Physicians must use best practices in COVID treatment
DEAR DR. ROACH: Is there a difference between COVID-19 treatment in academia vs. the real world? I had a telemedicine appointment the other day to see my internist, and he said to call right away if I developed symptoms consistent with COVID. He would order tests for me and start me right away on hydroxychloroquine, doxycycline and zinc. I told him I was surprised that he would prescribe these, since everything I’ve read recently supports no benefit from hydroxychloroquine. Also, I thought doxycycline was not beneficial for viral infections. He said he uses it, and it works. Your thoughts, please. — B.R.
ANSWER: All physicians are obligated to stay abreast of current standards of care for the practice of medicine. Unfortunately, physicians both in academia and in private practices do not always stay as current as they should. With COVID-19, it can be hard to keep abreast of all the changes and the sometimes-conflicting data that comes from clinical trials and expert recommendations. Although it might be easier for academic physicians to do so, my observation is that some private practice docs are really up-to-date while a few academic docs are behind on the latest updates.
Hydroxychloroquine appeared to show benefit in some early, uncontrolled studies, but the vast majority of the evidence, including the most reliable evidence from controlled trials, has shown no benefit and significant potential for harm for hydroxychloroquine, at least at the time of this writing.
Doxycycline is an antibacterial agent, and is used in people with COVID-19 and concurrent bacterial infections. It has been studied in early trials, as in addition to its antibacterial properties, it is anti-inflammatory as well and may have some antiviral effects. It may have a role in treatment, but it is not recommended for use until there are clear results from clinical trials, which at the time of this writing are lacking.
Similarly, there are theoretical reasons why zinc might be effective, and people with zinc deficiency have suppression of the immune system. However, there are no data showing benefit of zinc treatment in people with COVID-19, although zinc has shown modest benefit in some other viral illnesses.
Hydroxychloroquine has clear potential for harm, and some studies have shown worse outcomes in people with COVID-19 taking it. Zinc and doxycycline are both safe but unproven. Some physicians choose to use unproven but hopeful treatments when there is a low likelihood of harm, as is the case with zinc. Others prefer to have data showing that treatments are both effective and safe before using them. At the beginning of the pandemic, I saw many doctors, frustrated at the lack of treatment options, choose to try unproven medications out of a feeling they need to be doing something. Fortunately, now there are at least two treatments, remdesivir and dexamethasone, that have been proven to be helpful in people with moderate to severe COVID-19 infection.
I would not follow the recommendation of a physician who recommends hydroxychloroquine, whether they come from academia or private practice. Wishful thinking that it helps can lead to bias, especially since most people with COVID-19 will do well. We need to practice what the best scientific evidence says, not what our gut tells us. A single physician’s observation that it seems to work is inadequate in the face of evidence saying the contrary.