America’s Frontline Doctors. This viral video has been circulating over the last day or so and I’ve been replying to some on their posts, but I figured since so many are both sharing this post and have been engaging in civil conversation (thank you!), I’d piece together my thoughts here. It’s very long, but as a Registered Nurse and future Physician Assistant, here are my thoughts. I’ve watched the video (and the newest one too!), read the articles, and have been following the research (not the news!) on COVID since it first started. If you want a better understanding on HCQ use as treatment and post-exposure prophylaxis, read on!
Disclaimer: I refuse to politicize this situation. Cancel culture is dangerous. I have spent the last 5 years studying medicine, I have spent the last 7-8 years working in/being exposed to medicine. I am not discrediting these doctors in any way, I know just how hard they have worked to become knowledgeable in their fields and I respect their opinions and experiences. 100%. However, when recommending a treatment and declaring it a cure for COVID, it MUST be backed by credible research, not just personal experience. So, I would encourage you to at least do the research, read this post and the studies I am attaching, before suggesting and advocating for medical treatments without a medical license or education.
My biggest concern with this video is that the studies using HCQ (hydroxychloroquine) + Zinc + Azithromycin in the outpatient setting are still being studied, meaning they are not complete. Therefore, we cannot say, scientifically that this drug combination works or does not work. The other point to consider, is that Dr. Stella Immanuel is a medical director of an urgent care and board-certified pediatrician. Her license is not tied to any hospital privileges, indicating that she is an outpatient provider. This means the patients she is seeing and treating with the HCQ combo are the pts going to their general practitioner or local urgent care. Based off what we do know, most of the COVID deaths are occurring inpatient (in the hospital and ICUs), not outpatient. So naturally, the recovery rate is 100% in those who are not severely ill (outpatient) and without risk factors/complications. There is not sufficient evidence to say that we can safely treat COVID patients in the hospitals and ICUs with HCQ.
Earlier on in this pandemic, HCQ was used experimentally inpatient and was no longer recommended due to older patients developing cardiac arrhythmias and complications and other patients developing something called Stevens Johnson Syndrome (a drug reaction causing the skin to blister up and slough off, causing severe burns) even with short term use. The risk was too high without proven evidence that the drug actually works.
Many have been talking about the safety of HCQ and its use in pts with rheumatoid arthritis or lupus. Even as an antimalarial. Dr. Harvey Risch posted a research article advocating for the use of HCQ in the outpatient setting as a prophylactic measure. The studies he referenced followed the patients for 7-10 days after a course of HCQ + Azithromycin and reported zero cardiac side effects. Based on what I know of the drug, the half-life of HCQ is 40 days, meaning that it takes 40 days for half of the drug to be metabolized. So, imagine being hit with the highest drug dose (800mg) on day 1 and then days 2-10, you are taking 400mg a day. This medication is building up in the body and will take 40 days at minimum to be reduced by half. 4.8 grams of medication will be reduced to 2.4 grams in 40 days. Even that amount is sufficient to cause side effects long after the 7-10 days that these patients were being followed. I don’t know if these patients did or did not develop cardiac symptoms, but until we know and have data to support it, it is not safe or ethical to prescribe this drug for COVID.
Now the other point that is being discussed is the use of HCQ early on in the viral replication cycle to be most effective. The doctors in the video and Dr. Risch agree that by the time the patient is admitted to the hospital, it is too late for HCQ to be effective. The key point here to remember is that the general trend of progression is that a COVID patient does not become symptomatic until 7-14 days after exposure. Meaning, that the virus has had time to replicate enough to create symptoms. The premise of using HCQ to treat is based on a study published in 2005 stating that HCQ inhibits the replication of the SARS virus in vitro. It has also been found more recently that HCQ inhibits the replication of SARS-CoV-2 (COVID) in vitro as well. However, many medications have been shown to inhibit COVID in vitro, but have been ineffective in the human body. Once a pt is symptomatic and presenting to the clinic for care, the virus has replicated significantly, rendering the premise of this study inconclusive.
Fortunately, other randomized controlled trials (the gold standard for research) have been done, which I linked below, and are testing the efficacy of HCQ in an infected human body, not just cells. These, however, have shown that the use of HCQ in mild-moderate cases inpatient have actually extended a patient’s hospital stay and increased their rates of ventilation and intubation. Not saying that the HCQ caused the worsening symptoms, but simply demonstrating that the standard of care that the hospital is using (remdesivir – an antiviral medication) is actually better than using HCQ. They’ve done another study where 719 patients had a strong positive exposure to COVID and half were given HCQ, the other half were given a placebo. The results of those on HCQ were the same as those on placebo. Both either contracted or did not contract COVID at the same rate regardless of whether they were taking HCQ.
Now, I’ve been seeing a lot of misinformation regarding the research being done into HCQ as a viable treatment option. This post is not intended to declare HCQ ineffective, but rather help people understand that the Remdesivir, the current standard of care, has improved mortality rates compared to HCQ in studies that have been completed SO FAR.
However, there are currently 243 registered clinical trials evaluating the use of HCQ and COVID, many are in the outpatient setting. Researchers are hard at work studying the efficacy of HCQ. Many of these studies are actually being pushed out much more quickly due to an expedited process of peer reviewing the articles and data. However, science isn’t something that can be rushed. The recommended period of time to follow a COVID pt is about 28 days. So, following a large enough group of COVID patients for 28 days, in of itself takes a significant portion of time. The work is being done. I just ask you to be patient.
As far as trialing HCQ in an outpatient setting, the issue we run into, is that there is not enough conclusive data pointing to the benefits of HCQ YET compared to the current standard of care for physicians to deem this an appropriate treatment. Taking an oath to “do no harm” means that if the standard of care has been shown to be more effective than a treatment option, or a treatment that is being studied has not been proven yet to be beneficial or harmful, then it should NOT be administered until it is known to be both safe and beneficial. So, all this to say, it could definitely be a viable treatment option in the future; however, we don’t know YET if it’s safe or effective to give to COVID patients. The work is being done, the process is being expedited; however, I would argue that it is dangerous to state, as these doctors did, that a medication or med combo is a cure to COVID and we should no longer wear masks, when there is insufficient data to back that up.
Here’s why: In the 1960s, thalidomide was being prescribed by physicians as a novel treatment for morning sickness. It was deemed a miracle drug. However, they later found out when these children were born, that thalidomide was actually causing amelia (a birth defect where the baby is born missing one or more limbs). My point being, we just need more evidence before we start handing out HCQ.
I find it encouraging that all 350 of Dr. Immanuel’s patients have been prevented from going to the hospital. I hope that she has been compiling data and will submit this data for analysis and further research (larger sample sizes, double blinded randomized controlled trials, etc), since she is so hopeful. Historically, patients have shown significant improvement within 2-3 weeks and can relapse a few weeks after that, leading to ventilation and potentially death. Until we have data regarding her experiences, and when in the viral replication cycle these patients presented, were treated, and how long they were followed after discharge, I cannot comment on the validity of 100% recovery rates.
Please also consider the state of our economy. The insurance model in the United States closely ties access to healthcare/health insurance to employment. With sky high unemployment rates, those who are at the highest risk of developing COVID and dying from it are the least likely to have insurance, meaning that they are not going to the doctor until they are SEVERELY ill, which these doctors agreed, is too late for HCQ. So, under a national insurance model (which I am not necessarily advocating for!), this could be an option if HCQ is found to be effective in preventing the virus or preventing hospitalization from the virus. But here under our current insurance model, those who are dying from this virus, are not the ones who will benefit from this treatment.
Here’s the takeaway. These doctors clearly have experience in their respective fields and have put in the work to become licensed professionals. Some of them have experienced COVID firsthand and based on their experiences, have reason to believe that HCQ + Zinc + Azithromycin may be an effective prophylactic treatment.
HOWEVER, if nothing else, please hear this: Medication treatment decisions CANNOT be based on personal experience. It’s wonderful if HCQ helped your family member with COVID. However, there are studies that have demonstrated that other medications are MORE effective at preventing mortality rates compared to HCQ. We cannot change the standard of care when the evidence does not support a change. To do so would be both unethical and irresponsible.
So be patient, the fact that there are 243 studies ongoing to find a treatment for COVID gives me hope. The fact that there are vaccines in the works, being tested and studied, gives me hope. There is hope, America, now we just ask you to be patient!
Also, please just wear a mask. Even if it all turns out to be a hoax (spoiler alert: it’s not!), then at least you can rest assured knowing that you did not morally sacrifice someone’s life for your convenience or your political affiliation. Love your neighbor as yourself. Period.
Thanks for reading if you made it all the way to the end. You’re a rockstar!
Here are the studies referenced:
https://www.medrxiv.org/content/10.1101/2020.07.15.20151852v1
Additional source: Laurel Bristow, infectious disease clinical researcher
