Wednesday, April 8, 2020

Hydroxychloroquine: Hope or Hype?

Of all the potential treatments for the novel coronavirus plaguing the world, hydroxychloroquine (brand name: Plaquenil) seems an unlikely candidate.  For starters, it's approved to treat malaria which is a parasitic infection.  COVID-19 is a virus.  It's also used off-label in the chronic management of autoimmune diseases like lupus, Sjogren's Syndrome & rheumatoid arthritis.  To be fair, nobody quite understands how it works for those conditions, so there may be things we don't quite "get" about its ability to treat COVID too.  This was the case for the old cancer drug AZT which made a big comeback during the AIDS crisis, and for Thalidomide, which caused awful birth defects but is now being used (cautiously) in leprosy & multiple myeloma treatment.  

But where do the claims of Plaquenil's effectiveness for COVID even come from?  Reports from China found that chloroquine--the harsher brother of hydroxychloroquine--could inhibit SARS in vitro and showed apparent efficacy in treating COVID-19 in humans.  It's thought to work by decreasing acidity in endosomes, possibly preventing the endosome from releasing the virus into the cytoplasm.  A small non-randomised trial in France also found hydroxychloroquine to be a promising potential treatment.  That's great and all, but many things kill viruses in a petri dish including soap & an uzi.  We still don't know if it's effective in vivo (in the human body).  Plaquenil showed no human benefit against influenza and other viruses in randomized studies previously, so the results are mixed & preliminary at best.

SPECIAL REPORT: Forget Donald Trump's foolish tweets - malaria ...
Tweet from the president's official Twitter account promoting "H".

But the potential adverse effects are all too real:  retinal damage, cardiac arrest & neurological side effects like seizures or confusion.  While less common, these are all possible with chloroquine & hydroxychloroquine.  That's what makes President Trump's ringing endorsement & claims that it "can't hurt to try them" so dangerous.  Patients hospitalized on an emergency basis for COVID are not likely to disclose all other medications & supplements they're taking or inform their doctors of existing health conditions due to the dire state they arrive in, thus the risk of administering an experimental drug in this setting goes up.  One man already died from ingesting chloroquine in the form of fish tank cleaner; his wife was left in serious condition.  As naive & unrelated as that may sound, it illustrates the danger of a powerful figure going on national television & promoting an unproven substance without giving the proper precautions & warnings.  Time will tell if lawsuits against the president will follow these tragedies.  

Another problem with the public jumping the gun & hoarding these drugs is the shortage they're creating for patients who rely on them already to function.  Doctors & even dentists have been caught prescribing Plaquenil & chloroquine for their families since Trump announced he was hopeful about its use as a COVID treatment.  If patients with autoimmune disease--who make up a huge chunk of the chronically ill population--run out of their meds & have a flare-up that requires hospitalization during this pandemic, that will increase the burden on the healthcare profession exponentially & expose them to the virus unnecessarily.  Sjogren's Syndrome alone affects between 400,000 and 3.1 million adults in the U.S, with about half of those also having lupus, RA or another autoimmune disease in addition.  (And Sjogren's is only 1 of over 100 autoimmune diseases that exist).  Plaquenil is the only drug routinely prescribed to treat Sjogren's Syndrome, so running out is not an option for patients.  

All things considered, hydroxychloroquine is more hype than hope for treating COVID-19 at this point.  It's important to have hope but we must temper that with realism & caution.  Our best bet is to maintain the current social distancing & hygiene protocols until adequate testing & PPE are developed along with a vaccine and treatments that work.  Even then, we'll need to ease back into public life gradually & avoid giant gatherings like stadium events (ball games, concerts, etc) for a while.  Shutting down the illicit wildlife markets in China, Indonesia, Taiwan, Mexico & the Philippines should be an immediate priority to prevent future outbreaks of zoonotic diseases.  

As bad as this pandemic is, there could be worse things in our future if these viruses keep hopping the species barrier & adapting to the human body over time.  We didn't get the message with SARS, MERS or bird flu...will we learn from COVID-19?  

Warning!  Do not ingest fish tank cleaner.

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