- The massive influx of patients with Covid-19 in intensive care units mobilizes a lot of resources to ensure the best possible management.
- Many drugs are necessary for this global therapeutic management, but doctors fear a shortage of certain essential molecules, and organize themselves to avoid running out.
- A risk that revives the debate around the French reindustrialisation of the pharmaceutical sector, now dependent on Asia.
"Hospitals will soon run out of essential drugs to treat Covid-19 patients hospitalized in intensive care units." On Tuesday, in a letter to their respective governments, nine of the largest hospitals in Europe are calling for emergency measures to avoid a shortage of essential drugs, such as curares, corticosteroids or antibiotics. "Without European collaboration to guarantee a continuous supply of medicines, [these hospitals] may no longer be able to provide adequate intensive care within one to two weeks", fear these carers, members of the European Alliance of Hospitals academics.
"There is potentially a shortage of resuscitation drugs to come," also said Prof Bruno Riou, AP-HP crisis medical director. And for good reason, "the demand for certain drugs explodes by 2,000% in the world, which creates movements of tension," confirmed on Tuesday the Minister of Health, Olivier Véran, during questions to the government in the Assembly. What are these drugs for? How can caregivers deal with this risk of shortage? And how can this risk be avoided?
The explosion in demand for drugs used in resuscitation
In contact with the Medicines Agency (ANSM) and "certain laboratories live", François Crémieux, deputy director general of the AP-HP, indicated that "on the curares, it would seem that the production capacities could be reassuring nature ”. But the needs are exploding. “France's initial capacities were 5,000 resuscitation beds. They have been increased (…) to 10,000. From now on, we want to reach a target of 14,000 to 14,500 resuscitation beds throughout the territory, ”declared Olivier Véran at the end of the week.
While the situation is more and more tense in Ile-de-France, the resuscitation services in the region are pushing the walls. "We have tripled our capacities from 16 to 50 beds," said Professor Elie Azoulay, head of the intensive care unit at Saint-Louis hospital in Paris, at 20 minutes . And this thanks to the flawless mobilization of our healthcare teams, and the reinforcement of medical and nursing colleagues from the health reserve. This allows us to provide holistic care to patients. We talk to them, we reassure them, and we make sure that the families, mad with worry and whose role will be central at the end of hospitalization, are associated and informed every day. ”
Despite this measure, saturation awaits. The number of patients should increase further, but the reserves of hospital pharmacies are shrinking. "In intensive care, when we take care of a patient with an acute respiratory distress syndrome, we place him under mechanical ventilation, on the stomach, and under sedation, to optimize his oxygenation," describes Professor Azoulay. To provide this basic care, we administer a combination of curares, anesthetics and analgesics to allow muscle relaxation and sedation, and make artificial respiration comfortable and painless. But also corticosteroids - different from non-steroidal anti-inflammatory drugs, which one should especially not take in the case of Covid-19 - to fight against the inflammatory response of the organism provoked by the coronavirus on vascular structures and organs , and which partly explains the brutal worsening of the state of certain patients, explains the intensive care doctor. However, all these drugs are so used that we fear to run out in the coming days. ”
Optimize stocks
Curares, hypnotics, corticoids, antibiotics: "the products which are in high tension are known", abounded François Crémieux. The thirty-five hospitals in Ile-de-France "have identified the four or five therapeutic classes on which the risks were significant, due to the number of patients who will be treated throughout the month of April". But "the shortage goes far beyond France and is European", with "issues of fair distribution among all hospitals," said Professor Crémieux. "We are in a just-in-time situation, recognized on Monday on France 5, Nathalie Pons-Kerjean, head of the pharmacy service at the Beaujon de Clichy hospital (Hauts-de-Seine). We are working on optimizing our stocks ”. How? 'Or' What ? To avoid rupture, a group of anesthetists and resuscitation doctors from the AP-HP has developed a text, which "explains in detail the good principles of economy" of these "precious products", explained Professor Riou. Several methods make it possible to achieve "effectiveness without exceeding the dose and by adapting": devices measuring "the depth of anesthesia" or "the degree of curarization", drugs to "potentiate" the effect of hypnotics . "We can get a 20% reduction on the consumption of these products (...) without there being any significant consequences for patients," said Prof Bruno Riou.
At Saint-Louis hospital, Professor Azoulay applies this treatment optimization protocol. “We also have recourse to alternative treatments, the use of which is normally not widespread in intensive care, but which have proven themselves, such as ketamine or barbiturates. And we include a number of patients in clinical trial protocols for various drugs, including hydroxychloroquine. Today we are not short of therapeutic solutions, we are supplied for the moment, but the situation worries us ”.
“There is prioritization at regional level, by the ARS, of the distribution of stocks. We are strengthening supplies through increased sourcing in connection with the Medicines Agency, assured the Minister of Health on Tuesday. Wherever necessary, we identify with caregivers alternatives for certain drugs if they run out tomorrow ”.
The question of the reindustrialisation of the pharmaceutical sector in France
If this pandemic poses a heavy tension on the world drug market, the phenomenon of shortages is not new in France. Since the major pharmaceutical groups have outsourced the production of a large number of drugs outside the European Union, mainly to India and China, to reduce production costs, supply disruptions have multiplied. "These countries are today the world's leading suppliers of active ingredients used in the composition of medicines whose selling price is low, but which are among the most used by patients," explained 20 minutes before the start of the epidemic, Professor François Bricaire, former head of the infectious and tropical diseases department at the Pitié-Salpêtrière hospital. "They produce the active ingredients in 80% of drugs passed in the public domain".
But today, between the factories shutdown in China for several weeks, the decision of certain drug producing countries (India and the United States) to no longer export active ingredients, and the global explosion of With the demand for drugs needed to manage the most severe cases of coronavirus, the risk of shortages for these drugs poses an unprecedented threat. "The pandemic is putting our health system to the test (...), many professionals are alarmed by a significant reduction in stocks [of drugs, including curare] in hospitals," said LREM MP Michel Lauzzana on Tuesday. to the Assembly. The parliamentarian thus questioned the government on the tracks envisaged to "relocate the production of drugs and raw materials" in France.
"This crisis questions us about our pharmaceutical industrial strategy" affirms @lauzzanamichel (LaREM). He asked the Gvt about the tracks envisaged for "relocating the production of drugs and raw materials". #QAG #DirectAN pic.twitter.com/wdcQJgYqEA
- National Assembly (@AssembleeNat) March 31, 2020"The current situation poses the major question of the independence of France and Europe in the production of vital and essential materials", recognized the Minister of Health on Tuesday. "We must build the industrial and technological sovereignty of France and Europe, argued for its part Monday, on BFMTV, the Minister of Economy and Finance, Bruno Le Maire. If there is anything good that can come out of this crisis, it is an acceleration of this awareness (…) which must transform itself concretely ”.
On February 24, as the coronavirus epidemic progressed at high speed, Sanofi, a French giant in the pharmaceutical industry, announced its intention to "create a European leader dedicated to the production and marketing of pharmaceutical active ingredients" . A "new entity [which] would help secure the production of active ingredients" and "develop supply capacities for Europe (…) in an industry very dependent on Asia".
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