Ask the Pharmacist

Q) If I happen to get diagnosed with COVID-19, should I ask my doctor for that malarial pill President Trump has been touting?

A) Starting all the way back to March 19th and repeatedly since then, President Trump has endorsed the drug hydroxychloroquine as a “game-changer” during his regular coronavirus briefings and suggested that skeptics will eventually be proven wrong. He may yet turn out to be right, but at this moment, unfortunately, that is looking less and less likely.

Hydroxychloroquine is a drug that has been used for many decades as a relatively safe treatment for a number of autoimmune disorders such as lupus and rheumatoid arthritis. For millions of patients worldwide, this drug has proven to indeed be a “game-changer” by limiting the irreversible destructive effects these chronic conditions can cause.

Hydroxychloroquine is closely related to an anti-malarial drug called chloroquine which is used commonly today by many of us who wish to travel to endemic regions of the world such as Africa or south-east Asia. The president’s optimism seems to be based upon a paper that was written in France detailing 26 patients with confirmed COVID-19 who were given hydroxychloroquine along with a commonly prescribed antibiotic (azithromycin/ Zithromax).

This paper was published in a legitimate medical journal (as a side note, there are significantly more medical journals that are not respected by the scientific community than there are credible ones so when reading medical news in the press, it is important to know the original source of the material) and seemed to indicate the 26 patients treated did reasonably well in their recovery.

The journal has since retracted this study as, apparently, the author did not fully report the results (6 patients who didn’t get better were not included) which, when coupled with the paltry number of patients included and the lack of a “control” group (essentially similar patients who are cared for differently, perhaps by being given a placebo/ sugar pill), rendered this study pretty much useless. This does not mean the drug combination does not work, just that the evidence for its effectiveness is sorely lacking.

Since then, another study conducted on American veterans has just been released. It was based on 368 male patients who were already hospitalized with confirmed COVID-19 when they were separated into three treatment groups. One group were prescribed the two drugs in combination, another hydroxychloroquine alone and the third was treated only with the usual measures of care available at a hospital. The results were disappointing. There seemed to be an increased risk of death in those patients treated with hydroxychloroquine alone. As well, the combination therapy did not seem to lower the risk of a patient deteriorating to a point that they required mechanical ventilations.

To add to this doubt, there has also been another study out of China based on 75 patients that showed no benefit when patients were treated with hydroxychloroquine alone as opposed to normal care.  Once again, these are two small studies that do not prove conclusively that the drug(s) do not work for COVID-19, but they do not inspire a lot of hope.

This then begs the question, what if you are really sick with the infection rather than just mildly ill as most that become infected are. Is it worth taking the drugs then? President Trump seemed to think so by repeatedly emphasizing that the drugs have been used safely for years in many, many people.

I would in principle agree with this when it comes to treating people diagnosed with an autoimmune disorder. One of the reasons hydroxychloroquine is considered a first line treatment is its relative degree of safety compared to some of the other alternatives.

However, this does not mean the drug does not have the potential for side effects, some of them very serious. These can include severely low blood pressure, muscle or nerve damage and heart rhythm problems. It is the rhythm issue that is particularly worrisome. This is especially so when hydroxychloroquine is used in combination because azithromycin has also rarely been linked to this exact same side effect. Both drugs can prolong what is known as the heart’s QT interval which is the time it takes for the heart to “charge” between beats. When that time is too long, it can trigger an arrhythmia which can lead to sudden death or permanent damage to the heart.

Theoretically, when two drugs can cause the same side effect, the odds of incurring that adverse event could possibly increase. A report just published by a New York hospital seems to indicate that this risk is more than just hypothetical. The data indicates that the majority of the 84 patients they treated with hydroxychloroquine and azithromycin developed heart rhythm abnormalities. Nine of the 84 patients had severe prolongation of this interval. The authors are unsure why the number of people with COVID-19 suffering from this adverse effect is so high but it may have something to with their general level of health when they were prescribed the drugs (remember they were already hospitalized).

Collectively, these findings highlight the importance of awaiting the results of studies before there is widespread adoption of any new treatment. The good news in all of this is that, while experts aren’t ready to completely write off this particular combination, there are many other drugs that are promising with respect to helping us fight the coronavirus. One researcher mentioned that she had identified 80 agents that might help in some way to either prevent infection, fight off the infection or perhaps serve as a last ditch rescue attempt if you aren’t doing well on a ventilator.

It’s always hard to wait for science to provide proof of effectiveness and safety when you’re scared and perhaps even desperate for help. However, there are many well founded reasons why we force most patients to wait. Sometimes the cure can indeed be worse than the disease. For more information about this or any other health related questions, contact your pharmacist.