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Lack of essential medication leads doctors to adapt therapies while government acts to replenish stocks and specialists warn of limitations of alternatives
The lack of intravenous cyclophosphamide in Brazil has started to directly impact oncological treatments and severe autoimmune diseases, forcing doctors to reorganize protocols in real time in the face of scarcity. The problem gained traction throughout this year (2026), when hospitals reported increasing difficulties in maintaining therapeutic schemes considered standard, affecting everything from breast cancer to diseases such as lupus and vasculitis. In this scenario, the Ministry of Health initiated emergency purchases to try to replenish stocks, while specialists highlight that, although alternatives exist, they do not always present clinical equivalence.
An old drug, but still central to treatment
Cyclophosphamide is classified as an alkylating agent, widely used for decades in oncology and rheumatology, being essential in various clinical protocols. Its mechanism of action is based on the damage to the DNA of rapidly dividing cells, such as tumor cells and immune system cells in autoimmune diseases. Even being an old medication, it remains a reference in treatments considered standard, especially in breast cancer, pediatric tumors, and hematological diseases. In rheumatology, on the other hand, it is fundamental in severe cases, such as lupus with renal or neurological involvement and systemic vasculitis, making its absence difficult to navigate.
Direct impact on treatments and need for adaptation
In the face of scarcity, doctors have begun to adapt therapeutic schemes based on available options, which requires careful evaluation in each clinical case. In some scenarios, the oral version of cyclophosphamide is used, which is still available in the country, although this alternative does not meet all situations. Furthermore, alternative protocols have begun to be considered, even presenting differences in efficacy, toxicity, and indication. This movement has led medical societies to issue emergency recommendations, guiding professionals on how to reorganize treatments during the period of shortages, especially in more sensitive cases.
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Clinical strategies adopted during scarcity
Among the main strategies adopted, specialists recommend the reversal of treatment order, prioritizing steps that do not depend on cyclophosphamide. It is also possible to use the oral version in known schemes, such as CMF and CAF, which have support in clinical studies. In certain cases, doctors completely substitute the therapeutic scheme with other chemotherapy combinations that do not include the medication. In triple-negative breast cancer, for example, carboplatin emerges as a viable alternative. Nevertheless, these changes require strict criteria, as not all protocols yield equivalent results. In the most critical cases, such as pediatric tumors and bone marrow transplants, the guidance is to prioritize available stocks.
Alternatives in autoimmune diseases require caution
In rheumatology, the scenario is considered even more delicate, as cyclophosphamide plays a central role in inducing remission in severe diseases. In some cases, such as lupus with renal involvement, mycophenolate mofetil may be used as an alternative. In vasculitis, rituximab is indicated as it reduces the activity of immune system cells. Other medications, such as azathioprine, tacrolimus, and cyclosporine, may also be employed, depending on the severity and profile of the patient. However, according to the Brazilian Society of Rheumatology, these substitutions are not universally equivalent, which requires individualized assessment.
Supply shortages reveal fragility in the global chain
According to oncologist Clarissa Baldotto, president of the Brazilian Society of Clinical Oncology (SBOC), the problem is part of a broader scenario of scarcity of old and low-cost medications. These drugs have few manufacturers in the world, making the production chain more vulnerable to disruptions. The pharmaceutical company Baxter, responsible for the medication in Brazil, reported that there was a technical interruption at a partner factory, which affected global production. Although manufacturing has resumed, it is still operating at reduced capacity, which limits supply.
Systemic risk and impact on access to treatments
For oncologist Stephen Stefani of the Americas Health Foundation, the absence of cyclophosphamide goes beyond a specific problem, as it reveals a structural vulnerability in the healthcare system. According to him, these drugs represent the foundation of many treatments, and their lack alters the entire therapeutic logic, potentially impacting efficacy, toxicity, and costs. Furthermore, available alternatives tend to be more expensive or less studied, which can widen inequalities, especially in the public healthcare system.
Government tries to normalize supply with emergency measures
In light of the situation, the Ministry of Health announced, in 2026, the emergency purchase of 140,000 tablets and 80,000 vials of cyclophosphamide, with distribution planned for reference centers. At the same time, the ministry requested Anvisa to prioritize processes to increase supply, including exceptional importation and expedited release of batches. The official expectation is for a gradual normalization of supply starting in June 2026, after the partial resumption of production by the manufacturer.
The scarcity of an essential medication highlights weaknesses in the system and raises a question: how to ensure continuity and safety in treatments in the face of failures in the global drug supply chain?
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