Rheumatologists May Face Ethical Dilemmas With HCQ Shortage During the COVID-19 Pandemic

Rheumatologists may be faced with potential ethical dilemmas in the event that hydroxychloroquine (HCQ) supply becomes limited, according to an editorial published in The Journal of Rheumatology.¹

After studies indicating that chloroquine (CQ) and HCQ may have the potential to reduce the viral activity of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in tissue culture,²  a number of clinical trials were developed to test the safety and efficacy of CQ and HCQ in the treatment of coronavirus disease 2019 (COVID-19). A study by Gao and colleagues revealed that the CQ phosphate had “apparent efficacy and acceptable safety” in the treatment of COVID-19-associated pneumonia³; and a more recent study indicated the combination of HCQ and azithromycin in the treatment of COVID-19.⁴ However, the investigators of this report suggested that clinical evidence is currently lacking for the use of HCQ in COVID-19.

In addition, researchers indicated that though rheumatologists are not “gatekeepers” of HCQ access, they must consider and address some ethical issues that may arise as a result of the potential drug shortage.

• Rheumatologists must proceed with providing continued clinical care to patients with chronic diseases, including systemic lupus erythematosus (SLE), who require HCQ maintenance treatment; discontinuation of the drug could result in disease flares with significant mortality and morbidity.
• The safety of pregnant women with rheumatic diseases receiving HCQ must be strongly protected.
• While weighing the question of “who should get HCQ treatment?”, rheumatologists should strongly advocate for continued HCQ access for patients with valid clinical indications, including SLE and other autoimmune rheumatic diseases, such as palindromic rheumatism, Sjögren syndrome, cutaneous lupus, and milder forms of rheumatoid arthritis. These conditions may not necessarily require treatment with complex disease-modifying antirheumatic drugs (DMARDs) and patients may benefit from HCQ therapy. Patients with these conditions should not be denied continued treatment with HCQ.
• Rheumatologists should support HCQ use for COVID-19 treatment in hospital and/or intensive care unit settings, with a formal research protocol; off-label HCQ use should be prohibited.
• Since there is no current evidence that HCQ can prevent SARS-CoV-2 infection, rheumatologists are recommended to inform patients to ensure that prescribed HCQ be used by them and not by other family members as self-medication. It is important that patients are educated about never sharing their medications. 

Investigators noted that despite these recommendations, rheumatologists have to make the tough decision of choosing which of their patients should remain on HCQ, in the event of the drug shortage. If patients are being removed off HCQ, the researchers recommend an empathetic discussion about their contribution to society during this health crisis.

Investigators concluded, “In this unprecedented time, every single effort towards stemming this most awful global event should be made, but with caution to respect and adhere to the tenets of evidence-based medicine.”

References

1. Scuccimarri R, Sutton E, Fitzcharles M-A. Hydroxychloroquine: a potential ethical dilemma for rheumatologists during the COVID-19 pandemic [published online April 2, 2020]. J Rheum. doi:10.3899/jrheum.200369

2. Colson P, Rolain J-M, Lagier J-C, et al. Chloroquine and hydroxychloroquine as available weapons to fight COVID-19 [published online March 4, 2020]. Int J Antimicrob Agents. doi:10.1016/j.ijantimicag.2020.105932

3. Gao J, Tian Z, Yang X. Breakthrough: Chloroquine phosphate has shown apparent efficacy in treatment of COVID-19 associated pneumonia in clinical studies. Biosci Trends. 2020;14:73.

4. Gautret P. Hydroxychloroquine and azithromycin as a treatment of COVID-19: results of an open-label non-randomized clinical trial [published online March 20, 2020]. Int J Antimicrob Agents. doi:10.1016/j.ijantimicag.2020.105949