Hydroxychloroquine vs. Other COVID‑19 and Autoimmune Drug Options

Oct, 9 2025

Quick Takeaways

• Hydroxychloroquine is mainly an antimalarial that’s also used for lupus and rheumatoid arthritis.
• Most alternatives (e.g., remdesivir, doxycycline, azithromycin) target different viruses or bacterial infections.
• Safety profiles vary: hydroxychloroquine can cause heart rhythm issues, while ivermectin’s main risk is neurotoxicity at high doses.
• Cost and availability differ widely - generic hydroxychloroquine is cheap, but newer antivirals can be pricey.
• Clinical evidence for COVID‑19 treatment is strongest for remdesivir; hydroxychloroquine shows no clear benefit.

When you hear the name Hydroxychloroquine, you probably recall headlines from the early pandemic. The drug has a long history as an antimalarial and a disease‑modifying agent for autoimmune disorders, yet its role in treating viral infections remains controversial. This article breaks down how hydroxychloroquine works, what alternatives are out there, and which factors should guide a responsible choice.

What is Hydroxychloroquine?

Hydroxychloroquine is a synthetic 4‑aminoquinoline that was first approved in the 1950s for malaria prophylaxis. Over time, clinicians discovered it dampens the immune system, leading to approvals for systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA). The drug works by raising the pH inside intracellular vesicles, which interferes with antigen processing and reduces inflammatory cytokine release.

Why Compare It with Other Drugs?

Patients and providers often wonder if a cheaper, well‑known medication can replace newer, more expensive antivirals or antibiotics. Comparing efficacy, safety, cost, and approved uses helps avoid trial‑and‑error prescribing, especially when the evidence base is limited or mixed.

Key Alternatives Across Different Indications

Remdesivir

Remdesivir is a nucleoside analogue developed for Ebola but repurposed for COVID‑19. Administered intravenously, it inhibits viral RNA‑dependent RNA polymerase, shortening recovery time in hospitalized patients. Unlike hydroxychloroquine, remdesivir received FDA approval for specific COVID‑19 stages, but it must be given in a clinical setting.

Doxycycline

Doxycycline is a broad‑spectrum tetracycline antibiotic. It’s sometimes used off‑label for its anti‑inflammatory properties in mild COVID‑19 cases, but solid evidence is lacking. Its main advantage is oral dosing and low cost.

Azithromycin

Azithromycin is a macrolide antibiotic with immunomodulatory effects. Early in the pandemic it was combined with hydroxychloroquine, yet large trials showed no added benefit and an increased risk of cardiac arrhythmias.

Ivermectin

Ivermectin is an antiparasitic drug that gained attention for possible antiviral activity. In vitro studies suggested inhibition of SARS‑CoV‑2, but clinical results are inconsistent and high doses can cause neurotoxicity.

Chloroquine

Chloroquine is the parent compound of hydroxychloroquine. It shares a similar mechanism but has a worse safety profile, especially for eye toxicity. Most guidelines now favor hydroxychloroquine over chloroquine when an antimalarial is needed.

Plaquenil (brand name)

Plaquenil is the commercial name for hydroxychloroquine tablets in many countries. It’s marketed for SLE and RA, and the brand reputation sometimes influences prescribing habits.

Side‑Effect Profiles at a Glance

How to Choose the Right Option

Think of drug selection as a checklist rather than a guess. Use the following decision tree:

1. Identify the primary condition: COVID‑19, lupus, RA, or malaria prophylaxis.
2. Check FDA or Health Canada approvals for that condition.
3. Match the safety profile to patient risk factors (e.g., existing heart disease, retinal disease).
4. Consider cost and access - can the patient afford an IV drug like remdesivir?
5. Review drug interactions - hydroxychloroquine and azithromycin together raise QT risk.

If the goal is long‑term autoimmune control, hydroxychloroquine (or its brand Plaquenil) remains a first‑line choice. For acute COVID‑19 hospitalization, remdesivir is the only option with proven benefit. For mild outpatient cases, the evidence does not support routine use of any of these drugs solely for viral suppression.

Common Misconceptions

1. “Hydroxychloroquine cures COVID‑19.” Large randomized trials (e.g., RECOVERY, WHO Solidarity) found no mortality or hospitalization benefit.

2. “If it worked for malaria, it must work for viruses.” Mechanisms differ; antimalarial activity does not guarantee antiviral efficacy.

3. “All antimalarials are the same.” Chloroquine carries higher toxicity; hydroxychloroquine is preferred when an antimalarial is needed.

Monitoring and Follow‑Up

When prescribing hydroxychloroquine for lupus or RA, patients should get baseline eye exams and annual retinal screening after five years of use. Electrocardiograms are advisable for anyone with a history of arrhythmias, especially if combined with other QT‑prolonging drugs.

For remdesivir, liver function tests are monitored before and during therapy. Doxycycline requires checking for photosensitivity in patients with sun exposure.

Bottom Line

Hydroxychloroquine is a versatile, low‑cost medication with proven benefits for autoimmune diseases but no solid data for COVID‑19 treatment. Alternatives like remdesivir, doxycycline, azithromycin, and ivermectin each serve distinct therapeutic niches and carry their own safety considerations. Matching the drug to the disease, patient comorbidities, and cost constraints is the safest way to decide.