Q&A: What PCPs need to know about hydroxychloroquine, chloroquine for COVID-19

Recent reports have lauded hydroxychloroquine and chloroquine — drugs previously approved to treat malaria and rheumatic conditions — as a potential treatment for COVID-19.

President Donald J. Trump made multiple claims that using hydroxychloroquine and azithromycin could be an effective treatment for the disease and stated in a tweet that the drugs could “have a real chance to be one of the biggest game changers in the history of medicine.”

However, there is limited evidence on the effectiveness of hydroxychloroquine and chloroquine in treating COVID-19, and the boom in demand for these drugs has led to concerns that they will not be available to those with conditions like systemic lupus erythematosus and rheumatoid arthritis who depend on the drugs.

Jinoos Yazdany, MD, MPH, Chief of Rheumatology at Zuckerberg San Francisco General Hospital and professor of medicine at the University of California, San Francisco, co-authored a paper published in the Annals of Internal Medicine about clinical decision making regarding hydroxychloroquine and chloroquine. Healio Primary Care spoke with Yazdany to learn more about what primary care physicians should know about these drugs. – by Erin Michael

Q: What is the reasoning behind using hydroxychloroquine and chloroquine for COVID-19 treatment?

A: These drugs have some activity in lab experiments against viruses, including coronaviruses, HIV and influenza. Some small either uncontrolled or poorly controlled studies from France and China have shown a possible benefit in humans, but the methodological limitations and size of these studies makes it too early to know for sure if there is a significant benefit. Adverse events like cardiac toxicity need to be carefully measured and accounted for when deciding whether to use these treatments in people with COVID-19.

Q: The FDA recently issued an emergency use authorization to allow hydroxychloroquine and chloroquine to be used in certain patients with COVID-19. What does emergency use mean, and which patients can receive these drugs?

A: The authorization allows providers to prescribe these drugs to adults and adolescents with COVID-19 when a clinical trial is not available to the patient. Hospitals need to request access to the drugs through their states — the intention is for the drugs to be distributed to hospitalized patients with COVID-19.

Q: Should PCPs be prescribing hydroxychloroquine and chloroquine to patients with COVID-19? If so, who should they prioritize?

A: There is no evidence to support widespread prescribing of these drugs to all those infected with COVID-19, and unfortunately, there are growing reports of serious adverse events, including cardiac toxicity. The best course of action is to either refer patients for enrollment in a clinical trial, where use can be carefully monitored, or to reserve use for the hospital setting, where monitoring can occur more efficiently.

Q: Which patients should not receive the drugs?

A: These drugs can cause significant cardiac toxicity, including prolonging the QT interval. They should be used with extreme caution if the patient is using other drugs with similar toxicity.

Q: What can PCPs do to address misleading information about these drugs that is being spread by politicians and on social media?

A: Physicians should educate themselves about the strength of available data regarding hydroxychloroquine and chloroquine in treating COVID-19. They should counter misinformation being spread on social media and other news outlets with a balanced, scientific weighing of the evidence and send clear messages to their patients that the drugs should still be considered experimental at this point in time. Physicians should familiarize themselves with toxicities and ensure that patients understand potential risks. They should also avoid misuse of these drugs for the prophylaxis of COVID-19 because there are absolutely no data to support this right now. The latter will lead to shortages for people with rheumatic diseases like lupus or rheumatoid arthritis who need the drugs to control their condition.

Q: What data would you need to see to recommend these drugs as treatment for COVID-19?

A: Randomized, double-blinded, placebo-controlled trials that are large enough to answer current scientific questions regarding if, when and for whom these drugs are beneficial are the only way to get the data we need to guide medical decision-making. Trials also need to characterize drug adverse events so we can see if benefits outweigh harms. Given the magnitude of the current pandemic and the fact that 10 such trials are already underway, I expect we will start to see answers in a period of weeks.

References:

Twitter. Donald Trump. https://twitter.com/realDonaldTrump/status/1241367239900778501. Accessed Apr. 3, 2020.

Yazdany J, et al. Ann Intern Med. 2020;doi:10.7326/M20-1334.

Disclosure: Yazdany reports receiving grants from the National Institute of Arthritis and Musculoskeletal and Skin Diseases during the conduct of the study, as well as grants from Pfizer and consulting fees from Astra Zeneca and Eli Lilly outside the submitted work.