Should Hydroxychloroquine and Azithromycin Be Considered the Standard of Care for #Coronavirus #COVID19 ?

Artist’s rendition of Coronavirus

In a word: No.

Scientists and physicians are furiously looking for existing drugs that fight coronavirus (COVID-19). The combo of hydroxychloroquine and azithromycin showed promise in a French population.

These are my personal notes after reading the article below. They will bore you, so move along.

These researchers say hydroxychloroquine is generally safer and less toxic than chloroquine, a similar drug that had been used as a COVID-19 treatment in China (IIRC, 500 mg by mouth twice daily).

Contraindications to use of hydyroxychloroquine include G6PD deficiency (more common in Mediterranean populations that in the U.S.) , retinopathy, QT prolongation. Azithromycin and can also prolong QT interval, so  daily EKGs were done on these patients.

In lab studies, azithromycin seems to inhibit Zika and Ebola viruses. And it tends to prevent bacterial infections (pneumonia, sinusitis, pharyngitis?) that sometimes soon follow a virus infection.

Study Population

Twenty adult patients who were hospitalized, six of whom had no symptoms. (So why were they hospitalized? Authors don’t say.) Most of the patients with symptoms had upper respiratory tract symptoms (sore throat, runny nose, sinus congestion, or isolated low-grade fever and myalgias). The others had lower respiratory tract symptoms (symptoms of pneumonia or bronchitis, which will always include cough). The latter all had CT-confirmed pneumonia.

Hydroxychloroquine dose was 200 mg three times daily for 10 days. Twenty-six patients (average age 52) received the drug; six were deleted from analysis because they quit the drug. Of the 20 remaining, six received Z-pak to prevent super-infection (a bacterial infection along with the virus). How they chose who  got azith was not specified. The control patients (16) were others in various other hospitals (or clinics?).

Three of the 36 original enrollees were “lost to follow-up” because they were transferred to the ICU.

Results

Patients receiving the combo of hydroxychloroquine and azithromycin demonstrated greater rates of negative viral testing (via PCR) in nasopharyngeal swabs, in only three to six days in most patients. Note: averaged duration of viral shedding  in China was 20 days.

I saw no mention in the text about other real-world clinical outcomes such as death rates, decreased hospitalization length of stay, number of days before becoming symptom-free, etc.

My Assessment

This was a tiny pilot study that shows promise. Results my not be reproducible. Of course, we need a much larger study. If the drugs are widely available, I’d consider the combo as a treatment, particularly for the elderly or others at high risk of serious illness from COVID-19. This combo certainly CANNOT be considered the standard of care for this illness at this time. I’m surprised the authors are recommending it now, in the absence of any other proven effective anti-viral drugs.

Steve Parker, M.D.

Update on March 23, 2020: Dr David Gorski did a much more extensive and erudite fisking of the article. I highly recommend it to you if you have a medical or scientific background. I think he’d agree with my assessment. After reading his, I’m even less likely to prescribe the combo. He also discusses chloroquine, a relative of hydroxychloroquine.

Reference: Gautret et al (2020). Hydroxychloroquine and azithromycin as treatment for COVID-19: results of an open-label non-randomized trial. International Journal of Antimicrobial Agents – in press March 17, 2020 – DOI 10.1016/jinjantimicag.2020.105949

Steve Parker MD, Advanced Mediterranean Diet

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