Photo Credit: John Locher / AP
While a vaccine for COVID-19 won’t be available for the next several months and into 2021, hospitals and labs around the world are racing to find the best effective treatment for supportive care to buy time for patients’ survival.
Some of the most talked-about treatments in public discourse are chloroquine and hydroxychloroquine, which the Food and Drug Administration approved for “compassionate use” status last month, meaning doctors can prescribe these drugs to COVID-19 patients if they have an “immediately life-threatening condition.”
Hospitals and health centers in Southern Nevada have already used hydroxychloroquine to treat non-COVID-19 related conditions such as lupus and rheumatoid arthritis. For hospitals like the VA Southern Nevada Healthcare System, COVID-19 patients are only being treated with the drug on a case-by-case basis.
“VASNHS is only using hydroxychloroquine to treat COVID-19 in cases where veteran patients and their providers determine it is medically necessary, and in a manner consistent with current FDA guidance, said spokesman John Archiquette, adding that the hospital is also using azithromycin and moderate doses of steroids to treat patients.
Last month, Gov. Steve Sisolak signed an order limiting the use of hydroxychloroquine for COVID-19 patients who are hospitalized. Last week, the state began distributing a waiver for hospitals to start using the drug for outpatients as well as inpatients. On Tuesday, the University Medical Center became the first hospital in Southern Nevada to start prescribing the drug to patients who are sent home.
These anti-malaria drugs are both derived from the quinoline molecule and frequently used to treat autoimmune diseases such as rheumatoid arthritis and lupus. Hydroxychloroquine and chloroquine are different formulations for the same drug, although chloroquine is more toxic and isn’t as widely used, said Dr. Brian Labus, epidemiology expert at the UNLV School of Public Health.
Patients who are older or have preexisting health issues, exhibit moderate symptoms and have an abnormal chest X-ray, but are stable enough to be discharged are eligible candidates, said Dr. Thomas Zyniewicz, UMC emergency medicine physician. About 20 coronavirus UMC outpatients have been prescribed the drug in the last week.
One theory behind using hydroxychloroquine is that it may inhibit the virus’s ability to attach onto the cell. The other theory is that the drug’s anti-inflammatory mechanism may have a role to play in treatment as well.
“There are ongoing studies to determine that viral pneumonia and multisystem organ failure is a direct result of the virus damaging tissue, or your whole immune system causing inflammation-fighting the virus, which causes damage to tissue,” Zyniewicz said.
UMC is the only Las Vegas-area hospital prescribing the drug to discharged patients. Dr. Christopher Voscopoulos, medical director of the Southern Hills Hospital and Medical Center’s intensive care unit, said prescribing the drug in an inpatient setting allows for hospitals to control the environment, monitoring every aspect of a patient’s physiology.
“If they have a deleterious effect from it, I can immediately know that and initiate a treatment for that and minimize any risks,” he said. “When this or any drug is used in an outpatient setting, a much higher level of safety has to be considered.”
Most health experts say it’s too soon to determine how effective hydroxychloroquine is in treating COVID-19 symptoms, and whether the drug’s benefits outweigh its side effects, which Voscopoulos said could include heart complications.
“The data we have right now for hydroxychloroquine — and understandably so, the illness just became known in November of last year — is not great,” he said. “That doesn’t discount the data. Of course we would want large-scale randomized trials, but the reality is we don’t have that right now, so we have to turn to what we have.”
The information many are looking at is based on a French study and some Chinese in-vitro studies showing optimistic results. This has caused some in the health care industry and some politicians to embrace the drug as a possible treatment, even though the French study observed just 36 patients.
“It’s reasonable given the circumstances that we’re currently facing, that’s the best we have,” he said. “But from a balanced standpoint, if we were to have conducted our large-scale randomized control trials, maybe we would have looked at five to 10 thousand people instead of 36, which would give us more information.”
Zyniewicz said there likely won’t be any concrete results for at least another six months. While the benefits of hydroxychloroquine are yet to be determined, Zyniewicz said he worries that some of the controversy surrounding hydroxychloroquine is people are conflating it with chloroquine, which is an older drug that often has more severe symptoms.
“There seems to be confusion in the literature between hydroxychloroquine and chloroquine,” he said. “Chloroquine is the oldest drug used in third-world countries to treat rheumatoid arthritis, malaria, lupus. That drug is awful … There’s a crossover in literature right now, mainly lay literature, that says people in Brazil are dying from taking this drug and we shouldn’t use it. The drug they’re taking is not the drug we’re prescribing.”
The question Zyniewicz and his team looked at is whether COVID-19 patients with mild pneumonia could benefit from the drug.
“The conclusion we made is yes, and that’s why we decided to prescribe it,” he said, adding that the American Infectious Disease Society has endorsed the use of hydroxychloroquine in seriously ill patients admitted to the hospital and that the drug is already considered safe for rheumatoid arthritis and lupus patients. “Why would we hold a drug that is considered beneficial to moderately ill patients? I think our utilization of this drug is safer than we have seen in medicine up to this point,” he said.
Voscopoulos said one treatment hospitals are using that shows some promise is a technique called “proning.”
“Proning is when we have an individual lie on their stomach, which opens up the lungs more,” he said. “Normally this has been used as a treatment for an individual who has a breathing tube and is on a breathing machine. But what we’ve noticed is that this treatment has been so effective in helping our patients, that we have now for the first time advanced this treatment outside the ICU and are now using it for patients who are admitted to the hospital but are not yet critical.”
UMC CEO Mason VanHouweling has also touted this technique and said it has kept many patients off ventilators.
Voscopoulous said there has also been tremendous progress over the years in life support, which can buy someone enough time until they can heal themselves.
“I understand the public’s and everyone’s desire to have a targeted treatment and some kind of medication. It’s part of the basic human fabric of wanting and needing hope,” he said. “However, even if we don’t have a targeted treatment, that doesn’t mean we don’t have anything to offer you.”
As the health care industry continues to experiment with different treatments, the best thing the public can do is stop transmission from happening in the first place and slow down the spread of the disease so hospitals don’t ever become overwhelmed, Labus said.
“We’re using social distancing because we basically don’t have anything else,” Labus said. “If we start to have treatments available, that will change the way we approach the disease.”