COVID-19 treatments sold online without prescription requirements in the United States.

BACKGROUND The COVID-19 pandemic has increased online purchases and heightened interests in existing treatments. Dexamethasone, hydroxychloroquine, and lopinavir-ritonavir have been touted as potential treatments for COVID-19. OBJECTIVE To assess the availability of three potential COVID-19 treatment options online and evaluate the safety and marketing characteristics of websites selling these products during the pandemic. METHODS A cross-sectional study was conducted in June-August 2020 searching the first 100 results on Google, Yahoo, and Bing, mimicking a US consumer. Unique websites were included if they sold targeted medicines, were in English, offered U.S. shipping, and were free to access. Identified online pharmacies were categorized as rogue, unclassified or legitimate based on LegitScript classifications. Patient safety characteristics, marketing techniques, price, legitimacy, internet protocol (IP) addresses, and COVID-19 mentions were recorded. RESULTS We found 117 websites, 30 selling dexamethasone, 39 selling hydroxychloroquine, and 48 selling lopinavir-ritonavir. This included 89 unique online pharmacies: 70% were rogue (n=62), 22% were unapproved (n=20), and only 8% of identified sites were considered legitimate (n=7). All (100%) rogue pharmacies did not require a prescription to buy dexamethasone (n=19), while 50% and 61% of rogue websites did not require a prescription to buy hydroxychloroquine (n= 11) and lopinavir-ritonavir (n= 20), respectively. Overall, only 32% of rogue websites required prescriptions to buy these medications compared to unapproved (94%) and legitimate (100%) websites (p-value <0.001). Rogue sites rarely offered pharmacist counseling (3-9%). Moreover, drug warnings were unavailable in 86% of unapproved dexamethasone sites. It was difficult to distinguish between rogue, unapproved, and legitimate online pharmacies solely based on marketing characteristics of websites. Illegitimate pharmacies were more likely to offer bulk discounts and claim price discounts; yet dexamethasone and hydroxychloroquine were more expensive online. An inexpensive generic version of lopinavir-ritonavir that is not authorized for use in the US was available online. Some websites claimed hydroxychloroquine and lopinavir-ritonavir were effective COVID-19 treatments despite lack of scientific evidence. In comparing IP addresses to locations claimed on the websites, only 8.5% matched their claimed locations. CONCLUSIONS The lack of safety measures taken by illegitimate online pharmacies endanger patients, facilitating access to medications without appropriate monitoring by healthcare providers of clinical response, drug interactions, and adverse effects. We demonstrate how easy it is to go online to buy medications that are touted to treat COVID-19 even when current clinical evidence does not support their use for self-treatment. We document that illegitimate online pharmacies sidestep prescription requirements, skirt pharmacist counselling, and make false claims regarding efficacy in treating COVID-19 infections. Health care professionals must urgently educate the public of the dangers of purchasing drugs from illegitimate websites and highlight the importance of seeking treatment through authentic avenues of care. CLINICALTRIAL