Is hydroxychloroquine a miracle cure for COVID?

If you pay any attention to the news, you could be forgiven for thinking that there's a big medical controversy about whether the drug hydroxychloroquine is a miracle cure for COVID19 (the disease caused by the virus SARS-CoV2, like AIDS is the disease caused by the virus HIV).

Hydroxychloroquine is a drug that's used mainly to treat a number of different autoimmune conditions, most commonly lupus (but also rheumatoid arthritis, mixed connective tissue disease, among others). It's a derivative of an old malaria drug, chloroquine, which itself is a derivative of quinine, the substance that gives tonic water it's bitter taste. This is why the British invented the gin and tonic, to protect against malaria in India. 

Hydroxychloroquine (trade name plaquenil) is chemically similar to chloroquine and quinine but with fewer side effects. It's thought to be helpful against COVID because it has antiviral action in a test tube and blocks the entry of the virus into our cells. And because it modulates the immune system, it may help to tamp down on the body's "cytokine storm" when infected with COVID, which is a complicated way of saying that the body's immune system goes so crazy fighting the infection that it ends up causing damage beyond what would just be caused by the virus. Hence why a drug used for autoimmune conditions may make sense.

Hydroxychloroquine is generally combined with azithromycin and zinc for treatment of COVID patients. The azithromycin is an antibiotic that also has antiinflammatory (read: immune system modulating and not antiviral) effects. Zinc supplementation has been shown to shorten the duration of a cold by about a day. So this cocktail is hypothesized to help the body get through the COVID infection.

The reason this has been in the news is obvious - Trump purports it to be a miracle drug and has been recommending that people take it. There's some low quality research that's shown a benefit of this drug in COVID patients. Low quality meaning that it could be correct but could also be a false signal. Because there hasn't been a randomized trial (the only real way to prove the benefit of any medical intervention) all we can see are associations. Correlation is not causation.

There are also some anecdotal reports of people getting better with it that the news is running with, although the degree to which this is due to the drug versus due to the natural history of infection or regression to the mean is anyone's guess. The plural of anecdote is not data.

And then there's pushback to the idea that it's of any use from researchers here along with the mixed messages we have been getting from both experts and "experts." Tony Fauci is suggesting that we need to study it more. Dr. Oz is suggesting that it's the best thing he's seen since sea buckthorn oil. And a whole bunch of armchair medical experts, idiots on cable news, and random people on Twitter are suggesting that they're now plaquenil/COVID experts and can't believe the medical establishment won't let us have these life saving meds.

Like most things on cable news, the discussion is much dumber than it should be and misinforms more than it informs. 

I have been taking care of critically ill COVID patients on ventilators and talking with lots of colleagues and friends who are also taking care of these patients. 

We are ALREADY giving these medications to all patients who are super sick with COVID. Truly - almost all patients across the country admitted to the hospital with COVID are being given hydroxychloroquine and azithromycin twice a day. Not an exaggeration to say that almost all of them are already getting it.

It's clearly not a miracle concoction, because if it was, people wouldn't be dying from this disease left and right. The idea that hydroxychloroquine may do anything other than help a bit on the margins is ridiculous. Of course it might be slightly beneficial, but anyone who thinks that there's any possibility it's a wonder drug hasn't taken care of any COVID patients and hasn't talked to anyone taking care of COVID patients. 

I think it's totally reasonable to give plaquenil to COVID patients. Reducing the entry of the virus into cells and tamping down on our own immune response with a drug that's pretty well tolerated makes sense as long as someone isn't developing side effects, and most people do fine with it.

Some hospitals are giving it to their healthcare workers for prophylaxis. This is, again, totally reasonable in my eyes, but again, it's not a miracle drug. Masks, gloves, and hand washing are way more likely to be effective in reducing the spread of the virus. 

So what do you have to lose? The obvious downside is that all medications have side effects and plaquenil is no different. The major issue that it can cause is a cardiac rhythm problem called "Torsades de pointes" which is a life-threatening abnormal heart rhythm related to medications that block a channel in the heart. There's a genetic component of risk, but most of it is idiosyncratic and unpredictable. When plaquenil is combined with azithromycin, the risk is much greater. We would generally be following daily EKGs on patients on these drugs when they're in the hospital, but because of limitations in PPE, we've been resorting to suboptimal monitoring of something called the QTc interval, which is what is related to risk of Torsades.

The other risk that's much more rare is cardiovascular collapse related to plaquenil ("plaquenil induced cardiomyopathy"). I saw one case of this in residency, where a patient basically died over the course of a few hours related to plaquenil use. This is really rare and a low probability event, but it can happen. Although it seems to be related to total quantity of the medication taken over a lifetime, if we suddenly give it to millions of people, we are going to see some cases. There's no free lunch in medicine.

In my eyes, the bigger downside is that focus on hydroxychloroquine distracts attention from other things that could have a bigger impact. There are a lot of potential treatments that can help before a vaccine is developed, and we really need to figure out what works and what doesn't in COVID, not just guess about it and assume we are right. Spending a lot of time and resources arguing about hydroxychloroquine is a distraction.