Like a wedding guest piling food from a buffet onto their plate until there is no place left, doctors have been prescribing fistfuls of drugs when attempting to manage patients with Covid-19. We summarise based on current evidence from around the world, what scientists say works and does not, from among the treatments currently in vogue in India.
Azithromycin: This must be the most widely prescribed and misused antibiotic in this pandemic. Azithromycin, as with all other antibiotics, does not work in viral infections. Antibiotics are only warranted in patients who have evidence of a secondary bacterial infection as some hospitalised patients will have in the later stages of their disease. Indiscriminate use (as was the case even before the pandemic) in the hope that they will prevent bacterial infection only worsens antibiotic resistance, to which India is a frequent contributor.
Blood Thinners: Hospitalised Covid-19 patients have been observed to have a very high incidence of blood clots. There is current global consensus that all hospitalised Covid-19 patients will benefit from blood thinners injected daily just under their skin (like insulin injections). Though there is sound mechanistic reasoning, randomised controlled trials are awaited.
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BCG & other existing vaccines: While the world eagerly awaits a new and SARS-CoV-2-specific vaccine, the use of existing vaccines (BCG, Polio, MMR vaccines) in the hope they will work is inappropriate. Trials are under way to see if they will boost innate immunity. We know that BCG has already been given at birth to all Indians, and it does not seem to have helped keep our case numbers low.
Vitamin C: More vitamin C may have been consumed than oranges since Covid-19 began! It doesn’t work.
Vitamin D: A large meta-analysis just released shows that Vitamin D does not protect against Covid-19.
Favipiravir: This is an oral antiviral drug which was fast tracked by the Indian Drug Controller but is not yet approved in the EU or US. Its use should be restricted to mild or moderate infections only. Available data to support its use is sparse but Indian trials have just been completed and the results are awaited.
Hydroxychloroquine sulphate (HCQS): We now have compelling data from multiple large clinical trials including WHO’s SOLIDARITY and the UK’s RECOVERY trials to categorically say: HCQS does not work. Even Donald Trump may have stopped taking it by now — and so should you.
Ivermectin: This is an anti-parasitic drug widely prescribed in India and parts of South America to treat infections from worms. There is no evidence it has any role in Covid-19. It should not be used.
Miscellaneous “cures”: The state machinery has been used to distribute unproven herbal and Ayurvedic potions (Ukalo), homeopathic drops (Arsenicum album), and “treatments” peddled by god-men. Anecdotes and observations do not constitute scientific evidence. In the absence of evidence generated from rigorously vetted clinical trials, the distribution of these substances must be condemned. Pushing unproven and supposedly harmless “treatments” and distributing them to hundreds of thousands is not only disingenuous, but provides people false hope, and risks them lowering their guard. There are no magic pills to boost immunity to fix years of malnutrition, stunting, obesity, and chronically inflamed lungs.
Oseltamivir: This is an antiviral agent prescribed for tempering symptoms from the virus that causes influenza. It has no role in treating Covid-19 infection which is caused by a coronavirus.
Plasma: Our blood is composed of cells and plasma. Plasma from those who have recovered from Covid-19 carries naturally acquired antibodies, and, when transfused to critically ill patients with Covid-19, may help improve outcomes. This form of therapy is being used across the globe and trials to access its efficacy are under way.
Remdesivir: An intravenously administered antiviral medication, it has been shown to be effective in well-designed studies. It seems to shorten recovery time and hospital stay but does not reduce the chance of death. It is currently to be used only in hospitalised patients with severe disease.
Steroids: The only drug so far shown to have a striking impact on mortality is an old and inexpensive one. Current evidence shows that dexamethasone can reduce deaths by one-third in patients with severe Covid-19 infection who need oxygen therapy or ventilators. Their use should, however, be restricted to hospitalised patients. If they are given too soon in the course of an infection, or given to someone with only a mild infection, they could prevent the body’s own immune system from fighting the virus effectively.
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Tocilizumab: This drug is an injection originally used in patients with rheumatoid arthritis. It is being widely used to counter the severe inflammation (cytokine storm) that occurs in some Covid-19 patients. Its use can increase the risk of bacterial infections, and it must therefore be used with caution, if at all, in carefully selected patients.
Zinc: This mineral is also commonly prescribed, despite there being no evidence that it is effective.
In conclusion, six months into the pandemic, we must therefore acknowledge four facts:
- There are few proven treatments for Covid-19 to date, and most will help sicker patients. Dexamethasone, remdesevir, and blood thinners are all proving beneficial: each under very specific circumstances.
- The majority of patients will get well on their own without any treatment. In most, a healthy immune system will mount its own defence against the virus and overcome the disease. It is, however, said that physicians in India have always felt compelled to prescribe medications to their patients, because patients expect it. This is a self-fulfilling prophecy. As with other bad habits during the pandemic, now is a good time to break it, once and for all.
- Most current Covid drug studies are anecdotal reports or observational studies, which are not the same as, and inferior to, randomised controlled trials (RCTs) where impact on the disease is studied in two comparable groups with and without intervention. The mere announcement of a trial, anywhere in the world, even if an RCT, is not a green light for us to start prescribing these medications in the desperate hope that they will work.
- Some of the drugs in current use are likely to end up doing more harm than good. Now, more than ever, let us not abandon the primary Hippocratic injunction of Medicine: ‘primum non nocere’ — first, do no harm.
(Dr Zarir Udwadia is Consultant Chest Physician, PD Hinduja Hospital & Medical Research Centre, Mumbai. Dr Satchit Balsari is assistant professor in Emergency Medicine and in Global Health at Harvard University’s medical and public health schools. )
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