The Canadian Rheumatology Association (CRA) is committed to supporting its members in their efforts to continue to deliver optimal care for their patients with rheumatic diseases. At the same time, the CRA acknowledges the gravity of the situation with the COVID-19 pandemic and the importance of identifying effective treatments in a timely and scientific manner. The identification of hydroxychloroquine (HCQ) as a possible treatment for COVID-19 has led to significant off-label use, which now threatens access for patients with lupus and other types of inflammatory rheumatic disease who are reliant on this medication for disease control.# 
Although the CRA supports ongoing study for effective treatment for COVID-19, it calls for priority access to HCQ for patients with rheumatic conditions (including lupus and certain types of inflammatory arthritis) to treat these chronic diseases. The CRA further urges policy makers, regulators, and industry to work together to increase Canada's supply of HCQ to meet the higher demand.

# Recent Related Statements:
- Joint Statement on Use of HCQ and Azithromycin for COVID-19 from OMA, OPA and RNAO" The purpose of this position statement is to advocate for priority access of hydroxychloroquine for patients with rheumatic conditions while at the same time encouraging continued study and increased production of hydroxychloroquine to address the current higher demands for the drug due to the COVID-19 pandemic.

# What is the CRA's position regarding the use of hydroxychloroquine as a possible treatment for COVID-19?
The CRA's position statement on COVID-19 and hydroxychloroquine supply is available in full on our website. To summarize:
- Rheumatologists need to be able to continue to provide the best care possible for individual patients while also considering the well-being of society as a whole. As such, decisions about the ongoing allocation of hydroxychloroquine supply should also incorporate recommendations from rheumatologists who are experts in treatment with hydroxychloroquine for rheumatologic diseases, for which the medication is approved by Health Canada.
- It is imperative that every effort is made to ensure an adequate supply of hydroxychloroquine for all patients and that there is no interruption in patient care for people living with lupus or other types of inflammatory rheumatic disease.
- The Canadian Rheumatology Association continues to monitor the data available regarding the safety and efficacy of hydroxychloroquine as a possible treatment for COVID-19, and will provide further updates to this position statement as needed.

# Why is/was there a concern regarding the use of hydroxychloroquine?
Hydroxychloroquine has demonstrated antiviral activity against SARS-CoV-2 in tissue culture. These findings, as well as its relative tolerability in patients taking the drug for

# RHEUM.CA
Health Canada-approved indications, have raised interest in these agents as potential therapeutic options in the current COVID-19 pandemic. 1 2 3
Although the CRA supports ongoing study for effective treatment for COVID-19, it calls for priority access to hydroxychloroquine for patients with rheumatic conditions (including lupus and certain types of inflammatory arthritis) to treat these chronic diseases. The CRA further urges policy makers, regulators, and industry to work together to increase Canada's supply of hydroxychloroquine to meet the higher demand and to ensure an adequate supply of hydroxychloroquine for all patients who need it.

# What role does the CRA play in the advocacy for additional supply?
In providing this position statement, the CRA is advocating for increased supply to meet the higher demands of hydroxychloroquine during the COVID-19 pandemic. We hope that this can influence stakeholders including policy makers, regulators and the pharmaceutical industry to work together to increase Canada's supply of hydroxychloroquine.
The CRA's mission is to promote the pursuit of excellence in arthritis and rheumatic disease care. One of the ways it does this is by ensuring that CRA members and their patients are in possession of up-to-date guidance regarding access to medications so informed and appropriate treatment decisions may be made. Furthermore, the CRA works closely with key stakeholders including government officials, disease and patient groups and other national and provincial medical associations to both inform their decision making and to help guide our approach.

# Who was involved in the development of the position statement?
The position statement was developed by the CRA Therapeutics Committee and reviewed and approved by the CRA Board of Directors so that they can offer up-to-date guidance regarding access to hydroxychloroquine during these exceptional times.

# How exactly is hydroxychloroquine used in rheumatology?
Hydroxychloroquine is a disease-modifying anti-rheumatic drug (DMARD). This drug, either as monotherapy or in combination therapy, is used to suppress or control rheumatic disease. Hydroxychloroquine is an essential medicine for patients with lupus. It is also a mainstay of therapy for many patients with rheumatoid arthritis. In addition, it is used to RHEUM.CA treat other connective tissue diseases such as Sjogren's syndrome and dermatomyositis. It is the only medication shown to increase survival in patients with systemic lupus erythematosus (SLE) and has been shown to reduce SLE flares and prevent organ damage including cardiovascular events. 1. In SLE, it was demonstrated that stopping hydroxychloroquine resulted in over twice the risk of disease flare in patients 4 .
The use of hydroxychloroquine in SLE and RA is supported by many guidelines worldwide.

# What is the difference between a guideline, a consensus statement and a position statement?
The CRA classifies its guidance into clinical practice guidelines and position statements. Clinical practice guidelines follow international standards for best practice and provide recommendations for best practice based on the latest evidence. A position statement is a document that outlines CRA's stance on a topic relevant to its membership. They are generally developed as a quick response to emerging or controversial issues. Although there is usually insufficient time to adopt the same rigorous approach as clinical practice guidelines, position statements still refer to appropriate evidence-based literature and must be approved by the CRA prior to being released.
- Will this position statement be included in new CRA guidelines when they are developed?
As our guidelines are updated, new information will always be considered as part of the review process.

# How often will you update this position statement?
The position statement will be updated when new information or clinical evidence becomes available.