key: cord-308212-l8flyso7 authors: Kong, Ha Eun; Grant-Kels, Jane M.; Stoff, Benjamin K. title: Applying the ethical principles of resource allocation to drugs in limited supply during a public health crisis date: 2020-04-21 journal: J Am Acad Dermatol DOI: 10.1016/j.jaad.2020.04.078 sha: doc_id: 308212 cord_uid: l8flyso7 nan Saving the most lives/life-years is the highest priority. Random selection can be used for selecting among patients with comparable prognoses. Healthcare workers should be prioritized. With other factors equal, give priority to COVID-19 research participants. aligns with maximizing benefits e.g. saving most years of life or preventing further spread of virus. 45 During a pandemic, priority should be given to those whose survival would benefit most from 46 treatment in order to maximize benefit to society. Applying this principle to antimalarials, severe 47 COVID-19 patients as well as patients with malaria or severe rheumatologic disease, for whom 48 other effective treatments are unavailable, should be favored. If dermatology patients eligible for 49 antimalarials have other, comparably-effective treatment options, dermatologists should 50 recommend alternatives, particularly for mild-to-moderate disease. Finally, providers should 51 not prescribe these drugs to the "worried well," who may be hoarding medication in case of 52 illness. Clinicians must reassess allocation strategies as new data emerge. The efficacy of 55 antimalarials for COVID-19 should be assessed via randomized clinical trials (RCTs), which are 56 ongoing. For example, a small open-label French study demonstrated reduction in viral load, 57 but did not assess mortality or morbidity 1 . In contrast, for systemic lupus erythematosus (SLE) 58 patients, a RCT showed that discontinuing hydroxychloroquine leads to a 2.5x increased 59 relative risk of clinically-relevant flares and a 6x increased relative risk of severe exacerbation 60 compared to placebo 4 . While the benefit of antimalarials to COVID-19 patients remains 61 uncertain, high-quality evidence supports continuing treatment in patients with severe SLE. 62 What is the role of patient autonomy in public health emergencies? Under normal 63 circumstances, if a reasonable patient prefers antimalarials for skin disease, and the treatment 64 is indicated, then the drugs should be prescribed. However, patient autonomy is diminished in 65 public health emergencies, as healthcare ethics shifts priority to populations over individuals 5 . 66 Currently, many states in the US have limited prescribing of hydroxychloroquine, but these 67 limitations generally don't apply to patients on drug for approved indications 6 . In applying the 68 ethical principles of resource allocation (Table I) Table 1 . "Application of ethical principles of resource allocation in the COVID-19 pandemic" 107 (adapted from Emanuel et al. 3 ) 108 Saving the most lives/life-years is the highest priority. Random selection can be used for selecting among patients with comparable prognoses. Healthcare workers should be prioritized. With other factors equal, give priority to COVID-19 research participants. aligns with maximizing benefits e.g. saving most years of life or preventing further spread of virus. 109 Hydroxychloroquine and azithromycin as a 86 treatment of COVID-19: results of an open-label non-randomized clinical trial Potential Shortages of Hydroxychloroquine for Patients 89 with Lupus During the Coronavirus Disease Fair Allocation of Scarce Medical Resources in 92 the Time of Covid-19 A randomized study of the effect of withdrawing 95 hydroxychloroquine sulfate in systemic lupus erythematosus Ethical Framework for Health Care Institutions & Guidelines for Institutional Ethics 98 Services Responding to the Coronavirus Pandemic -The Hastings Center