Our Duty to COVID-19 Patients
December 30, 2020
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.