What's the harm with trying a drug like hydroxychloroquine? For example:
There has been a lot of “what’s the harm” logic for #COVID19 therapeutics going around like @ChrisCarrollMD pointed out.
— Viren Kaul, MD (@virenkaul) April 7, 2020
Let’s talk specifics, here’s the harm that comes from various Rx being evaluated currently. This is why the evidence of benefit is critical 👇🏽👇🏽
Hydroxychloroquine:
— Viren Kaul, MD (@virenkaul) April 7, 2020
🚨Cardiomyopathy and ventricular arrhythmias: ❤️ damage
🚨 Bone marrow suppression: Compromised immunity and bleeding risk
🚨 Hypoglycemia: Low blood glucose
Here’s @US_FDA’s fact sheet: https://t.co/dI40HwZbh4#COVID19
Lopinavir/ritonavir:
— Viren Kaul, MD (@virenkaul) April 7, 2020
🚨QTc prolongation & heart blocks: affects electricity in ❤️
🚨Risk of MI: ie heart attacks esp with previous structural heart diseases
🚨Hepatotoxicity: Liver injury. Critically ill pts can develop liver injury by other mechanisms, so added damage #COVID19
Tocilizumab:
— Viren Kaul, MD (@virenkaul) April 7, 2020
🚨Increased liver enzymes in 20-30%
🚨Liver injury resulting in transplant or death has been reported
🚨Low neutrophil and platelet counts
🚨 Anaphylaxis: Could be life threatening in sick patients
🚨 High TG level’s: makes using propofol (sedative) hard #COVID19
IVIG:
— Viren Kaul, MD (@virenkaul) April 7, 2020
🚨Low BP in 15%
🚨Anaphylactic reactions
🚨Pulmonary edema: fluid in lungs
🚨Aseptic meningitis
🚨Hemolysis: breakdown of 🩸 cells
🚨Kidney failure
🚨Thromboembolism: Increased clotting , which is already an issue with #COVID19
My goal is not to create a scare but provide education on why just using therapies isn’t as simple. The risks need to be weighed against the benefit.
— Viren Kaul, MD (@virenkaul) April 7, 2020
Problem is we don’t have good data to suggest benefit. And we do know the risks.
To deal with this pandemic ...
Last I checked one cannot walk into the local pharmacy and buy a bottle of Flinstones chewable hydroxychloroquine off the shelf. It can only be obtained (legally) by prescription under a doctors care.
ReplyDeleteThere is possible harm in nearly every med available.
"Last I checked one cannot walk into the local pharmacy and buy a bottle of Flinstones chewable hydroxychloroquine off the shelf. It can only be obtained (legally) by prescription under a doctors care."
Delete1. This post isn't about the access or availability (or lack thereof) of hydroxychloroquine to the general public.
2. In fact, this post isn't limited to hydroxychloroquine at all. Also mentioned are lopinavir/ritonavir, tocilizumab, and IVIG.
3. Rather this post is about the toxicities or harms of therapies under clinical trial. That is, there are benefits and harms to consider, but many people only consider the benefits. Minimally they need to consider both and weigh them against one another. This should've been fairly obvious from the tweets.
4. Again, this isn't what my post was about, but since you bring it up for whatever reason, the off-label use of hydroxychloroquine (among other therapies) is a serious concern.
"There is possible harm in nearly every med available."
1. Not all harms are equal. In general, nausea and vomiting are less serious than a heart attack or even retinal (eye) damage.
2. If you're concerned I'm against these therapies, let me allay your concerns: I'm not. On the contrary, I've explicitly stated more than once in previous posts that hydroxychloroquine is promising, and I've posted several posts in support of and even advocating IVIG. Not to mention I've positively mentioned other therapies (e.g. remdesivir).
Like so many aspects of this situation, this is confusing to me as a non expert. Obviously I understand that one has to consider the cost / benefit of any drug, but isn't this particular drug fairly routinely prescribed for other conditions? I know a Christian woman in the mental health field who tells me she took the drug fairly regularly when she worked in Africa as a Malaria preventative and there wasn't any major concern over negative side effects except over the extremely long term. I know Lupus has also been mentioned, which I assume (perhaps wrongly) would have to be taken on a regular basis since Lupus is chronic. Is there a reason some doctors believe there's more reason to be concerned about adverse effects in Covid 19 patients? Is it just the lack of clarity on the exact nature of the positive benefits? Is it an abundance of caution given the lack of knowledge on the disease? Again as a non expert I feel like it's been the joke for years with many drugs that are prescribed regularly that there will be a scrawl at the end of the advertisement listing a whole range of terrible sounding side effects worse than the disease. And I guess I thought one of the points of testing drugs already in use was that their risks were well understood. Not a criticism, just something I haven't been able to make sense of for myself.
ReplyDeleteThanks, WittenbergsDoor. That's a good question.
Delete1. I assume you mean hydroxychloroquine? If so, yeah, you're absolutely right, it has been used for other conditions. The FDA has approved its use in treating or preventing certain types of malaria, lupus, and rheumatoid arthritis. So it's safe to use in these conditions.
2. That said, few drugs are ever 100% safe, depending on the person, the person's state of health, their disease, etc. The same drug that might be safe in one person could do damage to another person. Hence why physicians carefully monitor some drugs in some people despite these drugs being generally safe. For example, if someone has lupus, doctors may need to have them regularly visit in order to monitor them for eye damage because the drug can cause eye (retinal) damage in a minority of people.
3. However, to more directly answer your question, a drug might be safe to use in one condition or disease (e.g. malaria, lupus), but unsafe to use in another condition or disease (e.g. Covid-19). It's sort of like saying a drug might be generally safe to use when it comes to high blood pressure, but that doesn't necessarily mean it'll be safe to use when it comes to a heart attack. And Covid-19 is a novel virus that we don't really know what will happen.
4. Oh yeah, I agree it's a bit of a joke when a scrawl at the end of a drug ad lists like every single possible side effect of the drug. I guess drug companies do that because they don't want to get sued. It might be better to simply list the most common or likely side effects and/or the most potentially serious or life-threatening side effects. As far as what's listed in the tweets by Viren Kaul, these are indeed more common and/or serious side effects. As you might be able to guess from words like "cardiomyopathy and "ventricular arrhythmias", hydroxychloroquine can cause fatal heart attacks in some people.
Not sure if that answers the question? Please feel free to ask more if not.
Hawk, what is your real name? You can tell me now or I will find out one other way.
DeleteAlan E. Kurschner
Delete"Hawk, what is your real name? You can tell me now or I will find out one other way."
1. Are you a stalker? Seriously, why can't you just leave me alone?
2. It wasn't solely my decision to remove you from Triablogue. So I don't know why you're singling me out. And Triablogue administrators already tolerated you for a long time (since at least here) before they recently booted you.
3. You already have your own website where you can talk about whatever you want.
4. If you absolutely keep insisting, then you already know how to contact Triablogue members in private: triabloggers@gmail.com.
His real name is classified. I have it on good authority that "Hawk" is the Archangel Michael, so I'd tread carefully.
DeleteIt's common for anti-vaccination proponents to claim they aren't really "anti-vaccination". For example, Jenny McCarthy claims: "We're not an anti-vaccine movement. We’re pro-safe-vaccine schedule" (source).
DeleteLikewise the pediatrician Paul Thomas claims about his book: "This is not an anti-vaccine book. It's not a pro-vaccine book. It's a pro-kids, pro-healthy children book" (source). However consider this review of Thomas' book as well as what has happened to Thomas' patients (e.g. here).
For further information, see what Tara C. Smith, a professor of epidemiology at Kent State, has said here.
For what it's worth (which is next to nothing!), I feel like a lot of the confusion and anxiety swirling around the coronavirus/COVID-19 situation can be attributed to a lack of critical thinking skills at all levels from the top experts down to the nobodies like me.
ReplyDeleteIt seems to me that many folks want "The Answer", but in real life this creature is rarely if ever found to exist. Consider:
*Epidemiologists routinely disagree
*MD's routinely disagree
*Virologists routinely disagree
*Hospital administration and med staff routinely disagree
And that's only a tiny, tiny sampling. Examples could be multiplied. It's trivially easy to expand the list to practically every profession imaginable.
My point is that it's pointless for folks to be seeking "The Answer" related to the current pandemic because it's nearly infinitely complex and has touched practically every aspect of life not only in our country, but the world.
Thus the answers will be complex and multifacted, but because we live in a 30-second soundbyte, 140 character limit world people often lack the patience and skill to *think deeply* about anything. And if we're being honest people are typically intellectually lazy, which I think is an artifact of the Fall. Scripture suggests as much when God commands His people to love Him with all their *mind*, among other faculties. The fallen mind is utterly depraved and *cannot* think rightly about anything, so as Christians we ought not be surprised by seeing the world in a constant state of confusion, deception, and anxiety. It's just been brought to the fore by coronavirus/COVID-19.
It disturbs the world's facade of "peace", "security", and "control". All of which are false. The world can offer these things (falsely), but it can't deliver because it doesn't possess them. Only God possesses these things in reality, and they are His alone to dispense as He wills according to His pleasure, and He's pleased to give them to His people who are united with Him by grace alone, through faith alone, in Christ alone, to the glory of God alone.
The world can't comprehend this, obviously, so we observe as the mire is stirred up by the endless raging of the sea of fallen humanity. It's a sad spectacle, but what else should we expect?
They're looking in all the wrong places for "The Answer", because they're asking the wrong questions. I'm not suggesting the Bible contains an encrypted cure for COVID-19, but it certainly contains the cure for mankind's most serious condition, which is sin and the enmity with God that accompanies it.
Well said, CD! Very good points. Thanks for the comment :)
DeleteThanks Hawk, I'd be interested in hearing your take on this approach for patients presenting at the ER with COVID-19 symptoms.
DeleteI felt like this article was in line with your OP about risks, and balancing those risks, when treating disease. For example the counterintuitive approach suggested in the linked article may cause other secondary problems (infections by opportunistic microbes, etc.) even though it may prove effective in preventing the need for intubation.
Anyway, curious what you think.
Hey thanks for that article, CD! In fact, I actually agree with what he's saying. He's talking about a cytokine storm which I've also mentioned in the past albeit among the obese rather than in general and more as a hypothesis to be tested than some more concrete. I mentioned it at the tail end of this post. And I've read other physicians who think the same (e.g. there are some links in my previous post). I don't know if it's a majority, let alone if there's any consensus, but I do think it's a reasonable and respectable position. Of course, like everything else in this pandemic, we need more data, but again it's definitely reasonable, I think.
DeleteHawk--
ReplyDeleteCould I get your take on this article?
http://web.archive.org/web/20200405061401/https://medium.com/@agaiziunas/covid-19-had-us-all-fooled-but-now-we-might-have-finally-found-its-secret-91182386efcb
Oof! Where to start. There are so many problems to go through. It'd take a lengthy post. Perhaps this is the main reason the article is no longer available on Medium but has to be found on the Internet Archive.
DeleteI think the core of his argument is that the coronavirus isn't targeting our lung cells but our red blood cells. Everything else he says is built on top of this claim. However, it's simply false our lung cells aren't targeted by the coronavirus (i.e. SARS-CoV-2/COVID-19). In fact, the coronavirus binds to what are known as ACE2 receptors which are expressed on lung cells called type 2 pneumocytes (as well as on other cells). This is true in our coronavirus SARS-2 and it was also true in SARS-1 back in 2003. That's one of the main features that alterted physicians and scientists to the fact that it's a similar virus.
The article didn't cite any scientific evidence, but the "best" scientific evidence I could find for his claim is this paper. However to my knowledge this paper hasn't even been published but is a pre-print at best. More to the point, this paper is based on a computational model, not on empirical or clinical evidence. Not that modeling is necessarily mistaken, but in this case we do need to see some concrete evidence as well. And there are plenty of people infected with the coronavirus so it should be relatively easy enough to see if the coronavirus is targeting their erythrocytes by binding onto their hemoglobin.
At best, maybe (a big maybe) this claim is suggestive and needs more research. However, if so (again a big if), the article needs to make far more modest claims.
On the bright side, I think I would likely agree with his politics (e.g. don't trust China). :)
I wanted to add:
Delete1. Just to clarify, the reason I point out the paper I mentioned above is pre-print is because pre-print papers typically haven't been peer reviewed. That's not to suggest peer review is flawless (far from it), but this particular paper could certainly benefit from a medical expect with a more critical eye evaluating it.
2. The paper argues that the coronavirus or more specifically certain parts of the coronavirus "attack the heme on the 1-beta chain of hemoglobin to dissociate the iron to form the porphyrin. The attack will cause less and less hemoglobin that can carry oxygen and carbon dioxide". However, if this were true, then the oxygen that's dissolved in the blood (plasma) aka the partial pressure of oxygen (PaO2) would be normal, while the oxygen carried by the red blood cells (measured by oxygen saturation as a percentage, e.g., 97%) would be low. Instead, what's seen in coronavirus patients is both PaO2 and saturation are low.
3. The paper argues "lung cells have extremely intense poisoning and inflammatory due to the inability to exchange carbon dioxide and oxygen frequently, which eventually results in ground-glass-like lung images". However, the fact is it's the inflammatory reaction to the coronavirus that's causing the "ground-glass" opacities in radiological lung images, not the "inability to exchange carbon dioxide and oxygen frequently".
Thanks, Hawk!
DeleteI don't have a medical background, but this didn't sound crazy. I really appreciate your clearing things up for me.
It's at once oddly interesting and immensely pleasing to me that one of the best resources on the 'net for both Christian philosophy and COVID-19/coronavirus analysis and opinion is also one of my favorite blogs which I've been reading for probably the better part of a decade now, T-blog. Well done guys, well done. You're performing a wonderful service and ministry to many here. Please keep up the good work!
ReplyDeleteThanks, CD! :) Super kind of you to say. I'll have to pass this along to the other Triablogue guys!
DeleteAlthough I should say I'm trying to step away from posting stuff due to other priorities in life. At least trying to post less frequently. :)