COVID-19 update: Thursday, July 30th

Hydroxychloroquine……(that is a doozey to spell – and this is super long so bring a snack and an extra cup of joe. Or, if you have no interest in this drug or it's headlines then just skip on over this today).

Let’s talk about hydroxychloroquine. First, I will say that there are some things we don’t know – but for what we do know, we have to trust the science, otherwise we are just guessing. And yes, sometimes we have to guess, like when this started, doctors had to guess, and do their best and just try things that seemed like they might work. And the fatality rate was around 6%. Now we aren’t guessing as much. Physicians have a venue through which they are sharing information and data regarding what works – and they are using that. We have conducted research and our fatality rate is down – lower than the global average. Our process is working.

The reason we want to research things is that we can’t all tolerate the same meds at the same doses. Race makes a difference, age matters, sex, weight, other meds you are taking, presence of other diseases, allergies, all sorts of things contribute. Consider your go to headache treatment. Mine is Tylenol. But we have lots of options because Tylenol doesn’t work for everyone. So by doing research we can figure out if the medicine/treatment we are recommending actually works and if it is safe for everyone and how long the list of possible side effects is going to be. We also need to know how much you need, how long you need to take it, and is it safe to take that much for that long. There are lots of things we need to know. With that said, let’s look at some of what we know about hydroxychloroquine.

1. Hydroxychloroquine has been used against malaria and other diseases for decades. It is an immunosuppressive and is also used with Lupus and arthritis. I am not a pharmacist or a physician so my knowledge of the mechanism of action for the drug is quite limited. If you are interested in that I know a pharmacist or two we can defer to. The first evidence that hydroxy (the nick name it got from it's friends which is delightfully shorter and easier to type) might be useful against SARS-CoV2 (the virus that causes COVID) was from test tube data in a lab.

2. Hundreds of clinical trials have been undertaken all around the world. It is being tested in low doses, high doses, as a stand-alone drug, or combined with azithromycin and others. It is and has been tested in mild cases and severe cases, in healthcare workers, pregnant women and those with HIV. In fact, as of June 1st there were over 203 clinical trials being conducted on hydroxychloroquine going on in the United States alone. 60 of these are dedicated entirely to using it as a preventative. It is not being ignored.

3. Physicians who claim the drug is a cure for the disease and claim to have used it to cure people have not produced the clinical documentation/evidence to support this. Some of these statements are being taken out of context. In mild cases, it is particularly important that we have evidence because mild cases will resolve without intervention – meaning they are going to get better without us doing anything at all. So how do we know it is from the med? And are the side effects going to be worse than the treatment?

4. On July 1st the FDA updated their website with additional warnings about the use of hydroxychloroquine and chloroquine (it’s sister drug) in hospitalized patients. Risks include: serious heart rhythm problems, blood and lymph system disorders, kidney injuries and liver problems and failure. These won’t happen to everyone of course, but they are significant risks and can’t be ignored.

5. Two early studies published in the Lancet were latter retracted because the PI (primary investigator or lead researcher) faked the data. While this wasn’t caught immediately, it was caught, and the study was pulled. Things like this can cause tremendous damage as we learned with the Andrew Wakefield autism study.

6. In small animal studies we have found that when the drug was given shortly after exposure it did have some benefits. The issue in humans is determining exposure. Most people don’t realize they have had exposure until symptoms develop or they are notified by contact tracers. (typically, 3 days post exposure, which is too late)

7. On June 5th, the UK announced results of a trial of 1542 hospitalized patients, it was the largest such trial to date. They compared patients who received hydroxychloroquine as treatment and died to those who didn’t receive it and died. Obviously, this was a mortality study to see if it could prevent death in hospitalized patients. The answer was no.

8. Another study was published last week looking at it as a prophylaxis (PEP) (meaning as a means of prevention). 821 people who had known exposure to COVID without protection (i.e. no mask) were sent the med to see if taking it prevented illness. The answer was no. Published in the New England Journal of Medicine.

9. A study conducted in Barcelona, Spain also looked at PEP. This study included 2300 people who had been exposed to COVID. Some were given hydroxychloroquine and others received standard care. No difference.

10. A meta-analysis (a study reviewing all the other studies) looked at 24 published studies, conducted in a variety of countries, on hydroxychloroquine as an effective treatment or PEP and found no evidence or weak and conflicting evidence that it did anything. These included randomized control trials (the gold standard) as well as cohort studies, and cases series. This study was published in the Annals of Internal Medicine.

11. The WHO has determined they will end their hydroxychloroquine research because we have found no evidence of value as a treatment or PEP.

12. There is one exception. Researchers think if given to people “just in case” it may make a difference. Pre-exposure prophylaxis (PrEP) may work. That is currently being tested in multiple trials, one of the largest is being done by the University of Oxford and is using healthcare workers as their test subjects. It began on April 29th and includes 40k people. Updates and overview are provided on clinicaltrials.gov

FINAL THOUGHTS: A couple of nights ago my teenage daughter was asking me about how vaccines work and I was giving her a quick overview of the different types of vaccines and how they work. Very very high-level stuff because she isn’t really a science person so I honestly didn’t think she was that interested but I am a nerd and couldn’t help myself. Then she asked me, “how would you even go about making a vaccine…like, where do you start?” To which I replied, “well, you start by being interested in science and then studying biology, microbiology, chemistry, virology, immunology…” at which stage she rolled her eyes in perfect teenage form and left the room. I called after her, “I didn’t get through the whole list” to which she groaned. Her response is most people’s, a little bit of interest in these things until you start discussing how much there is to know, learn and discuss. Then interest drops off significantly and we tend to cling very tightly to the little bit we know. In fact, most of us know just enough about something to be dangerous and have it mostly wrong but don’t realize it. Some of us turn to experts which is great. But when they start in-fighting it becomes hard to know what to believe….(although I hope we can all agree that gynecological issues are not caused by demon sperm deposited in women as they sleep). We all have opinions and scientists have them too , and everyone is entitled to their opinion, no matter how outlandish. This is why we then test our opinions to determine what is true. Because opinions are just that. Your, thoughts on the matter. And I honestly really enjoy hearing people’s thoughts on different matters, but It doesn’t make them right. Opinions are not truth. Opinions that are yelled are not closer to truth due to volume. Opinions that are typed in ALL CAPS don’t somehow become closer to truth. Opinions that are held by experts are still just opinions. We must not think to highly of our own opinions. Opinions must be tested because they are not truth. Truth is truth.