The "unbridled race" for using chloroquine and hydroxychloroquine to prevent or treat COVID-19 leads to shortages for patients with chronic inflammatory conditions and malaria in Brazil
References
1. David N. Juurlink. Safety considerations with chloroquine, hydroxychloroquine and azithromycin in the management of SARS-CoV-2 infection. CMAJ 2020;10.1503/cmaj.200528.
2. Marcelo U. Ferreira, Marcia C. Castro. Challenges for malaria elimination in Brazil. Malar J. 2016; 10.1186/s12936-016-1335-1.
3. Jack Goodman, Christopher Giles. Coronavirus and chloroquine: Is there evidence it works? BBC News. 2020. Available from: https://www.bbc.com/news/51980731
4. Charles Piller. ‘This is insane!’ Many scientists lament Trump’s embrace of risky malaria drugs for coronavirus. Science. 2020; 10.1126/science.abb9021.
5. Shao Liu, Ping Luo, Mimi Tang, Qin Hu, Joseph P. Polidoro, Shusen Sun, Zhicheng Gong. Providing pharmacy services during the coronavirus pandemic. Int J Clin Pharm. 2020; 10.1007/s11096-020-01017-0.
In April 8, 2020, Dr. David Juurlink provided an overview of potential harms associated with use of chloroquine (CQ) and hydroxychloroquine (HCQS) and suggested that the surge in prescriptions of these drugs based on speculation to COVID-19 prevention or treatment threatens the availability of these drugs for patients with malaria and chronic inflammatory disorders for whom they are known to be effective (1). Indeed, the urgent need for treatment imposed by the COVID-19 pandemic has led to the broadcast of misinformation on efficacy and safety of medications, which may have led people to an “unbridled race” for CQ and HCQS.
This scenario is not promising in low- and middle-income countries. Brazil has one of the highest prevalence estimates of systemic lupus erythematous and rheumatoid arthritis worldwide and contributes to 40% of malaria cases in the Americas. Malaria transmission remains endemic in the Amazon Basin, which accounts for 99.5% of the country’s malaria burden (2). Worryingly, COVID-19 cases in Brazil and Amazon region has increased considerably. Recently, The Brazilian National Health Surveillance Agency (ANVISA) published a rule that classifies CQ and HCQS as special control drugs to restrict access to these medications in pharmacies and avoiding shortages. However, we have found a dramatically driven up demand for these drugs and the stocks at various pharmacies are depleted. A similar phenomenon has also been reported in African countries, where people are stocking up CQ and HCQS and there are reports of deaths from overdose self-medicating (3,4). In this context, pharmacists can play a major role in educating and delivery of medicines to the consumer (5).
Despite optimism with CQ and HCQS, we need to be cautious. As shown by the Dr. Juurlink, CQ and HCQS can predispose patients to life-threatening arrhythmias and are extremely toxic in overdose (1). Until CQ and HCQS have proved their usefulness in the clinical setting for patients with COVID-19, Paracelsus ’words still seem meaningful: sola dosis facit venenum (“the dose makes the poison”).