Coronavirus: Use of arthritis drugs causes supply concerns

The HSE has asked doctors not to start new patients on a drug used to treat malaria, rheumatoid arthritis and lupus because it can be used to help patients infected with coronavirus.

Doctors have been asked to consider other therapies before starting non-Covid-19 patients on long-term courses of hydroxychloroquine, also known under its brand name Plaquenil, to ensure there is a supply to treat patients who are seriously ill with coronavirus.

Emerging data has shown that hydroxychloroquine may help sick patients infected with coronavirus for individuals suffering more severe symptoms, even though the effectiveness of the drug against coronavirus has yet to be proved in clinical trials.

Irish patients suffering severe coronavirus-related infections have been prescribed hydroxychloroquine – a less toxic version of malaria drug chloroquine – to reduce inflammation.

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US president Donald Trump and Brazilian president Jair Bolsonaro have touted hydroxychloroquine and chloroquine, which is not available in Ireland, as potential treatments for Covid-19 infections, increasing worldwide demand for the drug and putting pressure on supplies.

The HSE told leading hospital managers and doctors last week that the national stock of hydroxychloroquine for Covid-19 patients was being directed to the hospitals and the community stock was wholly for use for existing rheumatoid and lupus patients.

“We would ask you in this Covid-19 public health emergency that you would carefully consider alternative therapies before initiating new patients on long-term hydroxychloroquine for chronic conditions to support continuity of supply, where such alternatives are available,” said the HSE.

The direction came in a letter from Dr Vida Hamilton, national clinical adviser and group lead for acute hospitals at the HSE, circulated on March 24th.

Effective treatment

Another arthritis drug used to lower inflammation, tocilizumab – sold under the brand name RoActemra – has also been shown to be effective in treating Covid-19 patients in China.

Prof Geraldine McCarthy, consultant rheumatologist at the Mater hospital in Dublin and president of Irish Society for Rheumatology, said the group was concerned about possible shortages of the arthritis medications because of their potential effectiveness in treating Covid-19.

There is “a bit of a shortage” of tocilizumab, which is self-administered by arthritis patients through an injection,” said Prof McCarthy.

She said there was also “a bit of a shortage emerging of hydroxychloroquine at the moment”. She checked with her local pharmacist, who said that he was only able to order one box.

David Kane, a clinical professor in rheumatology and consultant at the Beacon Hospital in Dublin, said that some patients with lupus had reported shortages of hydroxychloroquine but the HSE had assured him there would be a continuity of supply for existing patients.

“It may be in stock with larger pharmacy chains,” said Prof Kane, the national clinical lead for rheumatology.

Redirecting drugs

He said there was “a limited supply” of tocilizumab in the country and that the intravenous supply may have to be directed from arthritis patients to those sick with Covid-19.

“We need to be careful how we use that. It may be that we have to divert it where patients were getting it for one condition that is not dangerous, that we may have to try and change the way we give it to them,” said Prof Kane.

Irish Times journalist Glen Murphy, who has recovered from Covid-19, said his mother who also tested positive for the virus and developed pneumonia, was treated with hydroxychloroquine while in hospital.

“This seemed to make a huge difference to her. She was given a small supply of the drug to bring home and she has now finished the course,” he said.

A spokesman for the Irish Pharmaceutical Healthcare Association said it had received "no reports of medicine shortages or supply disruptions caused by the pandemic".

Rheumatologists have advised people with arthritis and other autoimmune conditions not to go off immunity-suppressing drugs during the Covid-19 pandemic in case their conditions “flare”, leaving their immune systems even more unstable and at risk of infection.