Hydroxychloroquine: A Potential Ethical Dilemma for Rheumatologists during the COVID-19 Pandemic

Bottom Line:

Chloroquine and hydroxychloroquine are two antimalarial drugs commonly used in  the treatment of rheumatic diseases. However, these medications have recently attracted media attention with the idea that these drugs may play a role in the management of COVID-19. This creates an ethical dilemma involving resource scarcity and resource allocation away from routine rheumatology clinical care.

Reference:

Scuccimarri, R., Sutton, E. & Fitzcharles, M.A. Hydroxychloroquine: a potential ethical dilemma for rheumatologists during the COVID-19 pandemic. The Journal of Rheumatology (2020). https://doi.org/10.3899/jrheum.200369

Date Published:

1 May 2020

Synopsis:

Antimalarial therapy first started in the mid-17th century when bark of the Cinchona was found to be effective against a severe feverish illness known as malaria. The main acting ingredient was quinine, which was isolated and helped to derive the synthetic drug chloroquine. Sometime during WWII, it was observed that chloroquine improved autoimmune conditions such as lupus and rheumatoid arthritis. Later on, hydroxychloroquine was developed to reduce the toxic side effects of chloroquine, and these two drugs have been used widely for the management of several autoimmune disorders. Given some in vitro evidence of their efficacy, several clinical studies have been initiated to look at whether or not chloroquine and hydroxychloroquine clinically reduce the activity of COVID-19. However, current clinical trials have insufficient evidence to address the efficacy of chloroquine and hydroxychloroquine on COVID-19 associated complications. Considerable limitations include low sample size, non-randomization, ICU admissions, and death. Although current evidence is lacking, intense media attention has led to resource allocation of available supplies away from rheumatologists, who may still need these drugs to deliver clinical care to patients with chronic autoimmune diseases, and consequently must decide which patients have priority for treatment. As such, it is vital to ensure sufficient supply so that patients who need them are not denied access. In addition, any use of these medications to treat COVID-19 should be limited to the ICU under a proper research protocol. Importantly, patients with access to these medications should use them for treatment of diagnosed conditions and must never share them with others.

Summary by: Winston Li