Article Text

Download PDFPDF
Antimalarial use and arrhythmias in COVID-19 and rheumatic patients: a matter of dose and inflammation?
  1. Gian Luca Erre1,
  2. Edoardo Sean Ferraccioli2,
  3. Matteo Piga3,
  4. Arduino Mangoni4,
  5. Giuseppe Passiu1,
  6. Elisa Gremese5,6,
  7. Gianfranco Ferraccioli7
  1. 1 Dipartimento di Specialità Mediche, Chirurgiche e Sperimentali, Università degli Studi di Sassari, Sassari, Italy
  2. 2 Pediatrics, Universita degli Studi di Verona, Verona, Veneto, Italy
  3. 3 Rheumatology, University Clinic and University of Cagliari (CA), Italy, Cagliari, Italy
  4. 4 Discipline of Clinical Pharmacology, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
  5. 5 Division of Rheumatology, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
  6. 6 Dipartimento di Scienze gastroenterologiche, endocrino-metaboliche e nefro-urologiche, Istituto di Reumatologia e Scienze Affini, Università Cattolica del Sacro Cuore, Roma, Italy
  7. 7 Division of Rheumatology, IRCCS, Fondazione Policlinico Universitario A Gemelli, Catholic University of the Sacred Heart, Rome, Italy
  1. Correspondence to Dr Gian Luca Erre, Dipartimento di Scienze Mediche, Chirurgiche e Sperimentali, Università degli Studi di Sassari, 07100 Sassari, Italy; glerre{at}

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

We read with great interest the paper by Graef and colleagues, ‘Festina lente: hydroxychloroquine, covid-19 and the role of the rheumatologist’.1 As the authors correctly point out, despite firm evidence that their efficacy and safety are lacking,2 antimalarials are being widely prescribed for the treatment of patients with COVID-19. This, as also underlined with some concern by the European League Against Rheumatism President Iain McInness,3 has rapidly led to antimalarial supply shortages worldwide, primarily affecting patients with rheumatic disease, such as those with systemic lupus erythematosus and rheumatoid arthritis (RA). In these groups, low-dose antimalarials (hydroxychloroquine up to 6 mg/kg/day and chloroquine up to 4 mg/kg/day) are the mainstay to control immunological response and to prevent flare in view of their favourable efficacy and safety profile.

However, electrophysiological experiments in isolated cardiac preparations and animal models, and some case reports in rheumatic patients, have reported a proarrhythmic effect of antimalarials. Arrhythmias, potentially triggered by hypoxia, metabolic/electrolyte derangement and viral myocarditis, have been reported in 16.7% of hospitalised patients with COVID-19.4 While this suggests that antimalarial use may further augment the risk of fatal arrhythmias in patients with COVID-19, the evidence …

View Full Text


  • Collaborators GF conceived the original idea. GLE, ESF, MP, EG and GP contributed to methods of data collection, patient materials and data management. GLE, AM, ESF and GF wrote the manuscript. All authors reviewed, discussed and helped interpret the findings, commented on and approved the final version of the manuscript.

  • Contributors GLE.

  • Funding Data presented in this work are a part of the EDRA study (Endothelial Dysfunction Evaluation for Coronary Heart Disease Risk Estimation in Rheumatoid Arthritis study). NCT02341066. The EDRA study is a project funded by the Italian Ministry of Health and by the Regione Sardegna (RAS): GR- 2011-02352816, Ricerca Finalizzata 2011.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; internally peer reviewed.

Linked Articles