October 30, 2020
By Douglas L. Jennings, PharmD, FACC, FAHA, FCCP, FHFSA, BCPS
As the summer heat yields to the crisp autumnal air, and the verdant forests now turn to bright hues of yellow and orange, we find ourselves on all hallows eve. Nothing this year has been more terrifying than the COVID-19 pandemic, which grips the nation as daily case counts continue to soar. While the pandemic itself is certainly scare-worthy, nothing is perhaps more terrifying to a pharmacist than when good drugs go bad. In the spirit of Halloween, we take a look at some drug therapy “monsters” that if spotted, should be taken out on sight.
Hydroxychloroquine, “The Zombie”
Like the proverbial undead, stretching their decaying limbs as they ascend from the tomb, this antiquated drug therapy simply will not die. Sketchy endorsements from various politicians—along with some questionable evidence—bolstered initial support for this immunomodulatory drug therapy. Fortunately, the final results of the RECOVERY trial—which clearly demonstrate no benefit for this therapy—were published October 8th in the New England Journal of Medicine. At this point it’s time to load the shotguns. If you see this drug therapy zombie lurking the halls of your COVID-19 unit, shoot on sight.
Tocilizumab, “The Werewolf”
Like those unfortunate souls of yore who were afflicted with lycanthropy, those who contract COVID-19 are at risk of having their bodies hijacked and turned against themselves. In this COVID-19 scenario, the patient’s overactive immune system wreaks havoc, and causes potentially lethal damage to key organs and tissues. This pathophysiology makes immunomodulatory agents like tocilizumab—an IL-6 receptor antagonist—attractive therapeutic options for COVID-19. Unfortunately, 3 recent randomized trials failed to demonstrate any benefit of tocilizumab in patients hospitalized with COVID-19. So until further notice, treat tocilizumab like the Wolf Man and grab your silver!
Dexamethasone, “The Vampire”
Vampires are notoriously two-faced: masquerading as humans while simultaneously concealing a sinister, deadly side. Such is the story of corticosteroids for the treatment of COVID-19. Compelling evidence shows that dexamethasone (and other steroids) can reduce mortality in patients with severe symptoms of COVID-19. As a result, the most recent guidelines endorse dexamethasone as a treatment option for patients with COVID-19 who have significant oxygen requirements (high-flow nasal oxygen, noninvasive ventilation, or invasive ventilation). However, just as the duplicitous blood sucker turns dangerous after the sun goes down, use of dexamethasone in other COVID-19 scenarios can be dangerous. There is no data to support a benefit in patients with less severe manifestation of COVID-19, and as all corticosteroids can suppress the immune response and promote viral replication, dexamethasone should not be used in patients without significant hypoxemia. Bottom line: dexamethasone in mild stages of COVID should be given the count’s royal treatment—doused in garlic and left to bask in the morning sun!
Dr Jennings is currently an Associate Professor of Pharmacy at Long Island University and the clinical pharmacist for the Heart Transplant and LVAD teams at NewYork- Presbyterian Hospital Columbia University Irving Medical Center. He is an active researcher in his field, and he has published over 120 peer-reviewed abstracts and manuscripts, primarily focusing on the pharmacotherapy of patients under mechanical circulatory support. As a recognized expert in this area, he has been invited to speak at numerous national and international venues, including meetings in France, Saudia Arabia, India. Finally, Dr. Jennings has been active in professional organizations throughout his career. He is a fellow of the American College of Clinical Pharmacy, the American College of Cardiology, the Heart Failure Society of America, and the American Heart Association.