Hydroxychloroquine, Azithromycin and Zinc in Outpatient Medicine

Does hydroxychloroquine, azithromycin, and zinc help non-hospitalized/outpatient COVID patients in the community? The short answer is that we don’t know. If you are convinced 100% that it is a “cure” or 100% that it kills everyone, you need to take a step back and take a deep breath. Your emotions got the best of you. My inbox on IG was filled this morning with people requesting my response. I am open to being proven wrong. I welcome your opinions.

First of all, a series of disclaimers.

I am not going to take into account the credibility of certain colleagues in this video. This information could come from this physician or Dr. Fauci. I am here for patient care, not for salacious headlines of a persons character. Knowing that, however, my stance doesn’t change. We don’t have enough data.

I am not going to talk about masking, prophylaxis, and other things mentioned. I am keeping this apolitical. The focus is on HCQ, azithro, and zinc.

Some background about me

I am a Critical Care board certified physician. No outpatient medicine nor primary care for me. I do not envy the responsibility these physicians have in the community in trying to keep their patients from meeting my team and I in the ICU. I know they don’t envy me either haha.

Anecdotal Evidence

In the grand scheme of evidence, anecdotal is the worst one. You know, like when I say that I provide IV vitamin C, thiamine, and hydrocortisone to my septic shock patients and I feel they benefit from it. You know what that means to the medical community at large? Nothing, and that is okay. Right now, however, anecdotal evidence is all we have regarding this cocktail of hydroxychloroquine, azithromycin and zinc in the outpatient setting, unfortunately.

The current state of the hydroxychloroquine, azithromycin and zinc in outpatient: the evidence on 7/28/20

The state of evidence as of 7/28/2020 in the patients who are in the ICU as well as in the inpatient setting regarding using HCQ and azithromycin is not promising. I do not think I have read one study that includes zinc in the mix but I could be wrong and correct me if so. My opinion is that, once the patients go into the pro-inflammatory phase of COVID, it is too late for this cocktail to potentially work. When the CRP, d-dimer, and ferritin are through the roof, the patient has bigger problems. When you add medications that potentially affect the heart, an organ that we’re learning more and more every day also gets affected with COVID by myocarditis, it’s a recipe for disaster. Not to mention the pro-thrombotic effects of COVID in the later stages.

Upcoming data

I have made a call to the community of 60k+ who follow me on social media to help me find data, any data, regarding using this cocktail in the community. Long story short, there’s nothing thus far. A search on clinicaltrials.gov shows only one study and it is currently recruiting patients. They plan on enrolling 750 patients. My opinion is that they’re going to need a larger sample to prove one of their primary outcomes of “number of participants hospitalized and/or requiring repeat ER visits” simply because of how few patients end up in our hands at the hospital, relatively speaking. I am sure that the study won’t show a benefit because it may be underpowered for that endpoint. I could be wrong.

What I am personally seeing

In my personal practice, in speaking directly with these patients I am learning that many of them are coming to the hospital 5-14+ days after diagnosis. Many of them have had symptoms for a week or so before even being tested. But what the physicians in the video are suggesting is that if they start the therapy early, then the progression to needing hospitalization is ameliorated. We do not have any data, to my knowledge, that suggests that this does or does not work. In the absence of data, we need to do the best we can. My ICU data says don’t administer it, so therefore I do not use it in my practice. But who am I to tell an outpatient doctor what they can and cannot do in the absence of evidence?

We don’t know.

The population at large is up in arms about this video either in support or against it. In the absence of data stating that it does work or that it doesn’t work and causes harm, we need to allow clinicians the ability to practice medicine and decide what’s best for their patients. Not everything is solved by a clinical trial. If a primary care physician were to walk into my ICU and tell me how to do my job, I would lose my (explicative).

Going back to the original question: Does hydroxychloroquine, azithromycin, and zinc help outpatient COVID patients in the community? We don’t know.

Much love to everyone.

To read about many other things COVID that I have covered over the last several months, click here.

Check out this topic on my podcast!

Update #1

Shout out to Dr Davi Mota Alcantara who sent me this paper looking at HCQ in the outpatient settings. A very important limitation is that only 58% of the patients were tested for COVID. That means that 42% of patients were probably COVID or had high-risk exposures.

This study showed that it didn’t work to control symptoms.

It is important to know that, while not statistically significant, 10 patients in the control group ended up in the hospital and 4 patients in the HCQ group ended up in the hospital.

The Annals of Internal Medicine decided to make you create a login and password to see this article.

Skipper CP, Pastick KA, Engen NW, et al. Hydroxychloroquine in Nonhospitalized Adults With Early COVID-19: A Randomized Trial [published online ahead of print, 2020 Jul 16]. Ann Intern Med. 2020;M20-4207. doi:10.7326/M20-4207
Link to Abstract

Update #2

Shout out to Cortney @regercy who sent me this outpatient study from Spain looking at only HCQ. They did not use hydroxychloroquine, azithromycin and zinc in this outpatient study. This study was an RCT in outpatients using only HCQ. Patients had symptoms for 5 days or less. The primary outcome is viral load. There was no difference in that. 86.7% of patients were healthcare workers.

There was no statistically significant difference in hospitalizations. Even if we were to go crazy and extrapolate the not statistically significant difference as a difference nonetheless, it would lead to a number needed to treat of 83. That means you need to treat 83 patients to avoid one hospitalization, at best. 72% of the patients had an adverse event from the HCQ. “The most frequent treatment-related AEs among participants given HCQ were gastrointestinal (e.g., diarrhea, nausea, and abdominal pain) and nervous system disorders (e.g., drowsiness, headache, and metallic taste).” No major adverse reactions were noted. Will you be using hydroxychloroquine in the outpatient setting?

Mitjà O, Corbacho-Monné M, Ubals M, et al. Hydroxychloroquine for Early Treatment of Adults with Mild Covid-19: A Randomized-Controlled Trial [published online ahead of print, 2020 Jul 16]. Clin Infect Dis. 2020;ciaa1009. doi:10.1093/cid/ciaa1009
Link to Abstract

Nextstrain.org epidemiological data: https://nextstrain.org/ncov/global?c=region

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