Limited Global Supply, Ethical Concerns Could Curb Use of Antimalarials Against COVID-19

Although the antimalarial drugs chloroquine and hydroxychloroquine have been touted as potential treatments for coronavirus disease 2019 (COVID-19), physicians in Italy have warned that the global supply may not be able to keep up with demand, in a letter published in the Annals of the Rheumatic Diseases.¹

Chloroquine and hydroxychloroquine have been in use since the 1940s for the treatment of rheumatic diseases and have proven safe and well-tolerated in most cases, according to the letter authors. Adverse effects are typically mild, although serious complications, such as retinal and cardiac damage, can occur rarely when patients take cumulative doses over a long period of time.¹

Preliminary research has suggested that the drugs could be effective in treating pneumonia caused by COVID-19, and the treatments have already been included in Chinese guidelines on disease management. Previous studies have also shown that antimalarial drugs can be effective against viral infections, and clinical trials are investigating whether the drugs could help prevent the disease entirely.¹

Although some experts have suggested widespread use of chloroquine and hydroxychloroquine as a preventive measure, the authors noted that limited global supply could affect those who need the drugs for other illnesses, such as arthritis or lupus. Shortages are already affecting prescribers’ ability to provide the treatment.¹

According to the American Society of Health-System Pharmacists (ASHP), which keeps a database of drug shortages, Amneal, Major, Mylan, and Teva are all experiencing shortages of hydroxychloroquine, while Concordia, Prasco, Sandoz, and Zydus have the drug currently available. Amneal and Major have limited supplies, whereas Mylan has 200 mg tablets on back order and cannot estimate a release date, according to ASHP.²

In addition to the potential access issues, the authors also noted several ethical concerns. Because there is no hard evidence confirming that the drugs can prevent contraction of COVID-19, the authors questioned whether widespread use is wise.¹

“Is it permissible to take a controlled risk in the event of a pandemic?” they said. “In such a case: would it be reasonable to consider antimalarials as primary prophylaxis in healthy subjects living in highest risk regions or, at least, to use them in those testing positive for COVID-19, but still asymptomatic?”¹

Despite their hesitations, the authors also noted that the safety and efficacy of the drugs make them good candidates for mass preventive treatments, and they added that scientists seem to be leaning toward adopting the approach.¹

“If mass prophylaxis was accepted as an option worldwide, this would raise the question of whether there is enough supply of [chloroquine] and [hydroxychloroquine] to support this approach,” the authors concluded.¹

REFERENCES

• Limited supply may scupper proposals to use antimalarials to ward of Covid-19 [news release]. BMJ Journals; April 2, 2020. https://www.bmj.com/company/newsroom/limited-supply-may-scupper-proposals-to-use-antimalarials-to-ward-off-covid-19/. Accessed April 10, 2020.
• Hydroxychloroquine Sulfate Tablets. American Society of Health-System Pharmacists; Updated March 24, 2020. https://www.ashp.org/Drug-Shortages/Current-Shortages/Drug-Shortage-Detail.aspx?id=646. Accessed April 10, 2020.