Do tocilizumab shortages make it the pandemic toilet paper of rheumatology?
Do tocilizumab shortages make it the pandemic toilet paper of rheumatology?
I’ve lost count of days in lockdown, or even how many lockdowns we’ve had. All I know is that I’ve vaguely figured out what to do, because beneath the superficial unpredictability of their onset is a very predictable reality, in this new world.
That’s not to dismiss the deep, dark times we’re in now, or the very real potential of them getting deeper and darker. Any seeming indifference from me about lockdowns stems from the fact that their start is almost comical in its stereotyped manner.
The blip up in cases means lockdown, and one thing is certain: the news crew is off to the supermarket for some shots of shoppers standing in line and empty shelves. Don’t envy the poor minimum wage worker manning the checkouts that day, because panic is about to set in as people don’t get what they want. Of course, it has been toilet paper, never of real interest before, that has been the lightning rod.
The supply chains never stood a chance the first time around. They didn’t know it was coming, who would? At the beginning of the pandemic, it meant a lot of awkward conversations about the equitable distribution of toilet paper. Were people using more than they really needed? Who would look after the older and the poorer? What about people with gastrointestinal conditions? And, most importantly, did I have enough?
Choice became irrelevant – doesn’t matter if it was extra-long or aloe-infused, as long as it did the job. It then led to discussing alternatives, frankly an intolerable prospect. Facial tissues and kitchen paper towel sold out too, although in the end thankfully it didn’t come down to that. Some were caught hoarding, and really they were the losers in the end. No-one wants to be caught out with a garage full of toilet paper.
So, the lockdowns kept coming, and each time there was a run on toilet paper – but the supply chains got smarter. The factories were ready with capacity and kept stock in supply. There would be short-term outages, but not enough that many people got caught short.
Toilet paper can teach us lots of lessons. We in rheumatology – and our patients and our drugs – are not immune, so to speak.
Tocilizumab has been the pandemic toilet paper of rheumatology. Pre-pandemic, much like hydroxychloroquine, nobody but us really cared about it, except for a few other specialties who had reason to think about it occasionally as a novelty.
Then that balance between intensive care units and the community manifested in a real way. We saw what covid could do, and what tocilizumab could do in intensive care units. Thus, the first signal was raised that this was something we might need. Could we, should we, have known back then that we would eventually need more?
I am not about to shame anyone for not predicting how the pandemic would go, because no-one could. At the end of last year, with some negative studies, tocilizumab looked like it had run its race. Similarly, there were warehouses around the world filled with masks and hand sanitiser that companies simply couldn’t move, that they were bleeding from financially. No-one wants to end up with the garage full of toilet paper.
Yet here we are, scrambling for stock, trying to space patients out. We are starting to have these awkward conversations. While intravenous to subcutaneous is trickier, no-one really cares about pen versus pre-filled syringe now – and kudos to the TGA and the ARA for making that a non-issue.
We’re considering the facial tissues and kitchen paper towel equivalents in rheumatoid arthritis, none of which are quite the same but will do the job (in a pinch). Of course, in giant cell arteritis and systemic JIA only toilet paper will do, and really there is only so long you can use kitchen paper towels (as good as they are in the kitchen) in the toilet.
So, we hope that tocilizumab shortages are fleeting or at least as predicted and promised, and that the supply management behind the scenes is okay. We hope the supply chains are being managed effectively, and that the product shortage warnings legislated by the TGA are just the soft stop warning that will stop us from getting caught short, in a really messy way.
Of course, covid had to require a mechanism of action with just a single competitive commercial agent. Some might think this is a product of too much choice in the market, that it’s not valuable enough by itself, but arguably it is not enough choice which is the issue. We would never have this issue if it was TNF inhibitors in the spotlight (and maybe it will be). If anything, had sarilumab been around to take part of the load then maybe it wouldn’t be an issue.
Drug supply issues in general were a growing issue even pre-pandemic, but covid has just catalysed the issue. There has been plenty of reflection going on about this globally, and it sits in the ever moving sands at the intersection between regulators, industry, purchasers and clinicians like us. It is no one party’s fault, even though more could definitely be done. There are not easy solutions.
The danger, of course, is that the patients are in the middle, and they are the ones who will get caught short.
