North East Lupus Group: topic of the month, hydroxychloroquine

Many members reported trouble getting their usual brand of hydroxychloroquine from a pharmacy, so the group passed on the information below, written by Lupus UK in 2019. It is general information, not advice for any one person; supply and guidance change, and your doctor or pharmacist has the current picture.

Why hydroxychloroquine is prescribed

It is generally the first treatment for someone diagnosed with lupus, used for skin and joint involvement, muscle inflammation, fever, fatigue and pleurisy, to reduce the development of kidney disease and lasting damage, and because it lets the dose of steroids be lower. It is one of the few licensed drugs for lupus, with good evidence for its effectiveness and safety. A consultant arranges an eye examination when it is first prescribed, repeated every year after five years of continuous treatment, to guard against a very low risk of retinopathy.

Which brand is best

Hydroxychloroquine is the name of the drug, and there are several versions in the UK. Plaquenil was the original branded product and the only other branded one is Quinoric, made by Bristol Laboratories. Generic versions, cheaper and made off patent, are sold under the names of their manufacturers: Zentiva, Blackrock, Teva and Bristol. Every version holds the same amount of the active ingredient but differs in its fillers, and no single version suits everyone. Each person has to find the one that works for them.

Why Plaquenil is no longer available

In summer 2015 the manufacturer of Plaquenil de-branded it to a generic. The Zentiva version is made identically to the original. A prescription written as hydroxychloroquine sulphate 200mg, with or without Plaquenil in brackets, can be filled with whichever version the pharmacy has.

Reactions to Quinoric

A paper in the Journal of Rheumatology reported that many adverse effects are linked to the Quinoric brand, most often stomach upset, and sometimes nausea or flare-like symptoms. That is not everyone's experience, and a person who takes Quinoric without trouble has no reason to ask for a change.

If you have side effects

Tell your doctor or pharmacist about unexpected symptoms as soon as possible. Some side effects fade as the body gets used to a drug, so your doctor may suggest staying the course a little longer, or may lower the dose or try another drug. If you suspect the brand is the cause, discuss it with your doctor and report the reaction through the Yellow Card Scheme, naming the company whose version you took, especially if a change of version stopped the effects. For someone who tolerated Plaquenil, the generic with the same formulation is Zentiva; Blackrock and Teva have different fillers from Quinoric and from the Bristol generic. These may not suit any given person.

If the pharmacy cannot get your preferred brand

Lupus UK received many reports of pharmacists unable to dispense the Zentiva or Blackrock versions, often blamed on supply problems. At the time of writing there were no manufacturing or supply problems in the UK for those versions, and the charity promised further advice if that changed. It suggested giving the pharmacist the exact product description, including the supplier's product code, to help them order the right one.

If a pharmacist refuses because of cost

Some people were told that Zentiva or Blackrock were dearer than Quinoric. The charity accepted that Quinoric is the cheapest, but said the difference is small, unlikely to exceed fifty pence to a pound and fifty a pack, and far less than the cost of switching to other lupus drugs, treating side effects or investigating them.

When a medicine is prescribed by its generic name, a pharmacist may supply any suitable generic or branded product and is paid a set price under the NHS Drug Tariff, so cheaper products leave more margin. When it is prescribed by company, for example the Zentiva version only, the pharmacist may supply only that brand and is reimbursed for it, so the pharmacy should not make a loss.

Lupus UK thanked Professor Caroline Gordon and a lupus research clinical nurse specialist for their contributions, and asked to be told of continuing difficulties.