• hydroxychloroquine
• immune complex diseases
• inflammation

As the COVID-19 crisis moves to its next phase, from ‘acute to chronic’ as it were, it is important to note that a variety of immune modifier medicines are now being proposed or actively trialled in pursuit of a novel effective intervention for early through to poor prognosis coronavirus infection. Such imaginative and creative approaches are to be welcomed. Given the current mathematical models of COVID-19 pandemic resolution, it seems that this may be a lengthy scenario. In the meantime, some disease-modifying antirheumatic drugs (DMARD) are being used on a presumptive basis, for understandable compassionate reasons, though not always based on robust medical evidence. One consequence of widespread uptake of DMARD use in COVID-19 is that drug availability may be diminished and thereby hamper the management of existing immune-mediated inflammatory diseases and particularly rheumatic and musculoskeletal diseases (RMDs). Many people with RMDs are reliant on such DMARDs to retain their well-being and loss of therapeutics may lead potentially to flare, and disease progression. Mendel et al provide us with important evidence of hydroxychloroquine shortages in Canada provided via a survey of Canadian rheumatologists.1 They are to be commended for seeking evidence of the same. This aligns well with numerous similar reports emerging across European countries. The European League Against Rheumatism is committed to ensuring equitable access to the medicines necessary to optimally treat RMDs during the COVID-19 pandemic.2 This is especially the case when as yet, few or no randomised controlled data support the use of immune modifiers in the management of COVID-19. Thus, while we are supportive of high-quality clinical trial medicine and indeed are hopeful that successful outcomes will emerge in pursuit of a solution for COVID-19, we prefer that the use of agents such as hydroxychloroquine is reserved in the context of appropriate trials, be they of controlled or well-annotated cohort design.