Thread by @jpogue1

Welcome new followers. I wanted to pause and reflect before further commenting – which is something I would highly recommend we all do. With that, another brief thread

First off, for those asking, I'm an infectious diseases clinical pharmacist.Critically assessing the totality of evidence and working w/ physician colleagues to make patient care decisions is quite literally what we do. We are drug therapy experts and always work to optimize care

Second, I want to be crystal clear that we all want to find a therapeutic solution to #COVID19. Every single one of us. However, we cannot suspend disbelief to get there. We need to be critical of the emerging evidence and prioritize completion of well controlled trials

While it is true we may accept less data than usual in the interim, particularly if there is no major safety concern with a therapy, we can’t ignore what the data show and don’t. We are adapting on the fly as data become available, but the data must be assessed in its totality.

Therefore, if you believe HCQ has a potential therapeutic benefit because of in vitro activity and the “therapeutic success” w/ Chloroquine and that it should be administered to vulnerable patients due to its relatively mild adverse event profile that is rational and fair

References:
In vitro activity: ncbi.nlm.nih.gov/pubmed/32150618
ncbi.nlm.nih.gov/pubmed/32194981

"Efficacy"
ncbi.nlm.nih.gov/pubmed/32074550

But what we cannot do is ignore what the data are actually telling us. For example, the data that show therapeutic benefit in patients in China with chloroquine still remain unpublished. It is impossible to assess data that do not exist.

As I said, it is quite reasonable to give HCQ in the interim due to risk vs. benefit calculation, but to tout something as a cure is reckless as quite frankly we do not know. We are all hopeful, but we do not know.

Which brings me back to the initial thread about the HCQ + Azithromycin study. The focus of that thread was ONLY the combination and its “evidence”. Could HCQ + AZ improve outcomes over other therapies? Sure. So could any number of agents theoretically when given in combination

However, what we shouldn't do is claim this paper as supportive evidence. You can’t observe 6 pts who happened to be on the combo for other reasons and claim the 2nd agent played any role when there is ZERO evidence,even in vitro,to support this. You cant reverse engineer science

Here is where we come back to the risk benefit calculation. Both HCQ + AZ can have a negative impact on the heart. Using them in combo increases this risk. If there was reason to think this combo improved outcomes,then maybe the benefit > risk and we consider in selected patients

But currently there aren’t data that supports this for the reasons we previously discussed. Therefore, in my opinion, the risk is much greater than the potential benefit based on the current evidence. We can be nimble in our treatment recommendations, but we shouldn’t be reckless

And if additional data emerge tomorrow that changes the calculation we can address that when it does. I would be happy to be proven wrong over time and modify what we are doing with a more effective therapy. But that is not current the situation.

Stay safe and smart everyone. We are all in this together.