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How to Manage Temporary Effects of Hydroxychloroquine

By Christopher Spankovich, PhD

Hydroxchloroquine was recently approved by the U.S. Food and Drug Administration for emergency use to treat adults and adolescents with COVID-19. This drug is known to cause temporary side effects that include hearing loss, tinnitus (the perception of ringing, buzzing and humming without an external source) and balance issues.  These side effects usually reverse once the treatment is discontinued.  

Reduced hearing can be isolating and frustrating, but simple communication strategies can help. 

1. Watch the speaker
2. If you don’t understand, ask for clarification by repeating the information you heard
3. Place yourself at a good distance, not too close and not too far; you should be able to see the speaker (#1)
4. Be assertive: For example, ask for repetition, identify the part of the sentence you need repeated, or suggest moving the conversation to a quieter place
5. If you’re in a noisy room, suggest moving somewhere quieter, or turn off or down noise source (music, tv, etc.)
6. Turn your smartphone into an amplifier, check out the EarMachine App (must be used with headphones/earbuds)
7. Communication Partners should use CLEAR SPEECH. Clear speech is a method where the speaker talks slightly slower and louder, uses frequent pauses, and enunciates speech sounds more clearly. It is not exaggerated speech, but rather a style of speaking that is adopted intuitively by many talkers in difficult communication situations. The communication partner should face the person with hearing loss, make sure their mouth can be seen, and rephrase when something is not understood.
8. Understand hearing loss can be frustrating for the patient and communication partner. Communication is a two-way street, both patient and communication partner are advised to try to remain calm and do the best you can.

Tinnitus (ringing, buzzing, humming, etc) is a common side effect of change in sound input into the auditory system.  When sound input to the brains is disrupted, it attempts to change to compensate. The central gain and increase in neural activity to compensate can result in perception of a sound called tinnitus. This is known side effect of hydroxychloroquine and is often only temporary. If you are having difficulty with your tinnitus here are some tips. 

1. Understand the source: Tinnitus is a common side effect of reduced sound to central parts of the auditory pathway, it is not a sign that you are going deaf or having a serious adverse reaction. This may be a side effect of hydroxychloroquine, but is usually only temporary.
2. Habituation and cognition: Your brain can learn to find the tinnitus less important and habituate to the sound. Habituation is a process where your brain determines if some type of stimulus is important or not. For example, a ring on your finger or watch on your wrist is touching you throughout the day and stimulating neural receptors. But most of the day your brain is filtering this signal and you do not actually feel those items. Yet, when you think about it, you can.  Your brain does this the same thing with external sounds. For example, the air conditioner (AC). You may notice the AC turn on, that is because it is a new sound or change in your environment’s sound. However, shortly after the AC turning on you go back to watching TV or reading and do not notice the AC again until it turns off. It makes sense if you find the tinnitus to be annoying and bothersome. If you were driving your car down the road and heard a sudden grinding sound in the engine your first thought would not be positive or this is a good sign. Try to stay positive and understand that tinnitus is usually only temporary with hydroxychloroquine.
3. Use sound: Sound enrichment can help reduce tinnitus. Keep a steady soothing sound in the background or played through some earphones. The sound does not need to be loud, just loud enough to provide some relief. Broadband sounds such as white noise or pink noise and environmental sounds such as ocean or rain are commonly used. You can also just have a fan on in the background. In the bedroom consider ordering a soundpillow or dreampad, these are pillows that can deliver sounds to your ears to help you sleep. Even taking a shower can help ease tinnitus. There are many apps you can find on a smartphone that are free (e.g. Relax Melodies, Widex Zen Tinnitus, Resound Relief).
4. Attention: Just don’t think about the tinnitus. Well, it’s not that easy, tinnitus can be annoying and often persons with tinnitus can feel they have no control or can’t escape the tinnitus. However, this is false. Sound can help reduce how you perceive your tinnitus. So can attention. If you are bothered by your tinnitus, try not to focus on it. Do something to alter your attention, something positive and with sound. Put on your favorite movie, call-up a friend, go for a walk (if well enough). Do something positive to distract the brain from the tinnitus.
5. Sleep, diet, and activity: Sleep is critical. Use a nice soothing sound in the bedroom. Also follow sleep hygiene tips: make sure the temperature in the room is comfortable, have a comfortable pillow and sheets, etc.  Eating healthy is important for your general health and well-being, this will not cure tinnitus but will also not hurt it. Staying active, not just physically but mentally can help reduce your brains attention to your tinnitus and also keep you healthy.
6. Tinnitus associated with hydroxychloroquine is often only temporary. The tinnitus will likely resolve after your treatment.  If not, contact our office at (601) 984-5160 for further evaluation and management.

References

• Alvan et al. 2016. Concentration-response relationship of hearing impairment caused by quinine and salicylate: Pharmacological similarities but different molecular mechanisms, Basic Clin Pharm and Tox, 120 (1).
• Alrwisan et al. 2018. Azithromycin and sensorineural hearing loss in adults: A retrospective cohort study, Otol Neurotol, 39 (8), 957-963.