Docs should resist hydroxychloroquine temptation, say experts


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Doctors shouldn’t prescribe hydroxychloroquine for family and friends to treat COVID-19, write a group of authors including prominent pharmacists

In Australian Prescriber the authors, who include Associate Professor Ian Coombes, from the Royal Brisbane and Women’s Hospital Brisbane Department of Pharmacy and the University of Queensland’s School of Pharmacy, and Professor Jason A Roberts, from the Departments of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women’s Hospital Brisbane and the University of Queensland’s Faculty of Medicine and School of Pharmacy, write that prescribing medicines with putative benefit for COVID-19 disease “appears very attractive to consumers, clinicians and some senior politicians”.

“However, there are no medicines with any robust evidence of clinical benefit, including the antimalarial hydroxychloroquine, the antibiotic azithromycin and the antiretroviral combination of lopinavir with ritonavir,” they write in Australian Prescriber.

They write that “due to inappropriate prescribing and dispensing, hydroxychloroquine is now in short supply in Australia and globally”.

Controversy has surrounded Hydroxychloroquine after Australian clinicians began to overprescribe the drug on a “just in case” basis.

A small French study had produced preliminary results which showed that hydroxychloroquine and azithromycin combined could reduce viral load in infected people, but critics of the study said it did not allow solid conclusions to be drawn on the clinical benefits as yet.

However US President Donald Trump announced that hydroxychloroquine would be fast-tracked by the Food and Drug Administration as a treatment for the disease, prompting PSA to call for restrictions on “just in case” prescribing in this country.

PSA president Dr Chris Freeman wrote to prescribers in March asking them not to prescribe the drug unless it was genuinely needed.

The Department of Health introduced these restrictions in late March, noting that reported off-label prescribing of these medicines risked a potential shortage in Australia.

The authors of the new piece in Australian Prescriber note that hydroxychloroquine is not approved to treat or prevent COVID-19.

“Although there are major clinical trials now underway, there is currently little evidence that hydroxychloroquine is safe or effective for COVID-19,” says Assoc Prof Coombes.

“Using this medicine incorrectly and at the wrong dose could lead to serious side effects like seizures and heart problems.

“As an additional concern, the current hype around hydroxychloroquine and subsequent hoarding has led to shortages of the medicine. For some people with autoimmune diseases like lupus, there is no effective alternative to hydroxychloroquine, and stopping treatment can lead to serious harm and even death.”

The authors write that it is “encouraging” that pharmacy and medical professional organisations are sending out messages about the limited evidence about hydroxychloroquine efficacy and safety in COVID-19, as well as the problems thrown up by shortages.

“There may be a temptation to self-prescribe hydroxychloroquine or prescribe it for family and friends,” they write.

“Each state and territory has specific legislation that regulates this type of prescribing.

“The Good Medical Practice guide from the Medical Board of Australia cautions against prescribing for self, family, friends or coworkers. The Guide recommends ‘seeking independent, objective advice when you need medical care, and being aware of the risks of self-diagnosis and self-treatment’.

“In other words, all health professionals should have their own doctor. The guide also advises doctors against providing medical care to anyone with whom they have a close personal relationship because of the lack of objectivity, possible discontinuity of care and the risks to the doctor and patient.

“Some may argue that in a pandemic, prescribing outside of the guidelines is justified.

“However, from a medico-ethical and possibly legal perspective, the answer should be ‘no’ when considering a request to prescribe for a family member or close friend.”

Read the full opinion piece here.

Another editorial, in the Australian Journal of General Practice and by J Simon Bell, John A Bell and Darren J Creek, looked at the evidence and concluded that “there is currently no robust evidence to support prescribing hydroxychloroquine as a treatment or prophylaxis for COVID-19”.

“Doing so risks unnecessarily exposing people to side effects and depriving people with approved indications from accessing their medication,” these authors wrote.

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2 Comments

  1. George Markessinis
    23/04/2020

    There are a few factors about the COVID-19 situation that combine to create a ‘perfect storm’ for poorly supported claims to take hold and go ‘viral’ themselves:
    – the desperate need to find treatments
    – no current well-established drug treatments to compare with
    – a high rate of recovery with no intervention (other than symptomatic treatment and supportive care) making it easier to attribute recovery claims to various ‘cures’
    – heavy promotion through conventional and social media
    – endorsement from high profile public figures (notably not medical experts).

    I find that Science-Based Medicine (sciencebasedmedicine.org) is also a helpful site that thoroughly breaks-down and critically appraises studies and claims for their evidence and scientific validity. Their authors, many of whom are experienced medical professionals, certainly aren’t shy about calling things out if they don’t stand up to the rigors of scientific methodology.

    The handful of publications supporting hydroxychloroquine and azithromycin, often performed by the same authors, do not appear to stand up to scientific scrutiny when appraised in detail. Science-Based Medicine’s commentary can be viewed here:

    23 March 2020
    https://sciencebasedmedicine.org/are-hydroxychloroquine-and-azithromycin-an-effective-treatment-for-covid-19/

    30 March 2020
    https://sciencebasedmedicine.org/hydroxychloroquine-and-azithromycin-versus-covid-19/

    13 April 2020
    https://sciencebasedmedicine.org/miracle-cure-testimonials-aside-azithromycin-and-hydroxychloroquine-probably-do-not-work-against-covid-19/

  2. pagophilus
    23/04/2020

    G6PD deficiency anyone? Are patients going to be tested for this before being prescribed hydroxychloroquine?

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