The South African Health Products Regulatory Authority (SAHPRA)announced last week that doctors will be able to apply for access to the experimental Covid-19 treatment ivermectin in terms of Section 21 of the Medicines Act. Section 21 is a mechanism that allows for access to medicines that SAHPRA has not yet approved.

In allowing Section 21 applications as part of a controlled compassionate access programme, SAHPRA has essentially shifted the responsibility for deciding whether the antiparasitic ivermectin is safe and effective enough to be used in the treatment of Covid-19 on to doctors. This places an enormous responsibility on doctors, since those who do decide to prescribe the drug will be responsible for any potential side-effects.

How it will work

The SAHPRA guidelines for the use of ivermectin, a Schedule 3 drug, require that medical practitioners apply for approval to prescribe for every patient they wish to treat. While SAHPRA aims to respond to applications within 24 hours, it remains to be seen whether it can meet this target, especially if large numbers of applications are received. It also remains to be seen which specific companies will be allowed to supply the drug. 

The guidelines released last week were thin on details, but prescribing doctors will have to provide evidence of the drug’s registration and use in other countries and motivate for it as a treatment for their patients. They will need to provide package inserts and information on risks. They will also need to get patient consent. While these steps are required for any Section 21 or unregistered drug application, such as cannabis or cannabinoids, many medicines used off label usually have more robust efficacy and safety profiles in place to draw on.

The guidelines do not stipulate the dosages of ivermectin to be prescribed, as there is not enough data to support one dose over another. It also does not contain any warnings of what dosages might be considered toxic. This means that doctors will decide the dosage and for how long the treatment is required with no guidance from SAHPRA. While SAHPRA wants doctors to report on side-effects, it also did not provide any guidance on what doctors should be on the lookout for.

Some early-stage studies (mostly not published in reputable journals) have suggested ivermectin is safe at a low dose, but there is also some evidence suggesting that higher doses are required for efficacy. How high is high enough to kill the virus and when does it become toxic to humans? This has not been answered conclusively and doctors who prescribe the drug will to some extent be working in the dark. Presumably, it will come down to a doctor’s clinical experience, particularly with the treatment of infectious diseases.

Ethical doctors who do decide to prescribe ivermectin will probably stick to low doses taken only a few times and will have to monitor patients carefully for any potential side-effects. Such doctors will need to have independently studied the available evidence of the use of ivermectin in Covid-19 and be satisfied that the evidence supports their decision to prescribe it. They will, after all, be going against the advice of most leading regulators and health bodies that advise that ivermectin should not be used to treat Covid-19, except in clinical trials.

It is obviously a decision doctors should take professional responsibility for, but whether doctors can be held liable if anyone suffers ivermectin-related complications is not clear. Although unlikely, given the public interest in ivermectin, in the worst-case scenario a doctor could be called before the Health Professions Council of South Africa. 

On the positive side, the compassionate access programme could help flag safety concerns with ivermectin, if doctors report side-effects as they are required to, and if SAHPRA has the capacity to pull together and analyse all the safety reports – which might end up being very many. 

The programme will, however, not tell us anything about the drug’s efficacy since there is no control group or systematic study being conducted as part of the programme. There is, however, a real risk that confirmation bias will bolster people’s belief in the drug’s efficacy. It is estimated that about 90% of people diagnosed with Covid-19 do well with no intervention; they get better. That’s not even including asymptomatic cases. In other words, many people who will be given ivermectin who get better would have got better anyway. 

Authorities say not enough evidence

SAHPRA has said it cannot definitively say whether ivermectin has a significant risk or benefit for patients with Covid-19, which is why it is only providing preapproval access in terms of Section 21 at the moment. It has said it will look at a longer-term access protocol while awaiting scientific data from ongoing trials. Our understanding is that SAHPRA has received no applications for full registration yet, but reading between the lines it is clear, based on the available evidence, it would not register the drug to treat Covid-19 should it receive such an application.

The World Health Organisation, America’s Food and Drug Administration, the European Medicines Agency, Australia’s Therapeutic Goods Administration and the UK’s Medicines and Healthcare Products Regulatory Agency, after having reviewed the data have all decided not to authorise ivermectin for Covid-19 – either for prevention or treatment – until more data is available.

Assessing available evidence, the National Essential Medicines List Committee of the Department of Health found ivermectin trials, thus far, to be of low quality and recommends that the drug not be used generally for Covid-19. Instead, it recommends the drug be considered in a trial setting only.

Why then, if most leading health authorities advise against it, has SAHPRA said it would allow preapproval access outside of a clinical trial?

In indicating that it will issue Section 21 authorisations for ivermectin, SAHPRA has buckled under, first, the social pressure for access to the drug and, second, the legal responsibility on it to track and prevent the illegal importation and use of the drug – an enforcement function for which SAHPRA seems to lack the capacity. 

Stories abound about the drug being sold in many places, including hardware stores, at astronomical prices, and even then it is uncertain that what a person is purchasing is in fact ivermectin. It seems that by instituting a Section 21 process, SAHPRA will at least ensure that only products from reputable manufacturers are permitted – something that could well reduce the potential harm from products that are not quality assured.

But social and political pressure could also have played a role in the decision. Some doctors have already been suggesting to their patients that they use the drug. Some have advocated on webinars and in opinion pieces for wider access to ivermectin. Many have taken up the battle for access to ivermectin on social media – where proper evidence unfortunately often plays second fiddle to anecdote.

Some doctors are justifiably desperate for new means to treat patients in the face of devastatingly high caseloads. There is virtually no recourse for them, especially without the assurance of enough doses of vaccines for the general population. They have argued that, faced with high Covid-19 caseloads and the highly transmissible variant in South Africa, we cannot wait for the data on large double-blinded, randomised placebo-controlled trials and that in the meantime ivermectin is a risk worth taking.

Other doctors, probably the majority as far as we can tell, feel they want to be guided by the “best science” and will only change their minds on prescribing ivermectin when robust evidence is available. These doctors will most likely not apply for access to ivermectin for their patients.

Either way, the jury is still out.

Will ivermectin prove to be the miracle cure for Covid-19 that some believe it is, or will it go the same way as Vitamin C, Vitamin D, Remdesivir and Hydroxychloroquine? It remains to be seen. 

Whether SAHPRA has struck the right balance in allowing a controlled compassionate access programme while the data on ivermectin is still so uncertain also remains to be seen. DM/MC

Adele Baleta is an independent science writer, media consultant and trainer. 

This article was produced by Spotlight – health journalism in the public interest. Sign up for our newsletter.

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