medwireNews: Rheumatologists highlight that more research needs to be carried out before chloroquine and hydroxychloroquine can be recommended for the treatment of COVID-19, and emphasize the need for adequate supplies of these agents for people with rheumatic diseases.
Writing in an opinion article published in the Annals of Internal Medicine, Alfred Kim (Washington University School of Medicine, St Louis, Missouri, USA) and colleagues point out that a recently published nonrandomized study supporting the use of hydroxychloroquine in combination with azithromycin for the treatment of COVID-19 had a number of limitations.
These include “potentially substantial confounders,” such as assigning patients who declined treatment to the control group, and lower viral loads at the time of treatment initiation among participants treated with hydroxychloroquine compared with those in the control group.
Despite these limitations, “a simplification and probable overinterpretation of these findings was rapidly disseminated,” leading to rapidly growing public interest, say Kim et al.
In a second opinion article published in the same journal, Kim and co-author Jinoos Yazdany (University of California, San Francisco, USA) stress that “[d]ata to support the use of [hydroxychloroquine] and [chloroquine] for COVID-19 are limited and inconclusive,” whereas “evidence for the use of these drugs to treat immune-mediated diseases is not.”
For instance, hydroxychloroquine “is a cornerstone of therapy” for systemic lupus erythematosus, they add, noting that “landmark clinical trials have demonstrated that the withdrawal of [hydroxychloroquine] can lead to flares of disease, including life-threatening manifestations, such as lupus nephritis.”
Yazdany and Kim say that “[w]ell done, randomized clinical trials should be performed urgently to test potential therapies,” for COVID-19, including hydroxychloroquine, but meanwhile “we must do no harm to the patients with rheumatic disease for whom high-quality evidence shows that [hydroxychloroquine] improves health.”
They also note that some physicians have prescribed chloroquine and hydroxychloroquine as prophylactic agents for COVID-19, despite there being “absolutely no data to support this,” and call for safeguards “to discourage overutilization.”
Also discussing the topic of pre-exposure prophylaxis, the authors of a letter published in the Annals of the Rheumatic Diseases say that two European trials (NCT04303507 and NCT04304053) will investigate the efficacy of chloroquine and/or hydroxychloroquine for preventing symptomatic COVID-19 in healthcare workers and other at-risk individuals.
“If mass prophylaxis was accepted as an option worldwide, this would raise the question of whether there is enough supply of [chloroquine] and [hydroxychloroquine] to support this approach,” write Francesca Romana Spinelli (Sapienza University of Rome, Italy) and colleagues.
And in a press release accompanying publication of this letter, EULAR president Iain McInnes said that while international efforts to improve the evidence base for chloroquine and hydroxychloroquine use for COVID-19 are welcome, “EULAR is concerned […] that the diversion of drug supplies away from people with rheumatic and musculoskeletal diseases may compromise the health of this important and sizeable group of patients in Europe and beyond.”
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Ann Intern Med 2020; doi:0.7326/M20-1223
Ann Intern Med 2020; doi:10.7326/M20-1334
Ann Rheum Dis 2019; doi:10.1136/annrheumdis-2020-217367