Hydroxy for the Poxy

By SAM URETSKY

The New Yorker’s daily satire, The Borowitz Report (5/19) had the headline “Do Not Take This Drug” with the subhead “New Test Indicates Hydroxychloroquine Causes Delusions.” The magazine, which has a reputation for accuracy, notes that the piece is satire, and its description as “not the news” has accidentally been completely accurate.

The New York Times reported, “President Trump said on [May 18] that he had been taking hydroxychloroquine, an antimalarial drug the Food and Drug Administration warned could cause serious heart problems for coronavirus patients. He said he was taking the drug as a preventive measure and continued to test negative for the coronavirus.”

This is a drug that the Food & Drug Administration has warned, in a special web site, “FDA cautions against use of hydroxychloroquine or chloroquine for COVID-19 outside of the hospital setting or a clinical trial due to risk of heart rhythm problems.”

It’s important to recognize the difference between over-the-counter drugs (OTC), those you can buy at a drug store, supermarket, or vending machine, and prescription drugs, those which can only be ordered by a licensed professional and dispensed by a registered pharmacist. We think of OTC drugs as being safer than prescription drugs, and to some extent that’s true, but the more important consideration is that an OTC drug is one that a person with no special training can be taught to use with a good margin of safety.

A 2015 report in British Medical Journal began, “Across the 625.2 million ED (emergency department) visits in the USA from 2006 to 2010, 411 811 APAP aceto para aminophenol, better known as acetaminophen) -related toxicity ED visits were observed, with 45.5% resulting in inpatient admission, 4.7% requiring invasive mechanical ventilation and 0.6% involving death.”

Even the low dose aspirin which is given to prevent heart attacks, has been associated with bleeding ulcers. Safety is a relative thing.

By law, all drugs must be accompanied by an information sheet variously called a “package insert” or “full disclosure,” giving all the information needed to take the drug with at least a fair margin of safety, so that the benefits outweigh the risk. The package insert for an OTC drug is fairly short and easy to understand – the PI for a prescription drug is longer, and a good deal more abstruse.

There is a tremendous amount of information given in these sheets, special warnings, uses, doses, information on how the drug is absorbed and how it’s eliminated, and information about the adverse effects. The more common adverse effects are those which showed up in controlled studies, but there’s also a section for postmarketing surveillance, reports that came in after the drug was approved for sale. These reports are largely anecdotal – something bad happened to a patient who was taking the drug, but it may have been coincidence. It’s not uncommon to find totally contradictory reports – insomnia and somnolence, diarrhea and constipation. Any drug that’s been used widely enough and long enough will have a very long list of postmarketing adverse effects. Even so, when the list is long enough, or the effects are severe enough, they deserve attention.

The list of adverse effects of chloroquine includes the following:

Cardiovascular system: Cardiomyopathy, prolonged QT interval on ECG, torsades de pointes, ventricular arrhythmia, ventricular tachycardia

Endocrine & metabolic: Hypoglycemia (can be severe)

Hematologic & oncologic: Neutropenia, pancytopenia

Nervous system: Agitation, confusion, delirium, extrapyramidal reaction, hallucination

According to the Times, “Mr. Trump continued, explaining that his decision to try the drug was based on one of his favorite refrains: “What do you have to lose?”

Mr. Borowitz said that the evidence that hydroxychloroquine causes delusions was based on a preliminary observation involving one white male subject in his seventies. Sounds about right.

Sam Uretsky is a writer and pharmacist living in Louisville, Ky. Email sdu01@outlook.com.

From The Progressive Populist, June 15, 2020

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