Hydroxychloroquine (Plaquenil) Before and After Surgery
Hydroxychloroquine (brand name Plaquenil) is taken daily by many patients with lupus (systemic lupus erythematosus), rheumatoid arthritis, and Sjogren's syndrome. If you take hydroxychloroquine and are scheduled for surgery, you need clear guidance on whether to stop, continue, or adjust your medication. This guide covers the current recommendations and what to expect.
What Hydroxychloroquine Is and Why It Is Taken
Hydroxychloroquine is an antimalarial drug that also suppresses parts of the immune system. In autoimmune conditions like lupus and rheumatoid arthritis, the immune system attacks the body's own tissues. Hydroxychloroquine reduces this overactivity without completely suppressing immune function.
Unlike stronger immunosuppressants (methotrexate, azathioprine, biologics), hydroxychloroquine has a mild immune-modulating effect. It does not dramatically increase infection risk the way high-dose corticosteroids or biologic medications do.
Common reasons hydroxychloroquine is prescribed: systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), discoid lupus (a skin form of lupus), Sjogren's syndrome, and some connective tissue diseases.
Standard adult dosing: 200 mg to 400 mg once daily, typically taken with food or milk to reduce stomach upset. The dose is calculated based on body weight (maximum 5 mg per kilogram of actual body weight per day) to reduce the risk of long-term eye side effects.
Hydroxychloroquine has an unusually long half-life of 40 to 50 days. This means the medication stays in the body for weeks after the last dose. A single missed dose does not change blood levels meaningfully.
Should You Stop Hydroxychloroquine Before Surgery?
Current guidelines from the American College of Rheumatology (ACR) and the British Society for Rheumatology (BSR) recommend CONTINUING hydroxychloroquine through elective surgery. It does not need to be stopped.
The rationale: Hydroxychloroquine's very long half-life means stopping it days or even weeks before surgery would not meaningfully lower its blood levels. Stopping it also risks triggering a lupus or RA flare, which complicates recovery.
Hydroxychloroquine does not significantly increase infection risk at surgical sites. Studies in lupus and RA patients show that continuing hydroxychloroquine is associated with fewer post-operative flares without increasing wound complications.
In contrast, stronger immunosuppressants (biologic medications such as TNF inhibitors, JAK inhibitors, and high-dose methotrexate) are often held before surgery due to infection risk. Hydroxychloroquine is not in this category and is specifically excluded from those hold recommendations.
Always confirm the plan with your rheumatologist and surgeon before your procedure. In rare cases involving very high-risk surgeries, your care team may individualize the recommendation.
Monitoring and Long-Term Safety Considerations
The most important long-term safety concern with hydroxychloroquine is retinal toxicity (damage to the light-sensitive tissue at the back of the eye). This risk increases with cumulative dose over time, most notably after more than 5 years of use or lifetime cumulative doses above 1000 grams.
Annual eye exams with an ophthalmologist are recommended starting after 5 years of hydroxychloroquine use, or sooner for patients with pre-existing kidney disease, retinal disease, or those on higher doses relative to body weight.
Surgery does not accelerate or worsen retinal toxicity risk. Eye monitoring schedules should continue on their usual timeline regardless of surgery.
Hydroxychloroquine can prolong the QTc interval (a measurement of the heart's electrical activity). This is an uncommon effect at standard doses but becomes relevant if other QT-prolonging medications are added during surgery or recovery, such as azithromycin, ondansetron, or methadone. Your anesthesiologist should know if you take hydroxychloroquine.
Blood counts and liver function are sometimes checked periodically in patients on long-term hydroxychloroquine, though serious blood or liver problems are rare. Confirm with your rheumatologist whether any labs are due around the time of your surgery.
Recovery: Resuming Hydroxychloroquine and Watching for Flares
Because guidelines recommend continuing hydroxychloroquine through surgery, most patients do not need to 'restart' it. Simply continue taking it on your usual schedule unless your surgeon or rheumatologist explicitly tells you otherwise.
If you were instructed to hold it for any reason, resume at your normal dose as soon as you are able to take oral medications again. Due to its long half-life, the small gap from a brief hold will have little clinical impact.
Monitor for signs of autoimmune disease flare during recovery: increased joint pain or swelling, new rash (butterfly rash across the cheeks and nose is characteristic of lupus), mouth sores, unusual fatigue beyond normal recovery, or chest pain (which can indicate pleuritis or pericarditis in lupus).
Surgical stress can occasionally trigger lupus or RA flares even when hydroxychloroquine is continued. Contact your rheumatologist if you notice significant new symptoms within the first 4 to 6 weeks after surgery.
Frequently asked
Questions patients ask.
Does hydroxychloroquine increase my risk of infection after surgery?
No, not significantly. Hydroxychloroquine has a mild immune-modulating mechanism that does not meaningfully impair the immune response needed to fight surgical site infections. This is why it is specifically excluded from the pre-surgical hold recommendations that apply to stronger immunosuppressants like biologics and high-dose methotrexate. Your surgeon may take additional precautions based on your overall immune status, particularly if you are on multiple immune-suppressing medications.
Can hydroxychloroquine cause problems with anesthesia?
The main consideration is QT interval prolongation. At standard doses this effect is modest, but it becomes relevant if other QT-prolonging drugs are used during anesthesia or recovery. Inform your anesthesiologist that you take hydroxychloroquine and bring a complete medication list. They will plan your anesthesia and select post-operative medications accordingly.
I missed several doses of hydroxychloroquine around my surgery. Will this cause a flare?
Possibly, though the very long half-life of hydroxychloroquine (40 to 50 days) means that even a gap of one to two weeks causes only a modest decrease in blood levels. However, for patients with active lupus or RA, any reduction can theoretically trigger a flare. Resume your normal dose as soon as you can tolerate oral intake. Contact your rheumatologist if you notice new joint or systemic symptoms.
Is it safe to have hydroxychloroquine in my system during general anesthesia?
Yes. Hydroxychloroquine does not interact with the major anesthetic agents used for general anesthesia. The primary consideration, the mild QT effect, is manageable with appropriate drug selection by your anesthesiologist. There is no need to stop hydroxychloroquine before anesthesia for pharmacologic safety reasons.
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This guide provides general information. For instructions tailored to your specific procedure, ask your provider about QR Rx care plans.
These medication guides are for educational purposes only and do not replace medical advice. Always follow your healthcare provider's specific medication instructions.
