Second wave sees crisis over a certain drug

"Please help me to find Actemra 400mg injection (Tocilizumab) for my Covid patient mother. She is currently in ICU. Please help…" read a recent appeal by Sazzad Hossain on a public Facebook group.

He desperately needed the medication, sold under the brand names Actemra and RoActemra, for his critically ill mother but he couldn't source it after visiting all the large drug stores in Dhaka.

"Then I came to know that this drug can be purchased only from certain distribution centres of the importer company. I rushed to the centre only to learn that their stock was already exhausted," Sazzad said.

Appeals like Sazzad's have flooded social media recently as the drug is being used to treat critical Covid-19 patients, whose numbers are surging in the second wave of Covid-19, and so, making the drug one of the most sought-after medicines in the country.

While patients' families are desperately scouring the internet for leads, some are trying to pocket profits from the shortage in supply in the market.

The maximum retail price (MRP) of 400mg, 200mg, 162mg, and 80mg of Tocilizumab are Tk 49,242, Tk 24,621, Tk 16,923, and Tk 9,848 respectively. At distribution centres, patients can obtain this at a slightly lower price than retail.

However, unauthorised sellers have been found to be selling this drug at a price several times higher than the MRP, via social media platforms in particular.

On April 12, the Directorate General of Drug Administration (DGDA) and National Security Intelligence arrested three individuals for selling illegally imported Tocilizumab. They were selling each vial of the injection at a cost of Tk 160,000, according to an official on the raid.

DGDA Deputy Director Dr Md Akib Hossain, who conducted the raid last Monday, said, "Due to escalated demand, we are monitoring to ensure that these drugs are available in the distribution centres. We will continue our raid to ensure that these drugs are sold at MRP."

Sazzad was lucky in the end.

He was connected to a man, whose brother had died of Covid-19, who had an injection left over. Sazzad was able to buy it for his mother for around Tk 40,000.

EFFECTIVENESS IN TREATMENT UNCERTAIN

On March 19 last year, DGDA directed relevant companies to ensure the supply of nine medicines -- including Tocilizumab -- as per the national coronavirus guideline.

Interestingly, however, Tocilizumab was not developed for Covid-19 treatment and its effectiveness in treating coronavirus is yet to be confirmed.

A spokesperson for Roche Bangladesh Limited, manufacturer of Tocilizumab, said the drug was originally developed for the treatment of rheumatoid arthritis (RA), systemic juvenile idiopathic arthritis, polyarticular juvenile idiopathic arthritis, and giant cell arthritis.

It was first used for treating Covid-19 patients in China where, on March 3 last year, it was included in the 7th updated diagnosis and treatment plan for coronavirus issued by the China National Health Commission.

Last year, the Swiss pharma giant Roche had announced that the drug was not by itself an effective treatment for Covid-19 after early anecdotal evidence suggested otherwise. It is now being tested in clinical trials to treat Covid-19 associated pneumonia.

According to the latest version of the National Guideline on Case Management of Covid-19 in Bangladesh, Tocilizumab has been prescribed for Covid-19 patients who show "abnormal chaste imaging consistent with Covid-19", whose "respiratory status" is worsening rapidly over 24-48 hours (requiring more than six litres per minute oxygen) or are on mechanical ventilation.

It has also been prescribed when critical patients are suspected to have cytokine release syndrome.

DMCH medicine and infectious disease specialist Dr Forhad Uddin Hasan Chowdhury said, "Some critical Covid-19 patients show very high immune response against the infection due to which some protein cells of the immune system are produced in massive quantities. This condition is called a cytokine storm and it is fatal.

"Tocilizumab is an immune-suppressant drug and it can be used in some cases where Covid patients are suspected to have cytokine storms. Its dose depends on the age and weight of the person."

However, the drug comes with adverse side effects which are also potentially dangerous for Covid-19 patients.

"Tocilizumab can damage the kidneys and liver and both these vital organs are also damaged by severe Covid-19 infection. It can also reactivate silent tuberculosis.

"So, this drug should not be administered for all severe cases. Many critical patients are recovering without this drug at DMCH," said Dr Forhad.

The Roche spokesperson told The Daily Star that Tocilizumab is approved for treating cytokine release syndrome in many countries.

However, he said, "What researchers are now trying to determine is if there's a similar role in Covid-19 associated pneumonia, and if Actemra/RoActemra would be safe and effective in that situation."

Regarding the supply of Tocilizumab in Bangladesh, the Roche spokesperson said, "During the pandemic, the demand for Actemra has been increasing at a global level for both approved indications such as RA and the non-approved treatment of Covid-19.

"Manufacturing, supply and preservation of biotech products are complex and time consuming and that is why there was a crisis of this product in many countries.

"We have been working urgently to increase manufacturing capacity and supply by ramping up our own production network, as well as actively collaborating with external partners to maximise production of Actemra/RoActemra".