The following is an excerpt from our latest podcast with Dr Jonathan Silverberg on the rise and fall of hydroxychloroquine as a “wonder drug” for COVID-19 and the importance of evidence-based medicine. Listen to his full podcast through Soundcloud on The Dermatologist website.
Coronavirus disease (COVID‑19) is a different disease where there appears to be cardiac complications.1,2 The risk in this disease may be very different than what we’re used to in the dermatology setting...[we’re] starting to see studies that show there may actually be higher mortality rates related to the use of hydroxychloroquine (HCQ) to treat COVID‑19 patients...When we actually see the evidence, it doesn’t point to a very compelling story. As a clinician, of course, we can always prescribe what we feel is needed for our patients. In the critical care setting, there may be no other option to try. This is something we have to be very careful about. We have to be very careful about recommending for all patients without more clear-cut safety data and understanding of the risk‑benefit ratio.
Also, understanding that this perhaps false optimism about the value of HCQ is causing the run on the drug. It caused the temporary inability for our patients who are on it for years to be able to get their prescriptions refilled and caused potential relapses and safety concerns for those patients.
There’s an overall take‑home message, because this is not just the story about HCQ and COVID‑19. This evolution is really consistent with what we see all throughout medicine and the conversations about evidence‑based medicine. There are many who are on different sides of the coin with this. Some are big proponents of evidence‑based medicine. You can probably tell from my tone that I am a fan of evidence‑based medicine. These principles evolved over the years for good reason. We have clear methodology developed for a reason.
In dermatology, we’re used to having diseases that sometimes don’t even have names, let alone evidence, to support their treatment. We’re all too quick to pick treatment choices based on case reports or case series, or to move our own treatment decisions based on a single study, which is a big no‑no in the world of evidence‑based medicine.
What you see here is the value of evidence‑based medicine. You see why it is that we push for evidence‑based medicine principles throughout all of medicine and why we need more of a push, even in dermatology. Sometimes that first study that gets published...isn’t replicable. Even if one or two studies are replicable, sometimes you find out about unexpected harms down the road with better studies. It’s a cautionary tale. But, where we’re at right now, with respect to the evidence for HCQ in COVID‑19, is very mixed results.
For many patients, it may be better off doing nothing and using the standard of care, and not pushing the wanting use of HCQ without clear‑cut evidence. Of course, the beautiful thing and the challenging thing about evidence‑based medicine is it’s always evolving. There are now over 70 trials for HCQ being conducted globally. We will have an enormous amount of evidence, coming out soon enough that will help guide this story even more.
1. Shi S, Qin M, Shen B, et al. Association of cardiac injury with mortality in hospitalized patients with COVID-19 in Wuhan, China. JAMA Cardiol. Published online March 25, 2020. doi:10.1001/jamacardio.2020.0950
2. Driggin E, Madhavan MV, Bikdeli B, et al. Cardiovascular considerations for patients, health care workers, and health systems during the COVID-19 pandemic.
J Am Coll Cardiol. 2020;75(18):2352-2371. doi:10.1016/j.jacc.2020.03.031