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Festina lente: hydroxychloroquine, COVID-19 and the role of the rheumatologist
  1. Elizabeth R Graef1,
  2. Jean W Liew2,
  3. Michael S Putman3,
  4. Julia F Simard4,5,
  5. Emily Sirotich6,
  6. Francis Berenbaum7,
  7. Alí Duarte-García8,
  8. Rebecca Grainger9,
  9. Carly Harrison10,
  10. Maximilian F Konig11,
  11. Peter Korsten12,
  12. Laurie Proulx13,
  13. Dawn P Richards13,
  14. Philip C Robinson14,
  15. Sebastian E Sattui15,
  16. Manuel Francisco Ugarte-Gil16,
  17. Kristen J Young17,
  18. Alfred HJ Kim18,
  19. Jeffrey A Sparks19
  20. On behalf of COVID-19 Global Rheumatology Alliance
  1. 1 Division of Rheumatology and Clinical Immunology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
  2. 2 Department of Medicine, Division of Rheumatology, University of Washington, Seattle, WA, United States
  3. 3 Department of Medicine, Division of Rheumatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
  4. 4 Health Research & Policy, Division of Epidemiology and Department of Medicine, Division of Immunology & Rheumatology, Stanford School of Medicine, Stanford, California, USA
  5. 5 Department of Medicine, Clinical Epidemiology Unit, Sweden
  6. 6 McMaster University, Hamilton, Ontario, Canada
  7. 7 Department of Rheumatology, Sorbonne Université, Paris, France
  8. 8 Division of Rheumatology, Mayo Clinic, Rochester, Minnesota, USA
  9. 9 Malaghan Institute of Medical Research, Wellington, New Zealand
  10. 10 LupusChat, New York, New York, USA
  11. 11 Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
  12. 12 Department of Nephrology and Rheumatology, University Medical Center Göttingen, Göttingen, Germany
  13. 13 Canadian Arthritis Patient Alliance, Ottawa, Ontario, Canada
  14. 14 Princess Alexandra Hospital, Diamantina Institute, University of Queensland, Brisbane, Queensland, Australia
  15. 15 Division of Rheumatology, Hospital for Special Surgery, New York, New York, USA
  16. 16 Universidad Cientifica del Sur, Lima, Peru
  17. 17 University of Texas Southwestern Medical School, Dallas, Texas, USA
  18. 18 Division of Rheumatology, Department of Medicine, Washington University School of Medicine in St. Louis, Saint Louis, Missouri, USA
  19. 19 Division of Rheumatology, Inflammation, and Immunity, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
  1. Correspondence to Dr Jeffrey A Sparks, Division of Rheumatology, Inflammation, and Immunity, Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA; jsparks{at}; Dr Alfred HJ Kim; akim{at}

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As of the end of March 2020, the COVID-19 pandemic has resulted in over 850 000 confirmed cases and an estimated 42 000 deaths worldwide.1 All agree that safe and effective therapies for treatment and prevention are urgently needed. In the midst of this rapidly progressing crisis, evidence has emerged suggesting that antimalarial medications, such as hydroxychloroquine (HCQ), may be efficacious for COVID-19 treatment. After amplification from politicians, news outlets and social media, a rush to acquire supplies of HCQ resulted in worldwide shortages. Recent government policies may have exacerbated these issues, where wider use in both COVID-19 treatment and prevention were authorised or recommended by India, the US Food and Drug Administration and other countries.2–4 In response to dwindling supplies, several US states have issued restrictions on HCQ use including limiting dispensation quantities and verifying indications.5–8 Rheumatologists, researchers and patient partners must advocate for the appropriate distribution and use of HCQ, as millions of people with rheumatic diseases worldwide depend on HCQ to control disease activity and maintain quality of life. In doing so, we must also remind ourselves to ‘make haste slowly’ (festina lente).

Emanuel et al 9 published a well-timed commentary suggesting the following principles for fairly allocating scarce resources during the COVID-19 crisis: equal treatment, attempts to maximise benefits and prioritising the most vulnerable. These recommendations echo prior guidance published in 2016 by the WHO on how to address future infectious disease outbreaks.10 The report cautioned that ‘special attention should be given to ensuring that persons who face heightened susceptibility to harm or injustice during infectious disease outbreaks are able to contribute to decisions about infectious disease outbreak planning and response’. This ethical framework offers health systems a structure for approaching the use and distribution of HCQ during the COVID-19 pandemic to minimise …

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  • ERG and JWL are joint first authors.

  • AHK and JAS are joint senior authors.

  • Handling editor Josef S Smolen

  • Twitter @ebrheum, @emilysirotich, @larhumato, @MaxKonigMD, @pekor002, @SattuiSEMD, @mugartegil, @alhkim, @jeffsparks

  • ERG and JWL contributed equally.

  • AHK and JAS contributed equally.

  • Collaborators COVID-19 Global Rheumatology Alliance.

  • Contributors ERG, JWL, JFS, ES, AD-G, RG, PK, PCR, SES, MFU-G, AHJK and JAS contributed to the conception and drafting of the article. ES, CH and LP participated in every phase of the conception and drafting of the article as patient advocates. All listed authors provided critical revision for important intellectual content and final approval.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests FB reports personal fees from Boehringer, Bone Therapeutics, Expanscience, Galapagos, Gilead, GSK, Merck Sereno, MSD, Nordic, Novartis, Pfizer, Regulaxis, Roche, Sandoz, Sanofi, Servier, UCB, Peptinov, TRB Chemedica and 4P Pharma. RG reports personal fees from Pfizer, Cornerstones, Jannsen and Novartis. PK reports personal fees from GlaxoSmithKline, Sanofi-Aventis, Pfizer, Abbvie, Novartis Pharma, Eli Lilly and Bristol-Myers Squibb. AHJK reports grants from NIH (National Institutes of Health)/NIAMS (National Institute of Arthritis and Musculoskeletal and Skin Diseases) and Rheumatology Research Foundation and personal fees from Exagen Diagnostics and GlaxoSmithKline. JAS reports grants from NIH/NIAID (National Institute of Allergy and Infectious Diseases)/Autoimmune Centers of Excellence, the Rheumatology Research Foundation, the Brigham Research Institute and the R. Bruce and Joan M. Mickey Research Scholar Fund as well as personal fees from Bristol-Myers Squibb, Gilead, Inova, Janssen and Optum.

  • Patient and public involvement Patients and/or the public were involved in the design, conduct, reporting or dissemination plans of this research. Refer to the Methods section for further details.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.