Hydroxychloroquine for COVID-19 … my take

I am far from being any sort of infectious disease, emergency medicine or pharmacology expert and way out of my lane on this one, but if ‘Karen from Facebook’ can have a view, then why can’t I? What I do think I am good at is reading, evaluating and critiquing published scientific research as well as evaluating consensus among real experts and not just those who have a YouTube channel, and it is that which informs what I am writing about here. Observing all the political shitfuckery that has gone on around this has also been fun as well as informing and there is a lot to be learnt from the whole episode.

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Hydroxychloroquine is in a class of medications that were first used to treat malaria, but are now more commonly used as a disease-modifying anti-rheumatic drug (DMARD) to treat conditions like rheumatoid arthritis, lupus, childhood arthritis and some other autoimmune diseases. In March 2020, the then USA President, Donald Trump touted hydroxychloroquine as a ‘game-changer’ for COVID-19. We now know that it was not even close to being that. How did it end up there?

It all started with a paper from the French researcher, Philippe Gautret that appeared to show that hydroxychloroquine might be useful. I remember when all this first coming up going and having a look at the actual study rather than all the media and social media commentary. Even to me, it was pretty clear that all was not as it seemed from the paper, but that did not stop the whole hydroxychloroquine for COVID-19 taking off. That paper has now subsequently been flagged:

French hydroxychloroquine study has “major methodological shortcomings” and is “fully irresponsible,” says review

Source

That was it. That is all that it was based on. A study that should have raised red flags right from the beginning. What happened next was even more bizarre. The people behind the study allegedly engaged a PR firm based in New York to get a talking head on Fox News so President Trump could get alerted to it. It worked. Even FOX News opinion hosts lobbied the president that this was a game-changer. Laura Ingham was reportedly even in the oval office telling him that. She was the one who had no idea what happened to COVID-1, -2…-18 but was still “expert” enough to claim that hydroxychloroquine was the game-changer. It worked. Trump came out to widely promote it, for what I assume was to get credit for solving the COVID-19 pandemic with the drug. The real actual experts advising the president were ignored. The real experts all over the world pushed back, ‘hang on a minute‘, we have no idea if it works or not. All we have is one flawed preliminary study.

What happened next was that the use of hydroxychloroquine was supported by Trump, Republicans, right-leaning media, and “doctors” with no expertise in infectious diseases, but having a YouTube channel. The professors, the deans of medical schools, the board-certified infectious disease experts and the chairs of relevant departments in a teaching hospital; ie the real experts from all over the world pushed back. Anything about the lack of evidence on left-leaning media was seen as being nothing more than anti-Trump. The lack of evidence did not even get mentioned on the right leaning media. Surely it should be obvious which group those of us who do not have the expertise should be listening too.

As a consequence, many ‘Republican’ states in the USA purchased up large quantities of the drug, and even Clive Palmer here in Australia did the same, taking out full-page advertisements giving himself credit for donating the drug to a government that did not want it and he wanted to be seen as the savior for his gesture. Some of those states in the USA are now trying to find a way to get the supplier to buy the now unwanted drug back off them!

With the passage of time the research has been done with the overwhelming preponderance of the evidence is that it does not work and may be harmful. That is really clear. The current status of hydroxychloroquine by the expert panel here in Australia is “Hydroxychloroquine (not recommended)“. You only have to look up just who is on that taskforce and the depth and breadth they have in epidemiology, pharmacology, infectious diseases and emergency medicine. It is a really impressive lineup. They check the new research on an almost daily basis, evaluate it and critique it and synthesize it and make clinical recommendations. Who should you believe? Them? or right-leaning politician? or a talking head on a TV channel or a doctor with YouTube channel who has no expertise in epidemiology, infectious diseases or emergency medicine?

In the mix of the research, there is the occasional study that it may be helpful, but they are the exception and not the rule. Those studies get a lot of mileage on the right-leaning media. The studies that show it does not work get a lot of mileage on the left-leaning media. What a shitfuckery! Is this a left vs right issue? Is this an anti-Trump issue? Or is this a science-based vs a populist issue? To me, this is not a left or right issue, this is an issue of what the overwhelming preponderance of the good research shows. How can that be a left or right issue? It has been made into a partisan issue because of Trump’s claim it was a game-changer when it wasn’t.

Take, for example, the study from the Henry Ford Health Systems in July that got huge mileage in the right-leaning media; even Trump tweeted it out calling it coming from the “prestigious Henry Ford Health System” to pump it up, obviously because he mistakenly thought that the study backed him up. I went to the actual study at the time and not the over-hyped press release that was being widely touted. Even to me, it was pretty obvious the issues. This was only an observational study, so it was well down in the hierarchy or strength of evidence stakes (it was not a prospective randomised controlled study). While the group on hydroxychloroquine did appear to do better, it was pretty obvious to anyone who looked at the actual study that there were age differences between the groups, and the group who got the hydroxychloroquine also got more dexamethasone than the other group which we know is useful in COVID-19. So was it the dexamethasone or the hydroxychloroquine that worked? For the right-leaning media it was the hydroxychloroquine. From the design of the study, we have no way of knowing, so I rhetorically ask, how did they know it was the hydroxychloroquine? From what we know now, it was more likely to have been because of the dexamethasone.

I recall one of the opinion hosts on the right-leaning Sky News channel here in Australia waving that Henry Ford paper around demanding the resignation of Australia’s Chief Health Officer because of the prescribing restrictions that Australia placed on hydroxychloroquine. Even the right wing politicians, Craig Kelly and George Christensen made similar claims. Interestingly, infectious disease and emergency medicine physicians in Australia who actually treat the COVID-19 patients at the coal face were never restricted from prescribing hydroxychloroquine and none of them were calling for the alleged restrictions to be lifted. They never wanted to use it and there was a reason for that. That did not stop the right-leaning media from demanding resignations and beating up on the government for the alleged restrictions on a drug that the real experts did not want to use! Dentists did get banned from using it here. Who would you rather get your medical advice from? Talking heads on TV? or a politician? or an expert at the coalface who follows the evidence? Do you want to get your hydroxychloroquine from a dentist? I have yet to see any sort of apology or withdrawal of their claims by Sky New’s hosts or Craig Kelly and George Christensen. Then they wonder why the social media platforms are deplatforming those who just make stuff up.

It is also surprising that when any of the above gets raised in social media, that it does not take long before someone posts a link to a YouTube video from someone who claims that hydroxychloroquine works! I never cease to be amazed how many will give more weight to unverified claims on YouTube as opposed to the overwhelming preponderance of real experts in the area and the research on the topic. I recall going to look at one of those videos. The doctor made the claims that she had treated over 100 people with hydroxychloroquine and it cured them all. A number of sleuths looked into who she was and where she practiced clinically and it was widely believed that she was lying about treating 100 people. She was not board-certified in emergency medicine or infectious disease or had any qualifications or expertise in those or related area, so had no expertise at all in the topic, yet the video went viral and was widely believed. I do not get it.

Even if she did “cure” 100 people with COVID-19 using hydroxychloroquine, how did she know it was even the “hydroxychloroquine”? If you take 100 people who test positive and do nothing, 98% (or whatever the figure is) get better anyway naturally, so did her patients get better naturally or did they get better with the hydroxychloroquine? The only way of knowing is to take 200 people and give 100 the hydroxychloroquine and do nothing for the other 100 and measure the results (ie a prospective randomized controlled trial). Well, those studies have been done and as mentioned above the overwhelming preponderance of them shows that hydroxychloroquine does not work and in some cases may even be dangerous. Yet, she is still permitted to make her claims on YouTube. Is removing those claims censorship or is it protecting the public from bad information?

I often channel hop to get different perpectives and one thing I did obviously notice was just who the ‘talking heads’ that different channels use as “experts”. The left-leaning channels like MSNBC, CNN, ABC (Australia) tend to be the ones that get on the real experts such as the the professors, the deans of medical schools, the board-certified infectious disease experts and the chairs of relevant departments in a teaching hospital. Whereas Fox News and Sky News (Australia) tend to get on those who did not have that expertise and some have a YouTube channel. Lets not forget that it was Fox News who used the radiologist, Scott Atlas, to talk about COVID-19 whose views Trump liked and got him appointed to the White House task force. It was by all measures a disastrous appointment. I also recall another talking head on Fox News promoting hydroxychloroquine. They pumped her up as working at a very prestigious hospital network. I remember checking her LinkedIn profile and she had no expertise or experience in pharmacology or infectious diseases, but she was good enough for Fox News. That prestigious hospital network was listed in her LinkedIn profile, but that was all Fox News could use to pump up her “expertise” and give her credibility. She pushed the hydroxychloroquine. However, the next day that hospital network had to put out a press statement that they had never heard of her and she did not work for them.

The final point I will make is the President of the United States will always get the best medical care, they will have access to the best physicians who, in turn, will have access to the best of the best physicians to get advice to give the President that care. When President Trump was briefly hospitalized for COVID-19, he would have been given the best of the best. After his discharge, a list of drugs that he was given was released. Hydroxychloroquine was not on it. There would have been a reason for that.

At the start of the piece, I mentioned what a shitfuckery this whole episode was. It really was. One can only hope we can learn from it as there are certainly lessons to be learnt. I fear they won’t be learnt. As I always say on my other blog, I go where the evidence takes me until convinced otherwise, and this is a good example of that.

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Vitamin D and the Foot

Vitamin D and the Foot

I have been doing my weekly update on research and views for a few years now and you start to see patterns in the research and the literature. One that really stood out like a sore thumb was vitamin D. At one stage a year or so ago, I was commenting at least weekly on something to do with vitamin D and the foot. I even got feedback that I was some sort of vitamin D junkie (I’m not). More lately its probably once a month or so, but that is still a lot compared with other topics. Its hard not to miss how much research has been regularly and recently added to the threads on Podiatry Arena on vitamin D and the diabetic foot and the thread on vitamin D and foot and ankle injuries. With that sheer volume of content and research one can not help but think that it might be important and relevant.

What is obvious from all that research is the frequent correlation between lower levels or a deficiency of vitamin D and wide range of foot and ankle problems (from diabetic foot ulcers to stress fractures to muscle strains to the outcome of trauma etc). There are strong correlations between low vitamin D and a whole range of general medical conditions. Even more recent is all the research showing strong correlations between getting COVID-19, the seriousness of COVID-19, the outcomes of COVID-19 and vitamin D.

It is from there that there is a divergence between the science and the pseudoscience. The research has clearly and strongly demonstrated the correlation with low vitamin D and a whole lot of problems. We all know that correlation is not causation, but those promoting pseudoscience or selling vitamins do not get or understand the difference. That science is generally not so strong on the causation which has not stopped the cranks promoting the pseudoscience. There is generally very little evidence that prospectively links vitamin D to a higher risk of problems. There is also limited research showing that taking vitamin D fixes the problems that a deficiency is correlated to. That general lack of prospective evidence does not mean that vitamin D is not important, it just means that we need to be cautious about claims made for it and that context needs to be acknowledged.

Of course, generally, if someone is deficient in vitamin D, they probably should be taking supplements to get that up to normal. What should not be done is promoting vitamin D as a treatment if vitamin D levels are normal. Take any more than the required amount and the body just tries to excrete it. Vitamin D toxicity from over-supplementation (rather than an overdose of sun) is a thing and carries risks.

The COVID-19 case is an interesting one to observe. I have seen vitamin D supplements advocated to help prevent catching the coronavirus, probably from those selling vitamin D. There is no evidence that will work, despite the high correlation between COVID-19 and the vitamin D deficiency. Of course those sick with COVID-19 and are deficient should be given supplements as it just makes sense. The line has to be drawn at claiming vitamin D as a treatment for it, which certainly has not stopped the cranks with no experience in treating COVID-19 from claiming. While, I have doubts that this is the case, but it could well be that COVID-19 increases the demand for vitamin D, so the infection causes the deficiency rather than the other way around. These types of conclusions or hypotheses can not be made or excluded based on the current state of the science.

This area also attracts more than its fair share of clueless cranks, especially those who talk about vitamins boosting the immune system. If you hear anyone talking about that, stop listening or (preferably) call them out for their dribble. The last thing I want to do is boost my immune system.

Yes, vitamin D is important for foot and ankle problems; and yes, getting out in the sun and taking supplements is important. Just stop listening to the cranks. The buzz about vitamin D is overblown.

Disclaimer: I take a low dose of vitamin D as I have one of the conditions that correlates to low levels of vitamin D.

Postscript:
The issue is so important that we did a PodChatLive on it with Farrah Jawad.

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