Much of the print news and online commentary to date seems to fundamentally miss the point regarding why the drug combination of hydroxychloroquine and azithromycin might be very effective for treating and/or preventing severe cases of COVID-19 infection.
Even worse, many well-known media seem to be suffering from a derangement syndrome and have been promoting stories that clearly misrepresent the potential utility of hydroxychloroquine and azithromycin.
Furthermore, why are most COVID-19 cases simply like a “common cold” but in other patients (not just old people) there’s a rapid unexplained progression that often leads to death?
In other words, hydroxychloroquine and azithromycin work together to treat or prevent severe presentations of COVID-19 cases (when administered early enough) because they are treating (suppressing) a preexisting mycobacterial infection that has been activated by the COVID-19 infection.
The azithromycin is working as an antibiotic to treat a bacterial infection (i.e., the activated mycobacterial infection) that is attacking the lungs as well as other organs in the body. The combination with hydroxychloroquine is important because it enhances the antibiotic activity of azithromycin (by increasing the pH of the cellular micro-environment).
And in particular, NIH states that “[t]here are insufficient clinical data to recommend either for or against using chloroquine or hydroxychloroquine for the treatment of COVID-19 (AIII) ... [and] [w]hen chloroquine or hydroxychloroquine is used, clinicians should monitor the patient for adverse effects (AEs), especially prolonged QTc interval (AIII).”
The apparent ambiguity in the NIH guidance appears because it states that there’s not enough information to make a recommendation “for or against” the use of any antiviral or immunomodulatory therapy—which necessarily includes the drug combination—but then recommends “against” use of the drug combination outside of a (formal) clinical trial.
The guidance “against” use of the drug combination is misplaced, because it’s well accepted that drugs and therapies are used “off-label” routinely by competent medical practitioners to the benefit of patients without the requirement of instituting and running a formal clinical trial.
It’s not clear to me that the available evidence regarding the use of hydroxychloroquine in combination with azithromycin supports a “risk/benefit” assessment that warrants a blanket recommendation against off-label use.
At risk patients on a case-by-case basis should be allowed and encouraged (with their treating physician) to assess and to choose between the potential risk of QTc prolongation from off-label use of the hydroxychloroquine in combination with azithromycin and the alternative risk of almost certain terminal outcomes if there is progression to intubation/ventilation therapy.
Understanding that the coronavirus pandemic morbidity may be attributable at least in part to a preexisting mycobacterial infection may be critical to identifying and deploying in the short-term cost-effective off-the-shelf counter measures (e.g., the combination of hydroxychloroquine and azithromycin) that will immediately save lives and potentially arrest the panic associated with extreme manifestations of the COVID-19 pandemic.