Hydroxychloroquine and Chloroquine in COVID-19

A Survey of Prescription Patterns Among Rheumatologists

Bella Mehta, MBBS, MS; Carine J. Moezinia, MBBS; Deanna Jannat-Khah, DrPH; Allan Gibofsky, MD; Haley Tornberg, BS; Diyu Pearce-Fisher, BS; Susan M. Goodman, MD; Jane E. Salmon, MD; Said Ibrahim, MD

Disclosures

J Clin Rheumatol. 2020;26(6):224-228. 

In This Article

Abstract and Introduction

Abstract

Objective: With hydroxychloroquine (HCQ) and chloroquine (CQ) emerging as potential therapies for coronavirus disease 2019 (COVID-19), shortages have been reported. We aimed to understand how rheumatologists, one of the most common prescribers of HCQ/CQ, prescribed these medications to manage COVID-19 and to understand if their patients are affected by shortages.

Methods: Between April 8 and April 27, 2020, an online survey was distributed to a convenience sample of rheumatologists who practice medicine in a diverse range of settings globally, resulting in 506 responses. Adjusted Poisson regression models were calculated.

Results: Only 6% of respondents prescribed HCQ/CQ for COVID-19 prophylaxis, and only 12% for outpatient treatment of COVID-19. Compared to the United States, the likelihood of prescribing HCQ/CQ for prophylaxis was higher in India (adjusted risk ratio [aRR], 6.7; 95% confidence interval [CI], 2.7–16.8; p < 0.001). Further, compared to the United States and those with 1 to 5 years of experience, rheumatologists in Europe (aRR, 2.9; 95% CI, 1.6–5.3; p < 0.001) and those with 10+ years of experience (11–20 years: aRR, 2.5; 95% CI, 1.2–5.3; p = 0.015; 21+ years: aRR = 3.3; 95% CI, 1.4–7.4; p = 0.004) had a higher likelihood of prescribing HCQ/CQ for outpatient treatment. Of note, 71% of all rheumatologists reported that their patients were directly affected by HCQ/CQ shortages.

Conclusion: The results suggest that only a small percentage of rheumatologists are prescribing HCQ/CQ for prophylaxis or outpatient treatment of COVID-19. Medication shortages experienced by large numbers of autoimmune disease patients are concerning and should play a role in decisions, especially given poor efficacy data for HCQ/CQ in COVID-19.

Introduction

The coronavirus disease 2019 (COVID-19) pandemic caused by the novel coronavirus (severe acute respiratory syndrome coronavirus 2 [SARS–CoV-2]/2019-nCoV) has created a severe global public health crisis and economic disruption. Hydroxychloroquine (HCQ) and chloroquine (CQ) have emerged as potential therapies repurposed for COVID-19.[1,2] However, to date, there has been a lack of conclusive efficacy data in vivo,[3,4] and there are now early reports of potential toxicity and harm.[5,6] While randomized clinical trial results were pending, the US Food and Drug Administration on March 28, 2020, issued an Emergency Use Authorization of CQ and HCQ for the treatment of hospitalized COVID-19 patients.[7] This Emergency Use Authorization had global implications. Currently, most countries do not recommend HCQ and CQ for prevention and outpatient treatment of COVID-19, with the exception of a few countries, such as India.[8]

Hydroxychloroquine and CQ are inexpensive drugs that have been in use for decades. While CQ is additionally used for malaria prophylaxis and treatment, its less toxic metabolite, HCQ, is prescribed primarily for autoimmune diseases. As a result, CQ is predominantly prescribed by primary care physicians and infectious disease specialists, while both HCQ and CQ are routinely prescribed by rheumatologists for chronic autoimmune diseases.[9] Following media coverage and the touting of HCQ/CQ efficacy by various influential figures,[10] there have been reports of a surge in HCQ/CQ prescriptions,[9] resulting in shortages for autoimmune disease patients who regularly take these medications.[11]

Given both the questionable nature of the clinical evidence surrounding the off-label use of HCQ and CQ for COVID-19 and supply shortages affecting autoimmune patients, rheumatologists now find themselves in a challenging position during this pandemic.[12] Our objective was to understand how rheumatologists worldwide are prescribing HCQ/CQ for the prevention and outpatient treatment of COVID-19 and whether their patients are experiencing medication shortages.

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