Article by TRC, Pharmacists Letter

Posted April 3, 2020: Article in Progress. We’re releasing this article ahead of our May 2020 issue to quickly provide information to our readers. The information contained in this version is based on the best evidence available to us as of the date of posting. The final version may include revised recommendations.

  • Patients will rely on you for the bottom line about whether hydroxychloroquine or other meds prevent or treat COVID-19.
  • For now, supportive care remains the mainstay of treatment.
  • Some meds aren’t effective…such as oseltamivir or baloxavir.
  • And we’re waiting for solid answers from ongoing studies with others…remdesivir, sarilumab, tocilizumab, etc.
  • So far, lopinavir/ritonavir doesn’t look promising for severe COVID-19…but studies are looking at its use earlier in the course.
  • Chloroquine and hydroxychloroquine are in the spotlight. They’re thought to prevent some viruses from multiplying…plus they have immunomodulating effects.
  • But put the role of these meds in perspective. Initial evidence is lab-based…with few published human trials. Expect evidence to keep trickling in.
  • The buzz started with a French report of 6 patients who “cleared” the virus after 6 days on hydroxychloroquine and azithromycin.
  • Then an observational study from the same French group concluded that most patients on the combo had a “favorable outcome.”
  • But two small randomized trials from China found mixed results with hydroxychloroquine.
  • Be aware, these reports have MANY  flaws…and it’s too soon to say if reduced viral load correlates to COVID-19 outcomes.
  • Plus there’s still not an optimal regimen. Doses of hydroxychloroquine vary from 400 to 800 mg/day for 5 to 14 days.
  • Discourage inappropriate use. Emphasize that there’s no good evidence for using chloroquine, hydroxychloroquine, or azithromycin to prevent OR treat COVID-19 in the community.
  • For now, reserve these meds for use in a clinical trial or in hospitalized patients.
  • And follow your state rules, pharmacy policies, and payer guidance…many are requiring a diagnosis or days’ supply limits.
  • Keep the risk of QT prolongation in mind, even with short-term use…especially when hydroxychloroquine is combined with azithromycin or other QT-prolonging meds.
  • Explain that inappropriate use may prevent others from getting these meds for lupus, rheumatoid arthritis, or malaria.
  • See our chart, COVID-19 and Pharmacotherapy, for more details…and our COVID-19 Resource Hub for additional resources.

References

  1. Int J Antimicrob Agents Published online Mar 20, 2020; doi:10.1016/j.ijantimicag.2020.105949
  2. www.groupedeveillecovid.fr/blog/2020/03/28/clinical-and-microbiological-effect-of-acombination-of-hydroxychloroquine-and-azithromycin-in-80-covid-19-patients-with-atleast-a-six-day-follow-up-an-observational-study/ (3-31-20)
  3. J Zhejiang Univ Published online Mar 6, 2020; doi:10.3785/j.issn. 1008-9292.2020.03.03
  4. https://www.medrxiv.org/content/10.1101/2020.03.22.20040758v2.full.pdf (3-31-20)
  5. www.ama-assn.org/delivering-care/public-health/joint-statement-ordering-prescribingor- dispensing-covid-19 (3-31-20)
  6. www.ashp.org/Pharmacy-Practice/Resource-Centers/Coronavirus (3-31-20)

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