Via Financial Times

From the Oval Office to India’s top medical body, an old malaria drug is getting ever more billing as the world’s most immediate hope of an accessible treatment for coronavirus.

President Donald Trump has led the way as a champion of hydroxychloroquine, branding the drug a “game-changer” and inspiring boosterism on Fox News. India is recommending all its healthcare workers take the drug — which contains a synthetic form of the quinine that once made gin and tonic a popular antimalarial — and it is being tried out on a limited number of Covid-19 patients in Europe.

But some experts say that is a dangerous gamble given a lack of proof about the drug’s efficacy and the danger of side-effects.

Rather than a calculated risk, Mr Trump’s salesmanship has fostered a view that the rush to hydroxychloroquine is the result of desperation to find a way out of the pandemic. Advertising the drug’s potential from the White House podium, the US president himself said: “What do you have to lose?”

Eric Topol, director of the Scripps Research Translational Institute, said the promotion was “reckless, feckless and deplorable”. 

“It is singular in history where you have a president who is going against all the science,” he said. Mr Trump though has faced the same charge over playing down the threat of climate change.

Peter Navarro, Mr Trump’s top trade adviser, was reported to have handed out studies on the drug at a recent coronavirus task force meeting, claiming he understood them because he is a social scientist. But Trump allies are building their case on small studies that fail to meet scientific standards, as well as claims from an eclectic mix of doctors including a maverick French virologist Didier Raoult and Mehmet Oz, host of US TV’s The Dr Oz Show.

The federal government’s top infectious disease specialist, Dr Anthony Fauci, has taken a different view, warning that information on whether the drug works was “anecdotal”.

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“I think we’ve got to be careful that we don’t make that majestic leap to assume that this is a knockout drug,” he said earlier this month.

If hydroxychloroquine does work for Covid-19, no one is sure how. A 2006 study on Sars suggested it did not act as an antiviral that stops viruses from replicating, but some believe it may help treat patients by acting as an anti-inflammatory or helping the immune system fight the virus. 

Magnus Gisslen, a professor at the University of Gothenburg in Sweden, who is treating Covid-19 patients, said the hospital stopped using the drug a couple of weeks ago after hearing reports of significant side effects, which include those on a patient’s vision and heart. 

“Doctors are wrong to rush to treat people,” he said. “Evidence-based medicine is important.”

There have been reports around the world of overdoses of chloroquine, a related but more toxic drug, and while hydroxychloroquine is somewhat safer, the number of poisonings involving the drug doubled in the US in recent weeks, according to the American Association of Poison Control Centers.

In China the central government recommended chloroquine in early February, but then had to adjust the dose because of side effects. There is no official government guidance on hydroxychloroquine.

India has been less cautious, with a Covid-19 task force set up by the Indian Council of Medical Research recommending that it be taken by frontline healthcare workers likely to be exposed to coronavirus.

India, the global leader in generics manufacturing, also banned exports of hydroxychloroquine and its active ingredient. The US federal government, meanwhile, has stockpiled 30m doses. Those moves have contributed to shortages in the US and Europe for people who need it for its proven purposes — not only for malaria, but also for treatment of the autoimmune diseases lupus and rheumatoid arthritis.

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In the US, the Food and Drug Administration has given it emergency approval, meaning it can be used to treat Covid-19 while there is no approved alternative available.

But Jeremy Faust, an emergency doctor at Boston’s Brigham and Women’s Hospital, said one problem was that some doctors treating coronavirus are “throwing everything in the kitchen sink and seeing what happens” — and not isolating which drug it was that worked.

Editor’s note

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Mr Trump’s enthusiasm appears to be linked to a French study that claimed success in treating patients with hydroxychloroquine and the antibiotic azithromycin. But last week the medical journal that published it said it did not meet its standards. 

Other studies have been small, hurried and not gone through the peer review process that is meant to ensure robustness before publication. They have shown mixed results: one paper from China showed hydroxychloroquine working, another found it did not.

Michael Ackerman, a cardiologist at the Mayo Clinic, said although hydroxychloroquine was likely to be safe for 90 per cent of people, they were “potentially deadly” for a small proportion because they can disrupt the heart’s electrical system. “We could end up with drug-induced sudden cardiac death,” he said.

There can also be psychological side effects. Jessica Gold, assistant professor of psychiatry at the Washington University in St Louis, noted that the drug had been associated with increased anxiety, depression and sometimes psychosis.

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Most scientists are not intent on dismissing the drug as snake oil. They just want to wait for the results of large trials examining its safety and efficacy, including ones run by the World Health Organization and the US National Institutes of Health.

In the mean time, said Vish Viswanath, professor of health communication at the Harvard School of Public Health, it had become harder for accurate messages to reach people through the mainstream media — and easier for people to access scientific journals and make their own interpretations. This breeds unhelpful suspicions, he said, that “scientists never make up their minds”.

Additional reporting by Stephanie Findlay in New Delhi and Wang Xueqiao in Shanghai