Ontario should set up a lottery to allocate one of the few medications known to reduce mortality in critically ill COVID-19 patients in case supplies are exhausted during the punishing third wave, according to a new paper from the province’s scientific advisers.
The Ontario COVID-19 Science Advisory Table is asking the provincial government to prepare for the day hospitals run out of tocilizumab, an anti-inflammatory drug that physicians are already administering in smaller doses to make limited amounts go further.
Andrew Morris, an infectious disease physician and one of the co-authors of the new brief, said he and his colleagues hope a lottery won’t be necessary. “But hoping isn’t a plan,” Dr. Morris said. “In a thoughtful, methodical manner, you need to plan for the possibility of a shortage. This is a drug that is life-saving.”
The preparations for a tocilizumab shortfall in Ontario highlight how the third wave is putting pressure on treatment resources of all kinds, including drugs. Across Canada, at least 1,246 COVID-19 patients were being cared for in ICUs as of Monday night, according to The Globe and Mail’s tracking of provincial data – a record for the pandemic. About 60 per cent of those patients are in Ontario, although British Columbia also has a record number of coronavirus patients in its critical care beds and Saskatchewan is near a recent high.
Recognizing that strain, the federal government announced last week the creation of a COVID-19 critical drug reserve for medications used to provide supportive care in ICUs, including sedatives and muscle relaxants that are key for patients on ventilators.
The federal government has purchased an initial three-month supply of 12 drugs. Tocilizumab is not on the new reserve list, but that could be because of how hard it is to accumulate a stockpile of tocilizumab among a worldwide spike in demand.
The Public Health Agency of Canada did not respond by deadline to a question about why the drug isn’t part of the COVID-19 critical drug reserve. A PHAC spokesman said the government purchased as many doses as it could from maker Hoffman-La Roche.
“Working in close collaboration with provinces and territories, PHAC is facilitating the re-distribution of tocilizumab to Ontario from jurisdictions that may be in a position to donate tocilizumab due to less local demand,” Geoffroy Legault-Thivierge said in a statement.
Sold under the brand name Actemra, tocilizumab is a monoclonal antibody normally used to treat rheumatoid arthritis and the side-effects of some cancer treatments. Along with the steroid dexamethasone, it is one of the few pre-existing drugs that emerged from clinical trials as clearly effective in cutting the death rate from COVID-19, the disease caused by SARS-CoV-2. (Another drug, the antiviral Remdesivir, has been shown to reduce the length of time moderately ill COVID-19 patients spend in hospital. Unlike tocilizumab, it’s a new drug approved specifically for the pandemic virus.)
Although some Ontario hospitals ran out of tocilizumab temporarily in early April, supplies are mostly stable for the moment, Dr. Morris said. But it’s not clear how long that will last, given the record-breaking number of infected patients being admitted to ICUs and general medicine wards in the province daily.
Jennifer Mota, a spokeswoman for Hoffman-La Roche Canada, said that as part of its pandemic-related deal with PHAC, the company sent 1,700 doses of tocilizumab to Canada in April and will provide 1,900 doses in May.
The company defines a dose as 800 mg of the IV drug. The Ontario science table’s drugs and biologics clinical practice guidelines working group, which Dr. Morris co-chairs, already recommended earlier this month that “in light of ongoing drug shortages” physicians give COVID-19 patients a maximum of 400 mg of tocilizumab and refrain from offering second doses.
Menaka Pai, a hematologist at Hamilton Health Sciences and co-chair of the working group, emphasized the importance of making real-time data available about supply and location of the drug, another way the new paper suggests trying to stave off the need for a lottery.
“Some preliminary dashboarding has been done by the province,” Dr. Pai said. “But do we have a real-time dynamic dashboard that not only captures what’s happening in terms of ministry supply, but supply and demand across the province? No, we don’t have that.”
David Jensen, a spokesman for the Ontario Ministry of Health, declined to answer a question about more regimented tracking of the tocilizumab supply. He confirmed Ontario is expecting to receive extra doses from other provinces. The Ontario Critical Care Command Centre is taking over distribution of tocilizumab and “will determine an ethical way to distribute the drug,” he added.
Andrew Baker, the command centre’s incident commander, told hospital chief executives in an e-mail on Sunday, a copy of which was viewed by The Globe and Mail, that the command centre does not currently recommend a “randomization approach” – a lottery – “but recognizes that as articulated by the Science Table, randomization may become the best option in the future.”
The science table recommends that the lottery be provincewide so that limited doses can be shared fairly, no matter where a patient is being treated. The group also suggests setting up a committee to oversee the allocation process.
Sign up for the Coronavirus Update newsletter to read the day’s essential coronavirus news, features and explainers written by Globe reporters and editors.