Hydroxychloroquine for COVID in Primary Care: Clinicians Debate

Charles P. Vega, MD


June 23, 2020

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Recently, I posted a case drawn from my own clinical practice that involved management of an outpatient with COVID-19. In this scenario, a 52-year-old woman with fever, cough, and some shortness of breath was requesting a prescription for hydroxychloroquine. She was also asking about use of over-the-counter products for herself and as preventive therapy for her asymptomatic partner.

As is often true in my management of many of the patients in my own clinical practice, I chose the option of careful monitoring and no treatment. Many of you disagreed. As always, I appreciate the honest and constructive comments to this article. Now I'd like to share with you my responses to some of the principal themes you expressed.

Why Is This Patient Here in the First Place?

First, many readers voiced concern that this symptomatic patient was in my clinic at all. That is a very good point. It's critical for infection control in a patient with a positive test for SARS-CoV-2. In our practice, these patients are typically followed via telehealth, but this patient opted for an in-office visit. While a wave of practices have adopted telehealth, patients with COVID-19 infection may need to be seen in the clinical environment, perhaps because of acute complications or because of limitations of telehealth on the part of the patient or healthcare provider.

One disadvantage of telehealth is that it typically doesn't allow for collection of vital signs that add to other information about signs and symptoms of illness or improvement that are assessed with the visit. I have been encouraging outpatients with COVID-19 in my practice to self-monitor vital signs at home at least daily. Unfortunately, while I get some temperature readings, I typically don't get a lot of information about pulse rate, and even more rarely does a patient report data from pulse oximetry.

One thing that has been universal in my practice, however, is close follow-up at least every few days, even for patients who are doing well. As noted by several readers, the most severe symptoms of COVID-19 might occur during week two of illness. This observation has been confirmed in research on the clinical course of this infection. Therefore, patients should be well educated and vigilant about what to watch for — and when. The healthcare team should be there to help them routinely during this challenging and stressful time.

What About Complementary Therapy?

There was little commentary regarding the application of vitamins or complementary treatments for the prevention of COVID-19 infection, although there were several statements about the need for all of us to acknowledge what we do not know. When it comes to COVID-19, that is quite a lot.

The National Center for Complementary and Integrative Health emphasizes that there is no scientific evidence that any alternative therapy (herbal therapies, teas, essential oils, tinctures, and silver products such as colloidal silver) can prevent or treat COVID-19. The FDA has issued warnings to seven companies that were fraudulently promoting these types of unapproved products as treatments for COVID-19. The FDA noted in its announcement that several, particularly colloidal silver, could be harmful. An international Traditional, Complementary and Integrative Health and Medicine (TCIHM) COVID-19 Support Registry has been established to collect data on use of these therapies and to attempt to determine whether any have merit.

That being said, there appears to also be a low risk for harm. Routine doses of vitamins seem safe, but there is controversy as to whether high doses of certain vitamins, including vitamin E and beta carotene, might be harmful.

I would argue that allowing the reasonable use of supplements that are otherwise known to be safe, based on patient preference, is a good approach. There are randomized trials currently registered for commonly used vitamins and minerals (eg, vitamin C, vitamin D, and zinc) for the prevention and treatment of COVID-19; results from those will be welcome.

The Elephant in the Room: Should We Prescribe Hydroxychloroquine?

Understandably, the majority of comments were focused on the use of hydroxychloroquine in patients with COVID-19. At the very least, this issue is controversial and constantly evolving. A number of critics have pointed out flaws in the large observational study of veterans hospitalized with COVID-19 in the Veterans Affairs health system. This speaks to the fact that observational research is inherently limited and usually just hypothesis-generating.

This particular study has yet to be peer reviewed and published. By now, we are all much more familiar with how research published even in the most respected journals in the world can be highly fallible.

Multiple commenters found fault with the methodology and conclusions of research into treatment with hydroxychloroquine. The recent decision to retract a major observational study published in The Lancet underlines that we not only need to be aware of major research on COVID-19 infection, but we also need to be smart consumers who critically evaluate the value of each study.

There is no definitive research to dictate how hydroxychloroquine is prescribed to patients with COVID-19 infection. Therefore, individualized risk-benefit assessment and shared decision-making with the patient is very important in initiating treatment. Multiple commenters suggested this approach.

Moreover, there are hundreds of research protocols underway, and there will continue to be a robust stream of information — some of it quite contradictory — regarding best practices for COVID-19. Each healthcare provider should perform an honest self-assessment of how much she or he can absorb on a routine basis, which likely means finding trusted resources to provide context around raw research.

And we must all remember that scientific inquiry is never linear, but it is our best hope in fighting COVID-19.

Charles P. Vega, MD, is a clinical professor of family medicine at UC Irvine and also serves as the UCI School of Medicine assistant dean for culture and community education. He focuses on medical education with an intent to resolve health disparities.

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