Menaka Pai is an associate professor in McMaster University’s Department of Medicine. Andrew Morris is a professor of infectious diseases at the University of Toronto and a medical director at Sinai Health and the University Health Network. Srinivas Murthy is a clinical associate professor at the Faculty of Medicine at the University of British Columbia.
In the midst of Canada’s third COVID-19 wave, hospitals are becoming overwhelmed. Preventing disease through public health measures and vaccination remains the mainstay of our country’s response. Yet Canadians are still catching COVID-19, so making sure that patients who are sick enough to be hospitalized get the best possible treatment remains incredibly important. There have been hundreds of clinical trials internationally that have told us what does and does not work for this horrible disease. We know a lot more about how to treat COVID-19 than we did a year ago. But in Canada, we are about to run out of some of the most effective treatments.
The foundation of treatment is high-quality supportive care: oxygen, fluids, ventilators and heart-lung machines. These have the greatest effect on whether patients with COVID-19 will live or die. But medications also have a substantial impact on which patients will survive. We know that hydroxychloroquine does not make patients better. We know that steroids do make patients requiring oxygen better, so they have become the standard of care in hospitals around the world.
More recently, we have learned that tocilizumab – an anti-inflammatory monoclonal antibody designed for patients with rheumatoid arthritis and complications of cancer treatment – benefits patients hospitalized with COVID-19. For every 25 COVID-19 patients who get this medication, it may save the life of one person; this is a large benefit by any measure. Provincial clinical guideline groups and the Public Health Agency of Canada have recommended the use of tocilizumab based on a clear demonstration of benefit from high-quality clinical trials.
The problem is that we have almost run out of this medication in Canada. While COVID-19 hospitalizations surge, we do not have enough tocilizumab at its proven dose to treat all of the patients who need it. Canadians may – and should – ask why this has occurred.
Similar to vaccine access, there is a global rush for drug access, and getting enough of this medication to treat the surging number of sick Canadians is a challenge. Global drug supply from tocilizumab’s manufacturer, Hoffmann-La Roche, is limited. The company, which is the sole patent-holder, is selling supply to our federal government in small increments as it scales up production at facilities manufacturing a number of other monoclonal products.
In times of medication shortages, there are established frameworks that front-line clinicians and hospitals can implement. One of the best strategies is to restrict access and give the drug only to patients who will benefit most. This has already been implemented in Canadian hospitals. Another strategy is to consider alternative therapies that may have the same effect. In this case sarilumab, another monoclonal antibody also in sparse supply, is an alternative.
We could also give less medication to each patient, effectively rationing supply, but the risk is that nobody will benefit from the medication due to the lowered dose. Finally, we could implement a lottery system so that randomly selected patients receive the scarce medication, a strategy recommended by Ontario’s COVID-19 Science Advisory Table. This has the benefit of maximizing equity, as all patients would have an equal chance of getting the drug. But it would leave unlucky patients at higher risk for dying. Clearly, there are no good solutions, outside of scaling up supply.
As more and more sick patients flood our country’s hospitals, more and more drug shortages will occur. For some of the drugs we use to support severely ill patients – sedatives, pain medication, blood thinners – we can switch to alternative agents. But for some drugs specific to COVID-19, there is no fallback option.
In the midst of a third brutal wave of the pandemic, we are witnessing the failure of strategies to protect, bolster and steward our precious drug supply. This failure will make the last lines of defence in this pandemic – our hospitals’ medical wards and intensive care units – less able to provide high quality care and prevent deaths from COVID-19.
In pandemic planning, there has always been a focus on “the three Ss” – space, staff and stuff. Our ICUs are full, leaving no space to care for sick patients in many Canadian cities. The lack of staff has been clearly documented. Sadly, now we are running out of stuff.
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