Article Text

other Versions

Download PDFPDF

Hydroxychloroquine shortages among patients with systemic lupus erythematosus during the COVID-19 pandemic: experience of the Systemic Lupus International Collaborating Clinics
  1. Arielle Mendel1,
  2. Sasha Bernatsky1,2,
  3. Anca Askanase3,
  4. Sang-Cheol Bae4,
  5. Ann Elaine Clarke5,
  6. Nathalie Costedoat-Chalumeau6,
  7. Dafna D Gladman7,
  8. Caroline Gordon8,9,
  9. John Hanly10,
  10. Søren Jacobsen11,
  11. Ken Kalunian12,
  12. Anselm Mak13,
  13. Marta Mosca14,
  14. Bernardo A Pons-Estel15,
  15. Guillermo Ruiz-Irastorza16,
  16. Murray Urowitz7,
  17. Évelyne Vinet1,2
  1. 1Division of Rheumatology, McGill University Health Centre, Montreal, Quebec, Canada
  2. 2Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
  3. 3Division of Rheumatology, Columbia University Irving Medical Center, New York, New York, USA
  4. 4Division of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seongdong-gu, Republic of Korea
  5. 5Division of Rheumatology, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
  6. 6Centre de Référence Maladies Auto-immunes et Systémiques Rares, Service de Médecine Interne, Hôpital Cochin, Paris, France
  7. 7Lupus Program, Centre for Prognosis Studies in the Rheumatic Disease and Krembil Research Institute, Toronto Western Hospital, Toronto, Ontario, Canada
  8. 8Rheumatology Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
  9. 9Rheumatology Department, City Hospital, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
  10. 10Division of Rheumatology, Department of Medicine and Department of Pathology, Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada
  11. 11Copenhagen Lupus and Vasculitis Clinic, Section 4242, Center for Rheumatology and Spine Diseases, Rigshospitalet, Copenhagen, Denmark
  12. 12Division of Rheumatology, University of California San Diego School of Medicine, La Jolla, California, USA
  13. 13Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
  14. 14Rheumatology Unit, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
  15. 15Regional Center for Autoimmune and Rheumatic Diseases of Rosario, Sanatorio Parque, Rosario, Argentina
  16. 16Autoimmune Diseases Research Unit, Department of Internal Medicine, BioCruces Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, Barakaldo, Spain
  1. Correspondence to Dr Arielle Mendel, Rheumatology, McGill University Health Centre, Montreal, QC H3G1A4, Canada; arielle.mendel{at}

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

Early scientific and public enthusiasm for hydroxychloroquine (HCQ) as a potential therapy for COVID-19 has prompted over 100 registered trials to date, although its efficacy remains to be demonstrated.1 Unfortunately, accelerated demand for HCQ has the potential to diminish supplies for patients with systemic lupus erythematosus (SLE), which is worrisome due to the known risks of SLE flare after HCQ withdrawal.2 We previously reported that rheumatologists in most Canadian provinces observed HCQ shortages early in the COVID-19 pandemic.3 However, data are lacking on the global experience with HCQ access during the pandemic, specifically in SLE.

On 4 May 2020, we distributed an electronic survey to the 42 Systemic Lupus Erythematosus International Collaborating Clinics (SLICC) members affiliated with SLE referral centres (, with reminders after 1 and 3 weeks. Physicians were asked about experiences with HCQ shortages during the COVID-19 pandemic, and whether they had been contacted by patients and/or pharmacists regarding difficulties accessing HCQ. Physicians who answered ‘yes’ to the latter question were asked to estimate how many and what proportion of their patients with SLE were affected. We inquired about regional measures taken that exacerbated or helped mitigate HCQ shortages for patients with SLE (free text responses).

We received 31 responses (rate 74%) from 13 of 15 countries represented in SLICC, mostly from Europe (29%), the USA (26%) and Canada (23%). Over half (55%) reported either previous (39%) or current (16%) HCQ shortages among patients with SLE during the pandemic (see table 1). Two-thirds (65%) were contacted by patients and pharmacies regarding difficulties accessing HCQ. Seventeen provided estimates of the number and proportion of their patients affected, which corresponded to a median of 40 (IQR 15–90) patients per physician representing 15% (IQR 5%–35%) of respective SLE populations. Seven physicians noted that shortages resolved within 2–8 weeks. Members from four countries (Sweden, Denmark, Singapore, South Korea) reported no HCQ access issues among their patients.

Table 1

Experience of HCQ shortages among patients with SLE during the pandemic and regional mitigation strategies

Physicians identified regional factors contributing to HCQ shortages, including diversion of HCQ to hospitals (n=3), for clinical trials (n=2) or off-label empiric prescribing for COVID-19 (n=1).

Twenty-three (74%) reported system-level measures taken during the pandemic to preserve HCQ access for patients with SLE, which included limiting prescribing capabilities to specific specialties (n=9) or diagnoses (n=10) and limiting dispensed supply (n=3). Some restrictions may have inadvertently delayed HCQ access for patients with SLE, who had to wait for physicians to update diagnostic codes in medical records, confirm diagnoses with pharmacies or apply for waivers. In some cases, patients had to register for pharmacy dispensing programmes or were subjected to general dispensing restrictions. In Canada, the USA and the UK, patient and physician organisations advocated to health authorities for the rapid resolution of HCQ shortages.

Currently, there is no substitution for antimalarials in SLE. HCQ reduces disease flares,2 damage4 and mortality,5 with fewer adverse effects compared with glucocorticoids and immunosuppressants.6 Regardless of the ultimate efficacy of HCQ for COVID-19, preserving patients’ access to critical medications remains paramount. We observed that HCQ prescription restrictions were a common short-term strategy, although our cross-sectional survey was not intended to evaluate which mitigation strategies were most effective. Furthermore, physician estimates from single tertiary centres do not represent a comprehensive account of HCQ shortages or mitigation strategies and may not reflect the experience of an entire region or country.

According to this survey, HCQ access issues for patients with SLE occurred in multiple countries and continents during the COVID-19 pandemic. Because SLE can flare as little as 2 weeks after HCQ cessation,2 further study of outcomes among patients who lost access to HCQ during the pandemic is warranted.



  • Handling editor Josef S Smolen

  • Contributors AM, SB, EV: conception or design of the study; data acquisition, analysis and interpretation; drafting the work; revising it critically for important intellectual content; final approval of the version published. AA, S-CB, AEC, NC-C, DDG, CG, JH, SJ, KK, AM, MM, BAP-E, GR-I, MU: data analysis and interpretation; revising the work critically for important intellectual content; final approval of the version published. All authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

  • 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 AEC reports consulting fees (less than $10 000) from Bristol Myers Squibb, Exagen Diagnostics and AstraZenca, outside the submitted work.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting or dissemination plans of this research.

  • Patient consent for publication Not required.

  • Ethics approval The McGill University Research Ethics Board approved this survey.

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