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Ask Dr. Halverson: Hydroxychloroquine: An illustration of doctors' challenge treating COVID-19

web 4 17 Halverson photo
The COVID-19 pandemic is the most challenging infection our world has faced since the Spanish Flu in 1918-1921, which is estimated to have infected around 500 million people around the globe. Nearly 40 million died. We long for treatment and vaccines that will all but guarantee that we can take off our masks, not fear for our lives or the lives of others and get back to a new normal way of living. Hydroxychloroquine continues to be touted by some as a disease-changing treatment. Several of my patients have asked me to prescribe it, so that they have it immediately available if they test positive for the SARS-CoV-2 virus.
WHY HYDROXYCHLOROQUINE?
Hydroxychloroquine was first approved for medical use in the Unites States in 1955. In 2017, it was the 128th most commonly prescribed medication in the United States with more than 5 million prescriptions filled. It is inexpensive and used primarily for the treatment of rheumatological diseases such as rheumatoid arthritis and lupus. It is also used to treat certain types of malaria. Common side effects include nausea, vomiting, diarrhea and headache.  Severe side effects, which are much less common, include heart and vision problems. Most primary care physicians, including myself, currently have patients taking it for rheumatological conditions. 
In 2005, hydroxychloroquine was found to be effective in cell cultures against the SARS coronavirus, which killed around 8,000 people in 2003 before being contained. It is extremely important to note that it was a different coronavirus than SARS-CoV-2. In addition, effectiveness in cell cultures does not guarantee effectiveness in humans. However, because it had some effect against one type of coronavirus, was inexpensive and was easily available, it was tried early in the treatment of our current pandemic in China, Europe and the United States. 
In March of this year, President Trump began promoting the drug to prevent or treat COVID-19, citing several medical reports. The FDA did issue an emergency-use authorization March 28 for physicians to use the drug to treat hospitalized people with severe COVID-19 infections. This authorization was withdrawn on June 15 after multiple random clinical trials (the gold standard for evaluating the effectiveness of a medical treatment) failed to show that hydroxychloroquine was effective. There are still additional trials in progress that will be completed in the near future.

 

WHY DO SOME DOCTORS CONTINUE TO RECOMMEND HYDROXYCHLOROQUINE?
As with any professional group, the nearly 1 million physicians in the United States are a diverse group. A small number of physicians, including six who recently held a press conference in Washington, D.C., arranged by an organization called “Americas Frontline Doctors” (which most physicians had never heard of before) recently touted hydroxychloroquine as a cure and advised that if everyone was put on it, that it would stop COVID-19 in its tracks. “You don’t need masks, there is a cure,” claimed Dr. Stella Immanuel. She and the other five physicians who spoke were not wearing masks. In my opinion, this was irresponsible and dangerous advice and goes against the basic responsibility that a doctor has for his or her patients.
PRIMUM NON NOCERE
When we graduate from medical school, most physicians participate in the Hippocratic Oath Ceremony in which we pledge to uphold a number of ethical standards first stated by Hippocrates more than 2,500 years ago. For myself, and many of my colleagues, the statement, “primum non nocere” (Latin for “first, do no harm”), continues to guide our medical decision making daily. It is one of the principal precepts of bioethics that all students in healthcare are taught in schools around the world.  Another way to state it is that “given an existing problem, it may be better not to do something or even to do nothing, than to risk doing more harm than good.” Telling people to not wear masks is harmful. Telling them to take hydroxychloroquine is potentially harmful due to possible side effects.  
WHAT YOU SHOULD DO
Stay informed by following reliable sources. The ONLY drug trials that are relevant and guide therapy are peer reviewed, randomized clinical trials (RCTs).  Observational trials can suggest a possible treatment may work and should be used to design RCTs. RCTs are used to prove if a treatment works. In addition, social media posts that report that a person or people got immediately better when they take hydroxychloroquine (or budesonide or zinc or the Z-pak or several other currently reported drugs) should be ignored. I am as interested as any of you in finding effective, affordable safe medications to treat and/or prevent COVID-19. I will NOT prescribe or recommend a medication that has the potential to harm and does not have PROVEN benefit such as hydroxychloroquine. The vast majority of physicians will do the same. Ethically, our choice is clear.
Stay positive, stay committed, stay safe and stay well.

 

— Dr. Jim Halverson is a longtime Ojai physician who writes a weekly column on COVID-19 for the Ojai Valley News.