White Coat, Black Art·Q&A

'This isn't Halloween candy': Infectious disease specialist cautious over drugs touted as COVID-19 treatment

This month U.S. President Trump hailed two drugs as potential treatments for COVID-19. Infectious disease specialist Dr. Isaac Bogoch weighs in on the hype and the reality behind these medications.

The risks are not just theoretical, says Dr. Isaac Bogoch

An employee checks the production of chloroquine phosphate at a pharmaceutical plant in east China's Jiangsu province in February. The drug has shown some efficacy against COVID-19-associated pneumonia in early research, but more study is required, experts say. (Barcroft Media/Getty Images)
Listen to the full episode26:28

As researchers scramble for a COVID-19 vaccine, U.S. President Donald Trump touted the drugs chloroquine and hydroxychloroquine as a potential treatment for the virus.

But health officials have warned that the medications aren't necessarily the "game changer" hailed by Trump.

"It's great that people are hopeful. But obviously we have to ... really look at the data and look at what evidence we have that this may actually be a useful tool in the fight against COVID-19," said University Health Network's Dr. Isaac Bogoch, an infectious diseases specialist.

Last week, the World Health Organization (WHO) launched a global study to look into the use of existing drugs that could be repurposed to treat COVID-19, including chloroquine and hydroxychloroquine.

White Coat, Black Art's Dr. Brian Goldman spoke to Dr. Bogoch about the hype and the reality behind these drugs. Here is part of their conversation.

Drugs have to be studied in a systematic way with a well-designed clinical trial with the minimal biases possible, says Dr. Isaac Bogoch. (Craig Chivers/CBC)

What are chloroquine and hydroxychloroquine?

These are drugs that have multiple purposes.  

Chloroquine can be used to treat or prevent certain types of malaria. Sometimes these can be used in autoimmune diseases to help mitigate the effects of perhaps bone and joint problems and autoimmune diseases.

They're relatively commonly used drugs.

So where and how did these two medications start being used on patients with COVID-19? 

There were some theoretical possibilities that these drugs could have some ... antiviral properties. But really, I guess more accurately, maybe we would call them immunomodulatory properties, meaning: could this help the immune system fight off the virus?

And, you know, this really prompted a very small clinical study that involved … just over 30 patients.

I think there [were] maybe … 26 patients that actually received the drug and a few of the other ones were in the control group. And, you know, the results of this small study suggested that if you took chloroquine, it might reduce the viral burden in your nasopharyngeal tract.

You could reduce the amount of virus that people are shedding. And then in addition to that, [in] an even smaller number of people, they thought if we added another drug, a commonly-used antibiotic called azithromycin, it may reduce the virus burden even more.  

Doctors are warning people about self-medicating for COVID-19 with an ingredient in an anti-malaria treatment that's been touted by U.S. President Donald Trump — chloroquine. 2:04

It's a very small study. It's not conclusive at all.

We would say that this is something called hypothesis-generating, meaning this is great — there might be a small arrow pointing in the right direction. 

[Do] you think that it's plausible that chloroquine or hydroxychloroquine could be effective in some way against COVID-19?

I think we have to be open-minded.

You mentioned some of the rather old HIV medication — one's called [lopinavir in combination with ritonavir] — the brand name is called Kaletra. And, you know, we've already started to see some of these results play out. 

So, for example, just about a week ago with the New England Journal of Medicine, they published a study that didn't show any benefit of [lopinavir combined with ritonavir]. 

People said, "Oh, it doesn't work," and sort of unfairly crossed that off the list. 

But really you have to look at these studies with a critical eye.

Every study has strengths and weaknesses.

And, you know, this study that was published with this lopinavir/ritonavir-combination was really in the sickest of the sick. 

There's truly a significant number of unanswered questions we have that need to be addressed with these drugs.- Dr. Isaac Bogoch

Maybe any drug that has efficacy against the virus wouldn't have had a meaningful impact if it was started that late in one's course of illness. 

But that doesn't rule out these drugs, and certainly there's other studies that are looking at these medications for those who are infected with the virus and much earlier on in their course of illness.

So there's truly a significant number of unanswered questions we have that need to be addressed with these drugs. 

I know these are early days, but what's the best evidence so far on the effectiveness of either of these medications [chloroquine and hydroxychloroquine]?

So the best evidence we have is that tiny little study with 30-something people in it demonstrating that maybe it will reduce the viral shedding [how much virus is being shed by an individual which makes them infectious] in people who get this medication. 

The current evidence is minuscule. It doesn't mean it's zero. It doesn't mean it doesn't warrant further study.

It's very hard to look someone in the eye and tell them, 'Hey, you're sick. You should take this drug.'- Dr. Isaac Bogoch

It's just based on the current evidence we have now.

It's very hard to look someone in the eye and tell them, "Hey, you're sick. You should take this drug."

Obviously we're in unprecedented times. 

If we are starting treatment with these drugs, which many places are, we have to do so in a very ethical manner and that means describing to patients exactly what they are getting — that we don't know if this will benefit them or not.

[Some] emergency physicians and infectious disease specialists are recommending that all patients admitted to hospital with COVID-19 be given either chloroquine or hydroxychloroquine and azithromycin.... based on anecdotal reports that the medications improved symptoms and survival. How much should we trust these anecdotal reports?

Our BS detectors have to be on high alert. 

I think we have to be completely open-minded that this may indeed be a very helpful tool but nobody — nobody can look you in the eye right now based on the data that we have available and tell you with a straight face that this is going to work or not. 

It has to be studied in a systematic way with a well-designed clinical trial, with the minimal biases possible. 

Medical staff in protective suits treat coronavirus patients in an intensive care unit at the Cremona hospital in northern Italy in this still image taken from a video earlier this month. (LA7 Piazzapulita/Reuters )

Now I also appreciate that, you know, we're in the middle of a pandemic.

People are getting sick and people are dying and we have to be lenient as well and say, "You know what, I don't want my patient to die. I'm going to give them every opportunity for success. I'm going to give them the drug." And, you know, I think that's also something that clearly needs to be considered. 

But we also have to remember that … sometimes we're wrong and sometimes the drug may cause more harm than good.

The fact is we just don't know.  

We're hearing that in some parts of the United States and elsewhere there are shortages of chloroquine, hydroxychloroquine and azithromycin. How concerned are you about that?
 
That's unfortunate.

If, for example, these drugs do show benefit in clinical trials and actually need to be used, there's gonna be an issue in accessing these medications.
 
It's not time to just start grabbing up all these drugs and stockpiling them.

This isn't Halloween candy, and drugs clearly have side effects- Dr. Isaac Bogoch

If we find out that these drugs have benefits, we have to figure out a way to ... scale production to [distribute] these drugs to areas in need.

What's the harm in using these medications without scientific proof of effectiveness and safety?

These are drugs. You know, this isn't Halloween candy, and drugs clearly have side effects.

The ethical thing to do when we're treating people now is to let them know that we are not entirely sure if this drug will help or harm. 

These are conversations that should happen at the bedside between the clinical teams and the patient and perhaps the family of the patient to discuss … in very realistic terms what we know, what we don't know, what are the risks, what are the benefits, what are the alternatives of using these drugs.

We have to be very honest with each other and with ourselves … we have to be honest and transparent with our patients about this as well — and the risks are not just theoretical.


Written by Ruby Buiza. Produced by Dawna Dingwall. Q&A edited for length and clarity
 

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