It is very difficult to get any real information as my niece is reluctant to press the nurses (doesn't want to offend those taking care of him) as they never instigate a phone call update. She has spoken to a doctor all of three times since he was hospitalized on 3/19. (mini-rant, sorry) After some time my niece finally asked the nurse who supposedly asked a doctor about using tocilizumab. To our knowledge, it was never tried, nor was using recovered patient plasma or blood transfusion. We know he is getting TPN and they are using lasix and levophed PRN. At this point the chest x-ray still has opacity, but they are supposed to be trying to wean him off the paralytic drug slowly. He seems very critical but stable overall. I've discovered it's possible to be discouraged and hopeful at the same time. Thanks for asking about him.

Symptoms 3/12
Hospitalized 3/19
Vent since 3/22

Its so sad to read the last page of this thread and just see how far down the hole we are in terms of scientific literacy. This MUST be addressed when this crisis is over.

God help us.

74OA said:

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Dr. Coates spot-on discussion of the issue of virus treatment captures the essence of the argument for me. Scroll down about halfway: WHAT TO DO?

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Great read and thank you

74OA said:

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Dr. Coates spot-on discussion of the issue of virus treatment captures the essence of the argument for me. Scroll down about halfway:

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Coates is playing up a stereotype of academia that I don't is strong as he's suggesting. I've read, listened to, and spoke to both his"academic doctors" and "workplace doctors." Academics aren't so naive and detached from reality as he suggests. And they could, on scientific principle, object a lot harder than they have.

I think that's a good read and I know and get what's he's saying. But its now going to be used to play up the false dichotomy that you can't both have a willingness to use it and, at the same time, call it scientifically unproven.


And his use of "we" and "they" is a poor, unhelpful choice of words.

I think it actually devalues his opinion. The modern academic physician is almost purely clinical. In Texas the academic practices associated with A&M and UT are enormous. Very few people make their primary living off of research and lecturing. The "academias" researching COVID in our institution are the people on the front lines in the clinic, in the ED, and in the ICU actually managing these patients. They are using all these drugs in their practice and they have their own patients that they care about just as much as Dr. Coates cares for his. They're studying these drugs because they want to find out which is the best treatment at the best time. We have multiple studies going on at my institution as we speak and we are using all of these meds at different times. I've read quite a bit in the academic journals about this and I haven't come across a single one that advocates not treating the known COVID+ patients with HCQ or some other sort of treatment. I think it is very irresponsible to advocate otherwise. (not that you are advocating otherwise) just the dr coates referred to in the link

74Ag1 said:

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Infection_Ag11 said:

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littledude said:

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That's what's happening. It's being used all over the world already AND it's being studied to determine the best way to use it. Both things are happening at once and I don't know anyone who's saying not to use it at all until the results of the studies are known.

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Correct

I'm using it in 70-80% of the inpatient COVID patients I see, while simultaneously having serious doubts about overall efficacy and acknowledging what I'm doing is not evidence based.

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1) How many patients is that?
2) What stage of the virus were they in? Early, late?
3) What was your treatment?
Hydro, Az, ZN?
4) Results?

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1: A total of about 30 that I've been involved in the care of over the last 3 weeks, so I've probably given HCQ to roughly 23-25 patients off the top of my head

2: Most institutional algorithms recommend HCQ for moderate to severe disease, as does ours. GENERALLY, patients ill enough to get admitted are ill enough to get it. This usually means they have evidence of pneumonia and at least mild oxygen requirements. I had 4 who probably shouldn't have been admitted and didn't get HCQ due to either being low risk with mild disease (ie very young without hypoxia) or having a contraindication to HCQ (congenital long QT syndrome). A couple ICU patients came in tubed already in full blown cytokine storm and we went straight to an IL-6 inhibitor. Other than that most are getting it.

3: HCQ/zinc (because it's our institutional policy, but the zinc is pointless in most patients with normal diets)

4: Anecdotally it seems to make little to no difference. Most patients get better (and probably would have gotten better anyway), a few get worse and end up on remdesivir/siralumab/toci if possible. The ones who didn't get it (and weren't intubated from jump street) all did fine but again they had mild disease. Again anecdotal, but for severe disease I've had good results with the IL-6 inhibitors. Remdesivir seems to maybe help if given during the period when viral replication and primary pneumocyte destruction is still an active part of the disease process.

Again, none of this is based on the scientific method or objective data. Just merely my perception from a limited sample size.

Agree with this. Similar experience. I don't think giving it to patients once they are sick enough to be admitted is beneficial. We are doing it however. The unanswered question, so repeatedly mentioned on here, is HCQ within 48 hrs of symptom onset. To limit viral replication. We shall see.

Luckily there are ongoing studies to address this as it seems pointless to give HCQ when inhibition of viral replication is not the biggest issue. Same with remdesivir.

Until we get those results this whole debate is pointless in terms of efficacy.

"They've" also been know to specialize in paralysis by analysis. You know it when you see it

TXAggie2011 said:

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74OA said:

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Dr. Coates spot-on discussion of the issue of virus treatment captures the essence of the argument for me. Scroll down about halfway:

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Coates is playing up a stereotype of academia that I don't is strong as he's suggesting. I've read, listened to, and spoke to both his"academic doctors" and "workplace doctors." Academics aren't so naive and detached from reality as he suggests. And they could, on scientific principle, object a lot harder than they have.

I think that's a good read and I know and get what's he's saying. But its now going to be used to play up the false dichotomy that you can't both have a willingness to use it and, at the same time, call it scientifically unproven.


And his use of "we" and "they" is a poor, unhelpful choice of words.

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I agree the use of we and they was very a very poor choice of words. We as in all doctors are in these together I have been involved with research before and in have tremendous respect for what they do.

Look I write these articles on the fly at about 10pm after working all day seeing patients. I read some studies and try to answer questions patients are sending me. I have no editor nor do I have time to reread it. So unfortunately it came across wrong. I was trying to answer the question I keep getting about why there is such strong different opinions on the use HCQ/Z-pak

I was not trying to create a rift between the two types of doctors. We need both types for the best care possible.

Clinical doctors try drugs off label and report are findings to other doctors. If enough doctors see similar results then the academia doctors eventually prove us right or wrong.

There is a difference though in the way we approach things which I was trying to explain but one way is not necessarily better than the other. They both have advantages and work together to provide the highest level of care possible!

I hate to say this, but methylene blue is also used to treat tropical fish for ich.

So how long before...

Safe at Home said:

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I hate to say this, but methylene blue is also used to treat tropical fish for ich.

So how long before...

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Well, I'm headed to Petco. Who's with me?

Today I have a patient with bad multifocal pneumonia, on 5-6 L NC and all the inflammatory markers are way up. They have some comorbid conditions and are on 3 chronic QT prolonging medications with a QTC of close to 500. Because of this, and because they are 9 days out from symptom onset, I didn't mess with HCQ and went straight to toci in an attempt to keep them from getting intubated. We'll see how it goes overnight as the patient is being monitored in the ICU. Might give another dose tonight if they keep fevering.

This sounds like exactly where Toci has been getting the results that open people's eyes. I hope your patient turns a corner in the next 12 hours.

Despite many people (won't go into who/why as that's for the politics board), but two major medical schools are not following the herd of naysayers.

https://covid.yale.edu/clinical/protocol/COVID-19%20TREATMENT%20ADULT%20Algorithm%204.3.20_381497_47435_v3.pdf

https://inside.upmc.com/upmc-launches-clinical-trial-to-fast-track-covid-19-therapies/

Just one comment regarding HCQ from a health agency point of view. Before you (/government you) purchase millions upon millions upon millions of pills to enact effectively a mass administration program similar to ones run by the WHO (perhaps larger), don't you think you should know if you're getting a return in effectiveness and best treatment indication(s) before putting the money/effort behind it.

Thanks that's a nice flowchart

Dr. Raoult doubles down on the HCQ/Az combo.

French doc releases abstract on 1061 patients treated

TLDR: The HCQ-AZ combination, when started immediately after diagnosis, is a safe and efficient treatment for COVID-19, with a mortality rate of 0.5%, in elderly patients. It avoids worsening and clears virus persistence and contagiosity in most cases.

Rapier108 said:

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Despite many people (won't go into who/why as that's for the politics board), but two major medical schools are not following the herd of naysayers.

https://covid.yale.edu/clinical/protocol/COVID-19%20TREATMENT%20ADULT%20Algorithm%204.3.20_381497_47435_v3.pdf

https://inside.upmc.com/upmc-launches-clinical-trial-to-fast-track-covid-19-therapies/

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Nearly everyone is utilizing it in their treatment algorithm. That really says nothing about any institutions collective belief that it works or not. The flowchart you posted even acknowledges it isn't evidence based and standard of care is supportive.

McInnis 03 said:

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Any update on the situation after dosing toci?

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Didn't get intubated and inflammatory markers are going down. Patient feels a little better.

Quote:

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https://inside.upmc.com/upmc-launches-clinical-trial-to-fast-track-covid-19-therapies/

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Derek Angus is a world renowned critical care physician and researcher. He's been designing and promoting adaptive trial designs for at least 5 years. I recall sitting enthralled listening to him describe much the same trial design at an SCCM annual congress 4-5 years ago. Then again, I sit enthralled listening to him describe anything in his Scottish brogue

Another great researcher I've worked with, ID physician Andre Kalil in Nebraska, is running an adaptive design trial with NIH, starting with remdesivir. https://www.nytimes.com/2020/04/09/health/coronavirus-remdesivir-kalil.html


edited to add: LOVE this quote from Derek when he explains why we need to do trials: "We want to do the very best possible treatment for the patient in front of us, but we want to do even better treatment for the patient who comes tomorrow."