Coronavirus thread

[Nephrology]

That's an easy mistake to make these days but you're wrong.
There are ways to determine whether the narrative of the day is organic, attempting to look organic, or being pushed. I am highly suspicious of anything I see getting pushed. I want to know the reason it's getting pushed.
This is getting pushed. Hard.

Whatever your ideology or leanings, take off the tinfoil hat. The argument advanced in the Lancet article is supported by high quality data. If you can't construct a coherent, evidence based counter-argument, then you don't have a point. I don't know what else to tell you.

Maybe @Nephrology or @YVK or will check my work here. My lay take on Hcl and a lot of the other drugs is that we’re just now getting statistically significant numbers on survivability in the US hospital environment so that the trials can really prove anything, and no pharmaceutical has really been proven to be effective yet. Even the “most effective” remdesivir trials involved a relatively small number of patients and only 30%-40% of patients showing improvement. As far as I have seen there have been no trials of any drugs on people being treated post positive test and pre-hospitalization (I’m not counting the One doctor in New York).

I will say that the media started the love affair with HCL by touting some unreviewed small scale trials out of China (and later France) when this thing kicked off claiming it was a possible treatment. Then the medical community spoke up and said “well, we really don’t know, but as of now we have no evidence it does anything.” Then the President started talking about it on the news and that gave the media something to bitch about and the whole thing has become a giant partisan clusterfuck, like most things in our country.

I honestly to this day have no idea how HCQ was advanced into the public sphere or why, but in our early frenzy to do anything for the really sick COVID patients it ended up being fairly widely used (among a lot of other drugs). So far the only one that has shown some benefit is Remdisivir, which demonstrated accelerated recovery times in hospitalized patients (but no mortality benefit). Not exactly a magic bullet. HCQ at this point has been pretty repeatedly shown to not work and has a concerning potential to cause dysrhythmias.

You are correct in that it's become a massive clusterfuck. You know, typically, people don't have much interest in the wonky and dry world of clinical drug trials. Now, suddenly, this is a topic that everyone and their mother has an opinion on (as demonstrated repeatedly in this thread). It's really fucking frustrating. Media articles misrepresent findings in published literature and suddenly everyone is an expert with emotional investment in being right. However, most people also lack not only the ability to read and understand primary medical research, but also how to put it into greater context.

Here's the deal. Drugs don't work just because you want them to. Even if they work, they often don't work very well. In fact, just my opinion, but I doubt we'll actually develop a very good specific antiviral therapy for COVID-19. Viruses are very hard to target with drugs, and those drugs are often highly imperfect. For example, the only specific anti-viral we have for influenza - another respiratory pathogen that kills tens of thousands of Americans per year - is garbage. Tamiflu is generally better at giving you diarrhea than it is at treating the flu, and can cause really charming drug induced delirium. I have no reason to think we're going to do better with COVID-19.

In my opinion the best we can hope for is an effective vaccine. This is a playbook that has worked well for our species in combatting this kind of disease. Generally speaking, if a bug is badass enough to cause severe multisystem organ dysfunction and land you in the ICU - whether it is a virus, bacteria, or otherwise - you're already in pretty rough shape. Bacterial sepsis is a leading cause of death in the United States, and bacteria are far easier to target and destroy with drugs than viruses. We don't even know where to start in trying to repuporse drugs for COVID-19. Wondering what else we can throw at you besides the kitchen sink is asking the wrong question.

It is a waste of time for the public to worry about what ID is going to recommend for COVID19 pharmacotherapy. Nobody seems to be giving the same amount of attention to whether or not to prophylactically anticoagulate these patients, which is an actual ongoing debate in the medical community... not HCQ, which is rapidly proving to be just as dumb of an idea as it was when it was first proposed.

I was honestly surprised to see so much love for chloroquine right off the bat, since my biggest issue with the malaria pills was staff who refused to take them because they did not want the unpleasant side effects. Many of them would point at studies about the short and long term health risks of chloroquine as reasons they should not take the damn things, when they had malarone and other options provided to them. Don't get me wrong, I would have loved a cheap and widely available drug to have been an effective solution, but prior to this crisis, this one had some pretty major PR problems.

Why HCQ was embraced early on by medical professionals - despite zero quality evidence to support its use - is a social phenomenon that I would love to read a book about one day. I truly can't think of anything else like it. It's frankly kind of embarrassing.

[willie]

I have not seen the term "off label use" mentioned when HCQ is recommended, though that would apply. I always thought that off label implied backed by informal studies or hear say among doctors. Perhaps with the shutdown people including doctors are reading bullshit and repeating it--like everybody else. In early March a retired physician friend told me that HCQ would cure Covid-19. His 81 year old brother, a doctor, told him. Another 80 plus year old doctor serving hard time told the brother this in a letter. If I get the Virus, I will request a HCQ torpedo which is this drug mixed 1 to 100 with cannabis(hash oil)suspended in a firm bullet shaped matrix that some would call a suppository. We might add a touch of Soma to the mixture. And gimme some hydrocodone cough syrup to take the edge off. This is palliative care so no shitty comments please.

[David S.]

[where I continue to acknowledge my place atop Mt. Stupid.]

HCQ: the "data" seem to be a mixed bag.

India's ICMR found it helpful in preventing the COVID.

The big studies seem to be studying the "wrong thing". They seem to be studying it's use as cure for advanced stage COVID. The proponents of HCQ are suggesting: It be administered with zinc AND the treatment be started early (either as prophylactic or when first detected). By the time the patient is hospitalized, it's too late for HCQ/zinc/whatever to do it's thing.

I'm not sure if anyone's attempted smaller, quicker studies testing the above guidance. I do see a couple HCQ randomized trials being done pre-hospitalization with zinc. But they're months away. Hopefully in time for the second wave.

[Glenn E. Meyer]

Why HCQ was embraced early on by medical professionals - despite zero quality evidence to support its use - is a social phenomenon that I would love to read a book about one day. I truly can't think of anything else like it. It's frankly kind of embarrassing.

Whether it works or not is for the quality studies. To the question above, I propose thse factors:

1. Doctors are no different from anyone when it comes to personality factors.
2. Some wanted a quick cure for good reasons.
3. Some wanted to jump on the band wagon, esp. the media type doctors who figured out being positive was better for their sales pitch than being negative.
4. Some are politically motivated. DJT wanted the virus to go away as handling crisis is not his strong point. Thus, he first minimized whether it would hit here and then saying it would be minimal as we are handling it. Doctors who blindly accepted loyalty to the leader (a common Trump based disorder) had to go along.

Doctors going along with political horror shows is not unknown in recent history.

The human decision making flaws are common across all segments of humanity. Danny Kahneman demonstrated how 'trained' analytic types such as doctors, economists, lawyers, etc. make the same cognitive errors driven by emotional, quick decision factors and inability to think through evidence.

[Nephrology]

[where I continue to acknowledge my place atop Mt. Stupid.]

HCQ: the "data" seem to be a mixed bag.

India's ICMR found it helpful in preventing the COVID.

The big studies seem to be studying the "wrong thing". They seem to be studying it's use as cure for advanced stage COVID. The proponents of HCQ are suggesting: It be administered with zinc AND the treatment be started early (either as prophylactic or when first detected). By the time the patient is hospitalized, it's too late for HCQ/zinc/whatever to do it's thing.

I'm not sure if anyone's attempted smaller, quicker studies testing the above guidance. I do see a couple HCQ randomized trials being done pre-hospitalization with zinc. But they're months away. Hopefully in time for the second wave.

For starters, I am deeply suspicious of any/all research that comes out of India. I can't actually find the primary text of the studies they refer to but 334 study participants is not many, and I would be surprised if these results stand up under repeat investigation outside of the Indian subcontinent. That bias out of the way...Re: HCQ as prophylaxis, I'll reiterate a couple points:

1. There is not really a good mechanistic rationale for the use of HCQ in COVID, either for severe illness or prophylaxis. The in vitro work that has been used to ascribe mechanism to HCQ in COVID 19 is minimal and requires stringing together logical assumptions from only a few in vitro studies. In short, before HCQ was ever given to the first COVID patient, the rationale behind why it might work was sketchy, to be generous (to be fair this is true to some extent of all of the proposed study drugs to date, but HCQ is the biggest offender).

2. Presuming that it works, however, you are stuck basically with the same problem as Tamiflu, which prevents viral entry and thus theoretically is more effective before you develop disease (hasn't really borne out in clinical literature). The problem here - with COVID even more than flu - is that there is a lengthy asymptomatic phase before developing symptoms. If patients are asymptomatic for this early critical window of prevention, how will they know to seek treatment?

3. Let's assume it might still be effective early after symptom onset, even if this is not consistent with what we know from Tamiflu. Why would you give a drug with a potential to induce dysrhythmia to a patient who is healthy enough to stay at home? If you're sick but just uncomfortable and don't require hospitalization, then the benefit from any drug that may alleviate symptoms is relatively small. Weighed against even a small risk of developing an arrhythmia and dying of cardiac arrest at home, the cost/benefit ratio becomes questionable.

4. Let's further assume your goal is to prevent some of these early-course patients from going on to develop severe disease. Among those with minor illness, who you decide to treat, and what % of those will go on to develop severe disease? What % of those who would go on to develop severe disease are protected by HCQ? What % of those who would have been healthy w/o HCQ will develop potentially life threatening side effects?

As mentioned, lots of drugs - particularly many antivirals - work pretty poorly, and the cost/benefit ratio simply isn't always favorable. We are spoiled by antibiotics, which kill lots of common infections very quickly with minimal side effects. Antivirals are not nearly as efficacious. To repeat the analogy, we do not simply give everyone with fever and headache Tamiflu, even though tens of thousands of americans die of flu every year. There are good reasons for this.

Again: First, do no harm. Even if we had persuasive evidence that it has some prophylactic effect, you would need to demonstrate convincingly in a large study population that the benefit is outweighed by its risks. For the reasons described above, it seems unlikely that this will be true.

[MickAK]

This is wrong. You are not capable of "looking at the data and seeing if it's horseshit." In fact this is something you have repeatedly proven in this post.

https://www.google.com/amp/s/amp.the...s-for-covid-19

Yup.

[David S.]

@Nephrology. I appreciate your patience and contribution to this topic. ( along with the other medical pros).

[MickAK]

Here's another one.

https://www.medpagetoday.com/infecti.../covid19/86692

You don't need a medical degree to do data analysis.

[Nephrology]

https://www.google.com/amp/s/amp.the...s-for-covid-19

Yup.

See, this could be turn out to be a very a valid criticism of the article. However, it also may end up being a big nothing-burger. We'll find out! I'll be nonplussed either way. The nice thing about the research community is that as enough people do their part to answer a common question, we together arrive at a more complete understanding of the truth.

However, this doesn't have anything to do with your previous criticism of the article, which remains baseless. Furthermore, it does not change the fact that the paper's findings were largely consistent with many other research papers from different authors that have suggested the same thing. It certainly doesn't change the fact that in order to meaningfully critique the findings of clinical literature, you have to be able to read and understand the thrust of their argument first.

[Nephrology]

@Nephrology. I appreciate your patience and contribution to this topic. ( along with the other medical pros).

Any time!

Again, to reiterate, these are just my views and they are subject to change over time. I have pretty specific expertise relevant to COVID-19, but not to every possible relevant subtopic. I may prove to be wrong down the line - which, if you'll notice - is the reason I don't say things like "prove" or use hard absolutes with any of my predictions. I can only provide what is my best good faith interpretation of the literature and what I think it means, which is worth exactly what you paid for it.

Whether it works or not is for the quality studies. To the question above, I propose thse factors:

1. Doctors are no different from anyone when it comes to personality factors.
2. Some wanted a quick cure for good reasons.
3. Some wanted to jump on the band wagon, esp. the media type doctors who figured out being positive was better for their sales pitch than being negative.
4. Some are politically motivated. DJT wanted the virus to go away as handling crisis is not his strong point. Thus, he first minimized whether it would hit here and then saying it would be minimal as we are handling it. Doctors who blindly accepted loyalty to the leader (a common Trump based disorder) had to go along.

Doctors going along with political horror shows is not unknown in recent history.

The human decision making flaws are common across all segments of humanity. Danny Kahneman demonstrated how 'trained' analytic types such as doctors, economists, lawyers, etc. make the same cognitive errors driven by emotional, quick decision factors and inability to think through evidence.

I totally agree, and I'm the last person you'd have to convince that MDs are not infalliable. I guess I was just surprised to see it adopted at very high levels by our academic ID division, which has a lot of smart faculty, but in the face of uncertainty and fear I can understand why it had appeal. Still really remarkable.