CMDA's The Point

Our Duty to COVID-19 Patients

December 30, 2020
Photo: Pixabay

by Eric F. Hussar, MD

You see a 68-year-old male with diabetes and hypertension in the office for coughing, body aches and recent loss of taste and smell, whose symptoms started about three days ago. His pulse oximetry is 95 percent, and the lungs are clear. A COVID-19 test is run and comes back positive. He asks what can be done to decrease his risk for going to the hospital or even death. Unfortunately, you tell him, there are no easily accessible outpatient treatments for COVID-19, and you recommend he use over-the-counter treatments to help his symptoms and to let you know if he is getting significantly short of breath. There are times like this when we in the primary care realm can feel helpless or like there’s not much we have to offer for patients. But is this truly the case for COVID-19?

In our current medical environment, we certainly desire to have confidence in the treatments we prescribe, that they are deemed both safe and effective. And when available, having a strong evidenced basis for how we treat our patients is appropriate. Unfortunately, COVID-19 is so new on the scene that we do not have the luxury of having many randomized controlled trials. Even the FDA-approved Remdesivir has marginal benefit for patients who receive it, along with a difficult route of administration and an extremely costly price tag. Meanwhile COVID-19 continues to wreak havoc on our country and world. We are beyond 300,000 deaths in the U.S., and hospitalizations continue to rise. Though the evidence is mixed, there are oral, inexpensive treatments, that are generally safe, and could be a potential life or hospitalization saver for those caught early in the illness.

The most recent conclusions on Vitamin D is that there is not enough evidence to say it is effective for COVID-19. However, there is some evidence in small trials linking low Vitamin D levels to COVID-19 complications and also for treatment and prevention for upper respiratory viral infections. So, if the jury is still out, but the supplement is considered very safe, especially in daily moderate doses, why not recommend it to patients either for prevention or treatment in this era?

Fluvoxamine is a drug known to most of us as a selective serotonin reuptake inhibitor used most commonly for Obsessive Compulsive Disorder (OCD). I presume most of us would feel comfortable prescribing it for someone dealing with that issue, knowing it to be generally safe, barring other contraindications. A recent trial of 152 patients suggested a preventive effect of fluvoxamine on deterioration in patients already diagnosed with COVID-19 over a 15-day period.

Certainly, Hydroxychloroquine (HCQ) has seen its share of press throughout this pandemic. Used primarily for rheumatologic conditions for decades, it has been felt to be a safe treatment for many. Initial studies in China and then another in France suggested a significant potential for its use in COVID-19 patients. Though subsequent studies in the U.S. have questioned its benefit, a large inpatient study at the Henry Ford Health System was published in July 2020, which suggested a mortality rate in the HCQ patients that was half of that in patients who received no treatment. More recently, a meta-analysis was published looking at randomized controlled trials of early treatment with HCQ for treatment or prevention of COVID-19, including 5,577 patients in total. HCQ was shown to have a 24 percent reduction in COVID-19 infection, hospitalization and death (p=0.025), and without serious cardiac events.

Finally, Ivermectin has been shown in one trial to be superior to HCQ for prevention and treatment of COVID-19, and it was shown in another trial to hasten viral clearance by the body, at only 12 mg daily for five days.

It would certainly be simpler and easier for us to tell patients that there are no FDA approved or CDC recommended outpatient, inexpensive therapies. “Quarantine, use Tylenol and let me know if you’re getting worse.” Nevertheless, our duty to God and our patients should compel us to study these therapies more for ourselves, and then to have informed discussions (including disclaimers) with our patients, before possibly prescribing something that might keep them alive or out of the hospital.

Additional Reading

4 Comments

  1. Joshua J Morris MD on January 5, 2021 at 6:27 pm

    Absolutely, early treatment saves lives. Give the Ivermectin or HCQ! there is no downside- these are cheap, safe, readily available medicines being used all over the world. We’ve seen lots more side effects from vaccination than we have from HCQ or from ivermectin! If we had half the evidence for masks that we do for HCQ or Ivermectin, the mask controversy would be over….I work in the ED and see 10-20 cases per day- I prescribe these for people every chance I get and I advise my midlevels and colleagues to do likewise.

  2. Rick Vaughan, MD on January 5, 2021 at 7:51 pm

    I would treat any of my high risk patients with HCQ 200 mg tid x 5 days + Z-pac + Zinc 20 mg all for 5 days as early as possible after Dx(even before test results back). I think anything less would be poor medical care.

  3. Phillip Claybrook, md on January 7, 2021 at 1:23 pm

    I recommend reading the HCQ: A Morality Tale. It is lengthy but well written. It is a good reminder of what happens when we make “science” our god. We are witnessing all our man-made Towers of Babel crumble apart. I hear God asking “What do I need to take away before you will put your trust in Me?”

  4. Andrew Wong, MD on January 10, 2021 at 3:58 pm

    I agree that looking at the evidence and that supporting investigation of these therapies in well conducted studies is prudent. However, there is not zero risk in adopting unproven therapies. Although hydroxychloroquine was adopted early, there are studies that have shown a correlation with increased mortality. I am not saying it does or doesn’t help, but that we all need to be self-aware of how and why we are prescribing certain treatments. As physicians we need to stay up to date on evidence and ensure that our patients are informed as well if/when we prescribe treatments with limited or inconclusive evidence. It is difficult to see so many suffering and feel like we don’t have anything to offer, but we need to remember as Christian physicians, we always do have something to offer.

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