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Pharmacists are bracing for violence as people try to hoard malaria drugs Aralen (chloroquine) and Plaquenil (hydroxychloroquine) U.S. President Donald Trump falsely touted as "available almost immediately" for COVID-19 treatment.
The statement has led to drug hoarding, even though the only study showing effectiveness involved a subset of just six French patients who received hydroxychloroquine. Any other evidence is mixed and anecdotal.
Even with scant evidence, multiple sources agree these drugs are only for the sickest, most compromised patients. There is no evidence taking chloroquine or hydroxychloroquine can prevent COVID-19.
"The main point is the potential safety of the people who work in the pharmacy -- there has been a lot of heightened emotions when pharmacies don't have it," said Aileen Chi, a San Francisco Bay-area Pharm. D. who worked as a pharmacy practice resident at UCLA medical center's organ transplant department and in the research division of a pharma company.
"There are increases in firearm sales. A lot of pharmacists are worried that these heightened emotions can lead to violence against them. Half my (social media) wall is pharmacists sharing concerns. It's crazy times out there -- I never thought we'd have to put drugs like these in a safe and worry about people pulling guns to get them."
Aralen and Plaquenil are sister drugs developed decades ago to treat malaria. They've shown some anecdotal evidence in shortening the duration of COVID-19 coronavirus disease in patients with severe symptoms.
But these drugs are dangerous in themselves, and more so in combination with the antibiotic azithromycin (a drug combo implicated in the French study evidence for COVID-19 treatment by Aralen and Plaquenil).
Furthermore, even though these two drugs were first indicated for malaria, later the FDA approved them for use in patients with the chronic diseases lupus and rheumatoid arthritis. These drugs are vital to control flares of these autoimmune diseases, Chi said, and not having them is life threatening to people with lupus and RA.
Chi, who currently works as a medical science liaison with clinicians and other medical professionals for Dova Pharmaceuticals, explained some of the dangers of Aralen and Plaquenil, as well as the problems with hoarding and desperate COVID-19 patients.
MedicineNet: What do you think about all the hype surrounding chloroquine and its sister drug hydroxychloroquine?
Dr. Chi: I think the pharmacy community would be behind it if there were actual solid evidence, but there is limited data that is actually being published. Don't get me wrong, it's promising, but there isn't the evidence to say it's a magic bullet.
The single study is a France study in which they used the drug in a very small number of patients -- only six patients.
Some patients were on other drugs already -- the ones that were also on azithromycin by coincidence showed a greatly reduced viral load.
The thing is, this is not a randomized, controlled trial, which is a better-designed trial. This is an "open label" study where you're just observing patients. As a result it's hard to isolate variables -- there are a lot of variables with these patients, so we can't tell if this drug is what's making them better.
Also, we don't know what viral load means to clinical efficacy.
Meaning, if you're still stuck in bed fevering and short of breath with a low viral load, the fact that it's low doesn't mean much to you. It could make a difference, we just don't know yet.
MedicineNet: What is chloroquine?
Dr. Chi: It is approved as an antimalarial drug across the world. This drug is being used by patients with lupus; patients with rheumatoid arthritis are on it. It controls the flares of their disease. If anyone has ever had joint flares or a lupus flare, it can be life threatening.
When there is an excess demand for a drug that isn't in wide use, the production takes time to catch up. Right now, what we're seeing is a shortage across the U.S. due to the high demand for people using it for COVID-19.
MedicineNet: What's the difference between chloroquine and hydroxychloroquine?
Dr. Chi: The two drugs are basically two drugs of the same class. Hydroxychloroquine has a different salt base. Hydroxychloroquine is more potent and better-tolerated for most people.
Chloroquine has been known to prolong the QT interval -- that's part of the wave of the electrical signal of your heartbeat measured on an EKG. When this is prolonged, it can put you in a state of arrythmia called Torsades de Pointes, and that is life-threatening. It can cause sudden cardiac death.
Hydroxychloroquine, even though it's better tolerated, also has similar effects on the heart. It can actually exacerbate underlying heart conditions and cause chronic toxicity as well.
It has to be used under the supervision of a physician. A lot of people who do use these drugs do have an underlying condition.
MedicineNet: But people aren't taking it under the supervision of doctors?
Dr. Chi: People are using it based on what they see all over the internet, and the dosing isn't controlled in a way that will ensure people taking it reduce their risk.
Also, when drugs are taken in combination together, the risks of side effects are more profound. Take azithromycin -- that is a QT-prolonging medication itself. In addition to the gastrointestinal side effects -- diarrhea, nausea -- azithromycin by itself can cause life-threatening arrythmias.
There are people who believe that if you take it in short courses you can avoid the side effects that are reported for the drug, but that's not totally true. If you're taking it in higher doses in a short amount of time, then the risk for side effects can increase with the dose, no matter how short the course is.
When you're using it with drugs like azithromycin, the risk is still going to be high.
MedicineNet: Is there enough of these medications for the people with lupus and rheumatoid arthritis?
Dr. Chi: Right now, we're depleting supplies from people who need it. The whole supply chain is connected all over the U.S. That means if they don't have it in the community, they don't have it in the hospital.
We do agree that it has to be used in some (COVID-19) patients -- but now we're seeing people hoard it for prophylactic purposes, to prevent coronavirus.
MedicineNet: And in the meantime, those people with RA and lupus could die without these drugs?
Dr. Chi: And also patients with severe COVID-19 symptoms whose life might be spared by using this drug. We don't know for sure, but that little bit of evidence lends us some potential utility as part of the arsenal, whether or not it works.
MedicineNet: Anything else we should know about Aralen and Plaquenil? Warnings?
Dr. Chi: There are multiple forms of chloroquine used to clean fish tanks -- please do not confuse the two. They can be toxic, causing fatal overdose.
(Editor's Note: An Arizona man died March 23 after ingesting chloroquine phosphate fish tank cleaner, according to the Phoenix New Times.)
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