Dr. Collins' corona choices

Faith & Science Conversation
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The efficacy of an off-label use of a drug must be put through research and testing before it can be signed off on. He was speaking to the general populace, and “side effects” is the word choice he decided to use here, but he went on to discuss how it has not yet had enough evidence in cases for this use.

I don’t see how being concerned for the severity of these effects when there’s not enough data to back up its success is in any way a contradiction to “do no harm.” It sounds to me like he IS concerned and this is a very standard ethical consideration in medicine.

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Wow!! Quite a response. I’ll just walk passed the condescension and chuckle a thank-you for your time!

If I said “that Dr. Collins is unfairly or disingenuously holding back on something that he knows will help,” that was not my intent. Rather, it was my intent to ask about what appear to be different and/or inconsistent principles that are no doubt sincerely held.

Your own statement, “not yet been shown to be” reflects a standard for showing that you share with Dr. Collins – a standard that is valid even if it is not the only valid standard available. Your way of seeing is valid, but there may be other valid ways of seeing. I understand – we all get caught up in our profession’s way of seeing, and often discount other ways because of that.

The statement “you don’t want millions in the public to become your guinea pigs” is telling. A few days ago, there were reportedly some 41,000 hospitalizations, growing a few thousand daily. Not quite “millions.” As for doctors in those hospitals treating their patients as “guinea pigs” if they supervise the use off-label drugs – well, that’s not something I worry about. The doctors who have taken care of me over the years aren’t perfect, but they’re capable and caring. I don’t need to disparage them to feel good about what I do.

Your belief that the news media only reports successes is … charming.

I’m glad that you recognize healthcare has financial costs and constraints. As I recall, Dr. Collins said in the interview that this should not be the case in the US, perhaps just for coronavirus. As for shutting one’s “eyes to evidence and obligatory medical policy,” again, this presumes principles and standards for what one considers evidence and obligation. And no doubt you and he are sincere and resolutely believe you see things just as they are. Like everyone believes!

This assumption underlies your comments on auto design. You may be surprised that there was a time when we (or perhaps your parents) did drive around in “virtually armored ‘tanks’ .” Whether it’s right or wrong to find the expense unworthy – you seem to assume it’s universally right – the reason for redesign was not to save money; it was to reduce gas consumption and to improve air quality – things valued more by decision-makers than “a few lives from traffic fatality.”

I’m glad that you count yourselves among “at least a few good competent individuals still left in our present federal government…” But more likely there are a lot of good competent individuals in the present federal government (and in hospitals, going back to your earlier comment) – it’s just that they don’t fit into your tribe. Pity.

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One of the potential side effects of hydroxychloriquine is death by cardiac arrest. It’s not an “economic orientation” or a violation of the Hippocratic oath that doctors do a cost/benefit analysis and weigh “do good” with “do no harm.” That’s basic medicine. I don’t think it is analogous to put “costs” to health in the same category as “costs” to the economy. The question is “Should we recommend the use of a drug that has unproven benefits and known lethal side effects in some cases?” The answer is “No, not until we know more about whether the potential benefits justify the potential risks.” That seems pretty straightforward to me from an ethics point of view.

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No, it was not. It was an analogy showing how a treatment that is worthless has real costs in terms of human life, that can be appled to hydroxychloroquin as well. If I did not respond to your point, that was due to difficulty in understanding what your point was. I assume that is was in this sentence:

In other words, it seems you agree that you have the factor in the non-monetary costs when you propose a treatment. And I interpret Dr. Collins’ words as saying we have no evidence that the benefit of this particular treatment exceeds the harm it may cause at the present time. I have trouble understanding what you are asking as that seems in agreement. Care to restate your question?

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One of the potential effects of treatment with chloroquine or hydroxychloroquine is to make viral illnesses worse. In fact, that’s the only effect on viral illnesses that has actually been demonstrated.

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Live and learn

It’s not 1918 and we have a much more advanced medical technology. In this the first phase of the pandemic we need to continue these primitive distancing and containment methods. In the second stage we should be able to use our advanced medical abilities to effectively mitigate this pandemic. It is very possible that the virus like measles another airborne virus will wane during the warmer summer months due to transmissibility and seasonal immunity. In the upcoming second phase of the pandemic we should have identified from available medications that are already fda approved with known effects to treat the high risk patients intervening at an early stage preventing progression to the more severe conditions. Whatever the treatment It is known that viruses must be treated early to prevent the disease progression especially for the most at risk to experience more severe conditions. Early treatment for viruses such as the flu is necessary for the use of antiviral agents. We need to expeditiously and aggressively use this time in the first stage of the pandemic to actively explore these potential early intervention treatments. It is likely that once a patients ARDS symptoms appear it will be difficult to treat with any medication or therapeutic plasma /antibodies.

The current strategy for treatment and standard of care must be improved. There are currently upwards of 150 studies in the works in the US evaluating drugs and various therapies. We don’t need a treatment to cure this disease we only need a drug or more likely a cocktail of drugs to prevent patients going into the most severe forms of the disease needing ICU and assisted ventilation while improving overall outcome. Ideally we will have a take two and call me in the morning regimen available especially for those in highest risk groups that come down with the virus early in its course. The severe effects seen in some patients are primarily not due to the viruses direct damage but by the patients immune response and inflammation generated in response to the virus. Many times infected patients rapidly go from a stable condition to becoming unstable needing ventilation and experiencing organ failure. It is obvious that doctors must have a regimen for early intervention to prevent the onset of severe symptoms.

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It seems to me that the people who are saying, “Some older and/or already unhealthy people need to be sacrificed for the good of the economy, that’s an acceptable cost” are the same people saying, “Some people who have severe side effects to an untested drug regimen need to be sacrificed, just in case it helps some people, that’s an acceptable cost.”

Then there are others who say neither of those scenarios are acceptable. I don’t see the inconsistency.

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That observation wasn’t with regard to official news media outlets - which, it cannot be doubted, love to delve into tragedy and failure of all sorts. It was more a reflection on our personal preference for what we like to “noise abroad” of our own experiences. I think we have a bias towards remembering and sharing our apparent successes. If I try some remedy and it appears to work for me, it’s news that I’m most eager to share. And then I’m probably less likely to recall other instances where this same remedy (now invested with my hopes) may have failed. And in this age of social media and self-publishing, all this kind of bias becomes part of our world of news and personal influence.

Sorry about tones of condescension. It is condescension towards my own tendencies too as much as anyone else’s.

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I don’t see any inconsistencies. The cost in lives is not the same as cost in dollars. You can say that we shouldn’t spare any costs in getting good medicines to people while at the same time determining which medicines are good. If we don’t know the risk-benefit ratio for a medicine then it would be improper to push it.

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Christy. For myself I do know, that almost all drugs have dangerous side effects and contraindications often including death. Consider many of the cancer drugs which often essentially are cytotoxic. In fact consider that many over the counter drugs can have severe side effects or contraindications. The pharma industry and the FDA put these drugs through a somewhat rigorous testing regimen to identify safety and efficacy. Often in this testing and early in the release of the drug side effects and contraindications are identified sometimes much later! These are often mentioned in the fine print on commercials. ( may cause death)The FDA takes these side effects versus the benefit in weighing the drug suitability for use. This is the risk/benefit of the drug. All drugs have this risk benefit statistical analysis. What I am saying is that the standard of care for Covid is clearly not working now and we are losing to many patients to this virus. We have to figure out a regimen of FDA approved drugs that we already know their side effects and contraindications to intervene early In the progression to save lives. I know that people are talking about Chloroquine here but I am actually referring to a larger number of potential FDA approved drugs treatments to intercede early in the disease to reduce onset of the severity. There are a good number of fda approved drugs in trial to evaluate this risk/ benefit vs Covid 19. The FDA approved drugs will have well understood side effects and contraindications. We have a lot of very smart doctors around the country and we need them to be able to respond to their patients needs at the clinical level. I have seen many doctor communications where like in any war are figuring out the rules of engagement and looking for ways to improve standard of care treatment. As is the case with all viruses I am sure we need to intervene early as possible to prevent those at most risk categories from developing the severe conditions which is too late and difficult to treat. Personally, if I were in a high risk category I would rather take my chance with an early intervention with a drug with known side effects as long as I know that I don’t have a comorbidity contraindication to that drug than wait to see if I develop severe symptoms. Wouldn’t you?

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Early automobiles were relatively heavy with metal, to be sure, but not necessarily safer. And (as I think you are suggesting) there were other motivations in play for the young and exploding technology - originally an exclusive toy of the rich. Those “tanks” may have been heavier - but the only safety they had going for them compared to today’s vehicles would have been that they couldn’t go as fast. Apart from that - they were death traps, not just for the people in them, but the pedestrian populace still adjusting to their presence as well. No seatbelts, air bags, etc. And other less obvious features now help protect us in the modern auto. E.g. the made-to-collapse engine compartment that serves as a cushion between a solid frontal collision and the passenger compartment. In such an event, the last thing passengers would want is for their vehicle to be an entirely rigid structure - thereby transferring the entirety of the impulse straight onto the unfortunate occupants. If you’re going to have a wreck, you definitely want it to be in a modern car - not an old one. The much higher speed of the modern car would be the only factor that reduces the safety advantage the modern has over the old. But our infrastructure and behaviors also changed to accommodate those higher speeds.

Not sure what you even meant by the above. First - competent or not - I’m not even in government. Second, right now competence in government is golden wherever it can still be found - in any tribe. And there are times when I want to be able to lean on that competence. If any particular tribe reduces its own store of competency by its policies and attitudes, so much the worse for that tribe and …so much the worse for all of us whether we are members of that “tribe” or not.

[And I should hastily add, that as “golden” as competence is, there is something more valuable (and maybe tragically more rare) yet: integrity. If one or the other had to be missing, we would sadly have to let the competence go - better the bumbling, ineffectual good heart than the intelligent, highly effective devil. Education for the former may be easier to come by than reform for the latter.]

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Sure. But I don’t think it is wise or good practice to just throw drug cocktails at patients with a wish and a prayer. Lots of trials and experimental treatments are currently being investigated in studies with patients. Nobody is saying don’t look for those possibilities because…side effects. They are saying if we don’t know yet that there is any benefit at all to using a certain drug, maybe don’t imply it’s some kind of magic bullet. My friend has taken chloroquine for decades for lupus and now can’t get her prescription filled. That’s not cool either.

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Christy. Blessings and Happy Easter. Ok it is regrettable that since Dr. Trump for political reasons was promoting Chloroquine (Cq)that some are discounting the drug for the same reasons. It seems to me that some people really don’t want a treatment for cv 19? Waiting for a vaccine is not a good idea for the same reservations that many have for drugs. We should note that Dr. Fauci was a leader in the treatment of HIV and we still don’t have a vaccine for HIV. Instead we have a drug cocktail that took many years to develop.

Our medical doctors are really smart and have experience with their drugs indications and contraindications. They know that they need a drug to treat early and prevent onset severity. I know for a fact that they are using many drugs off label to try to treat cv19 based on the patient particular conditions. A battle is not fought well from headquarters and must be fought by the doctors in the field. I have seen respiratory doctors totally perplexed by the sudden onset of severe symptoms essentially helpless to prevent that. In my other posts I have mentioned that this virus works via a specific RAS pathway and in certain patients due to comorbidity or genetics are more susceptible to severity. I can’t stress enough that risk factors require early intervention in those patients rather than waiting for a patient to go south.

We don’t know if the drug (Cq)by itself or in combination with other drugs is effective in prophylaxis or preventing the severity of CV19. We understand the drug well enough in its use with arthritis and lupus as an effective immune suppressant that it may have benefit in reducing the expression of severe symptoms. Especially with positive reports coming from France, China and South Korea. The drug has very well known short term and long term contraindications. doctors know these risks well as the drug has been used effectively for years in arthritis and lupus patients. I doubt that the drug by itself has prophylactic antiviral effects but perhaps in combination with an antiviral agent may be beneficial for infected patients.

Due to the poor outcomes with the standard of care there is great benefit to evaluate drugs efficacy to prevent onset of severe symptoms. there are many other drugs in evaluation such as a number of Arthritis drugs, anti virals, Ace inhibitors, ARBs, anti parasite drugs, convalescent plasma and immunoglobulin. Each of these treatments using FDA approved drugs have well know contraindications. Any of these drugs may be found effective alone or in combination in certain instances. A clinical trial requires testing of drugs with unknown outcomes but we have the benefit knowing the side effects of established drugs and that to not treat the outcome is likely poor and the medical system will be overwhelmed.

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No one is saying that. Trials and studies are currently underway to test the viability in Michigan. https://wwmt.com/news/local/michigan-doctors-see-success-in-covid-19-treatment-but-say-more-clinical-trials-are-needed No is saying don’t test stuff. They are saying don’t make claims that aren’t actually supported.

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Thank you for this reference. I know for myself and hope for all our members to never get their scientific or medical information from politicians or the news media. I don’t put my faith in them. There is a lot of very active medical and scientific research coming out in real time from around the world. It is incredibly active and developing science. Necessity is the mother of all innovation. We really don’t need a magic bullet for this we just need a shotgun approach at this stage to control this virus.

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Clinicaltrials.gov lists all active and recent reputable trials
ClinicalTrials.gov

The above was a US only search, showing 80. You can search outside the US too. Thanks

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Thank you Randy. It is incredible seeing all the information coming out about cv 19 research. It is actually gratifying to see the world of scientist coming together. I am seeing very good research coming out of China and even Iran. Maybe we as a people can learn something from this. Blessings and Happy Easter.

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Iran has a good education system. It is no surprise that they can produce people of the caliber of Field prize winner Maryam Mirzakhani who went to Sharif Institute of Technology before doing her PhD at Harvard or have people doing high level research (though they have the problem of government officials not necessarily listening to scientific advice).

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Yes, I have been following a case study by Dr Reza Nejat of a Covid patient with ARDS that responded in a dose response to the arb inhibitor Losartan. It’s interesting because other studies are showing these as risk factors early in the disease but maybe is beneficial to treat ARDS.

This disease is very tricky. Pathology reports out of China show blood clots in organs and dvt forming. This explains the organ failure seen. The question is why this is happening. It seems to be like an autoimmune response. This virus is playing games with the immune system. Happy Easter and Grace.

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Cost should not be a factor in reaching a cure/anti-viral for this. Governments around the world were short-sighted just a few years ago when SARS appeared. The research got to the penultimate stage, but the final stage was left to private pharmaceutical companies to complete and it never was. Why? Because those private companies decided they would just lose money if they invested £billions only to have to stockpile the vaccine. An absolute disgrace. One wonders how far we would now be into finding a vaccine for Covid-19 if the SARS trials had been done properly. It was a coronavirus too.