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Across the globe, concerns of hydroxychloroquine (HCQ) supply shortages for patients with rheumatic disease are growing,1 in part as a consequence of the immense scientific and public enthusiasm for HCQ as a potential COVID-19 therapy.2 3 However, published data on the occurrence of HCQ shortages during the COVID-19 pandemic are presently lacking. Therefore, we conducted a national survey of 531 Canadian rheumatologists between 14 and 24 April 2020. The 5-question electronic survey (French or English) included province of practice, whether respondents were concerned about HCQ shortages in their province, and whether they had been contacted by patients or pharmacies regarding difficulties renewing HCQ prescriptions during the COVID-19 pandemic. Physicians who answered ‘yes’ to the latter question were asked to estimate for how many patients this occurred. The McGill University Health Centre research ethics board approved this survey.
Of 134 rheumatologists who completed the survey (25% response rate), three quarters (n=102, 76%) were concerned about HCQ shortages, while 81 (60%) had been contacted by pharmacies or patients regarding difficulties accessing or renewing HCQ (see table 1). In the province of Quebec, 29/31 (94% (95% CI 79 to 98)) physicians had been contacted, compared with 52/103 (50% (95% CI 41 to 60)) in the rest of Canada. Among those contacted by patients/pharmacies, 71 (88%) provided a numerical (rather than qualitative) estimate of the patients affected, with a median of 50 patients per physician in Quebec (IQR 25–100), compared with a median of 4 (IQR 2–5) patients per physician in the rest of Canada (p<0.0001 for Mann-Whitney U test).
In his editorial, Dr McInnes notes the imperative to protect HCQ supply for patients with rheumatic diseases.1 While Quebec has reported higher COVID-19 rates (256/100 000 population) than the rest of Canada combined (70/100 000 population), the substantially different experience of Quebec rheumatologists may furthermore be an unintended consequence of system-level mitigation strategies to proactively manage impending HCQ shortages. Following optimistic reports of the possible effectiveness of HCQ for COVID-19, Quebec health authorities determined that there was a significant risk of HCQ shortage in the province (only 2–3 weeks of estimated supply available) and made the unprecedented decision to restrict HCQ access for all indications except systemic lupus erythematosus (SLE) (as well as pregnant and paediatric patients) to reserve supply for these vulnerable groups.4 Patients such as those with rheumatoid arthritis (1% of the Quebec population)5 abruptly lost HCQ access. Pharmacies now contact rheumatologists to confirm diagnoses, potentially causing delayed access even for eligible patients. Whether these restrictions have succeeded in protecting specific groups, such as patients with SLE, from shortages, and to what extent HCQ cessation among all others will lead to disease flares, remains to be determined. In SLE, there is already ample evidence to indicate that HCQ discontinuation could lead to hospitalisation or even death.6
Due to the limited number of survey questions (to maximise response rate) we could not assess provider characteristics such as type of practice (academic vs community). Furthermore, physicians experiencing more HCQ access issues may have been more likely to complete the survey. Nevertheless, the consistent estimated number of affected patients per physician in most provinces (median five or less) and the drastically higher numbers reported in Quebec (10-fold more) lends validity to our observations.
Our survey establishes that HCQ shortages are reported by rheumatologists in most Canadian provinces during the COVID-19 pandemic, with over half of respondents receiving at least one notification of a HCQ access issue, now believed to stem from regional distribution problems rather than lack of supply. Monitoring the clinical impact of shortages for patients with rheumatic diseases and mobilising efforts to restore HCQ access are now critical.
Contributors AM, SB, EV: Study conception, design, data acquisition, analysis, interpretation of data, drafting work and revising it critically for important intellectual content, final approval of the version submitted. CT, DL, SRJ: Data analysis, interpretation, drafting work and revising it critically for important intellectual content, final approval of the version submitted.
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 CT reports advisory board (Abbvie, Boehringer Ingelheim, Celgene, Lilly, Medexus/Medac, Merk, Pfizer, Sandoz), consultant (Celgene, Centocor, Medexus/Medac, Merk, Pfizer), speaker (Medexus/Medac), all outside the submitted work; SRJ reports site investigator (Bayer, Boehringer Ingelheim, Corbus, GSK, BMS), advisory board (Ikaria, Boehringer Ingelheim), all outside the submitted work.
Patient and public involvement Patients and/or the public were not involved in the design, conduct, reporting or dissemination plans of this research.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; internally peer reviewed.
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