilance and Pharmacoepidemiology, Faculty of Medicine, Toulouse University Hospital (CHU), 37 Allées Jules Guesde, 31000, Toulouse, France
- UMR 1027 Pharmacoepidemiology, Assessment of Drug Utilization and Drug Safety, INSERM, CIC 1426, University Paul Sabatier Toulouse, Toulouse, France
| | - Yannick Degboe
- Department of Rheumatology, Faculty of Medicine, Toulouse University Hospital (CHU), Toulouse, France
| | - François Montastruc
- Department of Medical and Clinical Pharmacology, Centre of PharmacoVigilance and Pharmacoepidemiology, Faculty of Medicine, Toulouse University Hospital (CHU), 37 Allées Jules Guesde, 31000, Toulouse, France.
- UMR 1027 Pharmacoepidemiology, Assessment of Drug Utilization and Drug Safety, INSERM, CIC 1426, University Paul Sabatier Toulouse, Toulouse, France.
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Manzo C, Gareri P, Castagna A. Psychomotor Agitation Following Treatment with Hydroxychloroquine. DRUG SAFETY - CASE REPORTS 2017; 4:6. [PMID: 28258476 PMCID: PMC5336441 DOI: 10.1007/s40800-017-0048-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We describe the case of an elderly woman with elderly-onset rheumatoid arthritis, where the use of 4 mg/kg/day of hydroxychloroquine (HCQ) was followed by the onset of psychomotor agitation with marked physical and verbal violence towards her partner, including throwing objects at her partner. No disturbance in sleep and no anxiety, nervousness, or irritability had emerged before the onset of her psychomotor agitation. The disappearance of agitation following targeted pharmacologic intervention and HCQ interruption, its re-onset after reintroduction of the drug, and the high score (9) of Naranjo’s algorithm are surely linked to the existence of a causal relationship between HCQ and psychomotor agitation. HCQ may produce undesirable effects on the central nervous system, mainly irritability, nervousness, emotional changes, and nightmares. To the best of our knowledge, there are only a few case reports of psychosis due to HCQ. No favoring condition such as pharmacokinetic interactions or a personal and family psychiatric history was present in our patient. The neuropsychiatric manifestations we observed could be considered a bizarre-type adverse drug reaction linked to an individual’s hypersensitivity.
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Affiliation(s)
- Ciro Manzo
- Internal and geriatric department, Rheumatologic outpatient clinic and geronthorheumatologic service, Hospital "Mariano Lauro", viale dei Pini 1, 80065, Sant'Agnello, Naples, Italy.
| | - Pietro Gareri
- Center for cognitive diseases and dementias, Catanzaro Lido, ASP Catanzaro, Catanzaro, Italy
| | - Alberto Castagna
- Center for cognitive diseases and dementias, Catanzaro Lido, ASP Catanzaro, Catanzaro, Italy
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