Take chloroquine or hydroxychloroquine along with zinc ASAP (so you can avoid being hospitalized). ETA: Preferably after talking to your doctor about it. See references below for more details. If you didn’t buy chloroquine/hydroxychloroquine ahead of time, beg your doctor for a prescription, or call doctors around you until you find someone willing to give you a prescription (because unlike China and South Korea, it doesn’t seem to be part of the standard treatment for COVID-19 in the US).
Based upon limited in-vitro and anecdotal data, chloroquine or hydroxychloroquine are currently recommended for treatment of hospitalized COVID-19 patients in several countries. Both chloroquine and hydroxychloroquine have known safety profiles with the main concerns being cardiotoxicity (prolonged QT syndrome) with prolonged use in patients with hepatic or renal dysfunction and immunosuppression but have been reportedly well-tolerated in COVID-19 patients.
[...] Hydroxychloroquine and azithromycin are associated with QT prolongation and caution is advised when considering these drugs in patients with chronic medical conditions (e.g. renal failure, hepatic disease) or who are receiving medications that might interact to cause arrythmias.
Just because something is dangerous in overdose doesn’t mean that medical supervision is needed: for example acetaminophen, or even water. The relevant thing is that the therapeutic dose is close to the lethal dose for chloroquine, and chloroquine dosing is complicated.
Wei Dai’s first link was a doc with medical guidelines written by people with medical expertise (though not (explicitly) for civilians, I would expect legal risk to deter medical professionals from making guidelines for civilian use). That link is now dead, but archived here.
It included the South Korean guidelines:
According to the Korea Biomedical Review, the South Korean COVID-19 Central Clinical Task Force guidelines are as follows:
1. If patients are young, healthy, and have mild symptoms without underlying conditions, doctors can observe them without antiviral treatment;
2. If more than 10 days have passed since the onset of the illness and the symptoms are mild, physicians do not have to start an antiviral medication;
3. However, if patients are old or have underlying conditions with serious symptoms, physicians should consider an antiviral treatment. If they decide to use the antiviral therapy, they should start the administration as soon as possible:
… chloroquine 500mg orally per day.
4. As chloroquine is not available in Korea, doctors could consider hydroxychloroquine 400mg orally per day (Hydroxychloroquine is an analog of chloroquine used against malaria, autoimmune disorders, etc. It is widely available as well).
5. The treatment is suitable for 7 − 10 days, which can be shortened or extended depending on clinical progress.
Notably, the guidelines mention other antivirals as further lines of defense, including anti-HIV drugs.
My current strategy is to follow these guidelines (with hydroxychloroquine + zinc) if medical treatment is unavailable, there’s strong evidence that the illness is COVID-19, and serious COVID-19 symptoms are present. I’ll also have activated charcoal on hand to help mitigate accidental overdoses. I’m trying my best to familiarize myself with the risks involved so that I can make good decisions if the situation calls for it. Of course, my primary strategy is prevention in the first place.
I haven’t been following developments around hydroxychloroquine very closely. My impression from incidental sources is that it’s probably worth taking along with zinc, at least early in the course of a COVID-19 infection. I’ll probably do a lot more research if and when I actually need to make a decision.
I don’t have the energy to write a 5000 word blog post explaining my reasoning, but I think ≤10% chance HCQ has clinically significant effects against COVID, chances of really impressive effects even lower.
Based on these two studies, it looks almost certain that hydroxychloroquine is at least as safe as a placebo for reducing symptoms [of COVID-19], and the drug probably reduces the incidence of symptoms by a little more than 10%.
The 10% is a relative reduction, not absolute. I don’t know how Scott Alexander defines “clinically significant”. Some authors thought that “significant” meant a 50% or 90% relative reduction in cases, although I personally think that a 10% reduction matters. But I have no medical experience and no medical training. If you read Stat News, you know more about medicine than I do.
I also conclude:
It seems that hydroxychloroquine probably brings down hospitalizations, but it’s unclear by how much.
And:
If you have to go to the hospital, stop taking hydroxychloroquine.
That fact comes from a large (n = 4716) randomized controlled trial, which found that hydroxychloroquine is almost certainly unsafe for treating patients who have been hospitalized with COVID-19. The drug caused about a 7% relative increase in deaths.
Bear in mind that I redid some of the statistics from the studies because I thought they were incorrectly concluding that hydroxychloroquine had no effect. If you don’t trust my math (I wouldn’t trust a stranger’s math), you can see my work here. And I wrote the post for an audience who might not know what Bayes is.
I think this is unsafe advice, specifically using chloroquine and hydroxychloroquine without medical supervision.
These are not benign drugs (chloroquine being worse) and you are advising people use it while unwell with an emerging and poorly understood disease that could potentially alter its safety and pharmacokinetic/dynamic profile, and without any consideration for potential other health issues people have or medications people are taking (eg many antidepressants and anyone with diabetes).
If you have chloroquine/hydroxychloroquine, you should go see your healthcare provider before taking it do the baseline tests and discuss relevant side effects for your individual situation.
If you have COVID-19 and have chloroquine/hydroxychloroquine, you should not be taking them without medical supervision. If you are young and healthy, you are more likely to have side effects from the drugs than have a severe infection.
If you are unwell enough to be admitted to hospital, bring your drugs with you and ask the doctors to prescribe it while you are an inpatient, with appropriate monitoring, using your own supply (and keep it with you, rather than in the hospital’s drug cupboard—lots of theft of hospital supplies happening)
I’ve added some information about possible side effects to my comment. Obviously “with medical supervision” would be preferable, so sure talk to your doctor on the phone about it first if you can. (I think visiting a doctor’s office is too risky at this point.) But if your doctor can’t or won’t talk to you about taking chloroquine/hydroxychloroquine, and you don’t have preexisting conditions that make chloroquine/hydroxychloroquine more dangerous for you, it seems to me safer to take it than not. Unfortunately I’m unable to find quantitative information about the risk of side effects (UpToDate says “Frequency not defined” under “Adverse Reactions”), so it’s hard to make a really informed decision about this. Perhaps to be safer, one could take chloroquine/hydroxychloroquine at home at a lower dosage than is recommended for severely sick hospitalized patients? Would you agree with that, or do you think “young and healthy” should refrain from taking any dosage, absent medical supervision? If so, what is that based on? (E.g., are you a doctor with first-hand experience or some other source of information about chloroquine side-effects?)
Hydroxychloroquine is pretty well tolerated from what I’ve seen (never seen chloroquine given we have a safer alternative). The most common side effect is nausea/vomiting/diarrhoea and this is the only thing I could find a rate on (~10%). There are also a collection of rare, severe side effects.
Some of my concerns are:
Most of our safety data would be targeted at use in relatively well patients with rheumatological or dermatological disease, not acutely unwell infective patients (I have no idea about its safety profile in malaria other than it’s not really used anymore due to resistance)
Unknown dosage—as you suggested a lower dose might be safer but could also be below the therapeutic dose (the studies DO seem to use a fairly high dose)
The chloroquines come with a risk of QT prolongation; coronavirus comes with a risk of myocarditis—I would expect one would have much higher rates of arrhythmias. Also worsened by the other QT prolonging medication one would be on by then (azithromycin), and electrolyte abnormalities present in critical illness/from GI side effects of the drugs and infection. Admittedly, myocarditis seems to be a late development and the patient would be in ICU already, rather than early in the disease
Most of this probably comes down to the unknown—this is extremely early days into the investigation of using hydroxychloroquine for COVID19. I don’t think we know enough about this to be using it outside of the medical setting. Maybe my risk threshold would be for its earlier use in those over 60 or those with isolated hypertension? I’m unsure. This could all change within 1-2 weeks as I’d expect there’ll be significantly more data.
Huh, that’s quite weird. I wonder whether we can ping any of the people at Google we know about this, since I thought that document was quite good, and I linked to it a few times.
Check for G6PD deficiency before taking chloroquine (can be done through the 23-and-me interface) as it can cause haemolysis. Apparently not an issue with hydroxychloroquine: https://www.ncbi.nlm.nih.gov/pubmed/28556555
Take chloroquine or hydroxychloroquine along with zinc ASAP (so you can avoid being hospitalized). ETA: Preferably after talking to your doctor about it. See references below for more details. If you didn’t buy chloroquine/hydroxychloroquine ahead of time, beg your doctor for a prescription, or call doctors around you until you find someone willing to give you a prescription (because unlike China and South Korea, it doesn’t seem to be part of the standard treatment for COVID-19 in the US).
https://docs.google.com/document/d/e/2PACX-1vTi-g18ftNZUMRAj2SwRPodtscFio7bJ7GdNgbJAGbdfF67WuRJB3ZsidgpidB2eocFHAVjIL-7deJ7/pub
https://www.youtube.com/watch?v=vE4_LsftNKM
https://www.lesswrong.com/posts/un2fgBad4uqqwm9sH/is-this-info-on-zinc-lozenges-accurate
https://www.connexionfrance.com/French-news/French-researcher-in-Marseille-posts-successful-Covid-19-coronavirus-drug-trial-results
ETA: Some relevant information from the CDC:
Quoting Rob Wiblin:
“DO NOT TAKE IT OUTSIDE MEDICAL SUPERVISION: “Chloroquine is very dangerous in overdose.”″
https://www.facebook.com/photo.php?fbid=886113990345&set=a.509700885225&type=3&theater
Just because something is dangerous in overdose doesn’t mean that medical supervision is needed: for example acetaminophen, or even water. The relevant thing is that the therapeutic dose is close to the lethal dose for chloroquine, and chloroquine dosing is complicated.
Hydroxychloroquine is 40% less toxic while still being effective, according to this article: https://www.nature.com/articles/s41421-020-0156-0
Medical supervision may not be available if current trends continue, so we must carefully weigh the options available to us.
This sounds like a prime opportunity for people with medical expertise to write guidelines on how to use it for civilians.
Wei Dai’s first link was a doc with medical guidelines written by people with medical expertise (though not (explicitly) for civilians, I would expect legal risk to deter medical professionals from making guidelines for civilian use). That link is now dead, but archived here.
It included the South Korean guidelines:
My current strategy is to follow these guidelines (with hydroxychloroquine + zinc) if medical treatment is unavailable, there’s strong evidence that the illness is COVID-19, and serious COVID-19 symptoms are present. I’ll also have activated charcoal on hand to help mitigate accidental overdoses. I’m trying my best to familiarize myself with the risks involved so that I can make good decisions if the situation calls for it. Of course, my primary strategy is prevention in the first place.
That’s great, thanks for the info.
Here’s a negative study about hydroxychloroquine that just came out: http://www.zjujournals.com/med/EN/10.3785/j.issn.1008-9292.2020.03.03 (archive link because the website seems to be down)
What’s your current epistemic state re hydroxychloroquine?
I haven’t been following developments around hydroxychloroquine very closely. My impression from incidental sources is that it’s probably worth taking along with zinc, at least early in the course of a COVID-19 infection. I’ll probably do a lot more research if and when I actually need to make a decision.
A couple minutes after I wrote this question I found out Scott Alexander said July 29:
Last week I read the literature and concluded:
The 10% is a relative reduction, not absolute. I don’t know how Scott Alexander defines “clinically significant”. Some authors thought that “significant” meant a 50% or 90% relative reduction in cases, although I personally think that a 10% reduction matters. But I have no medical experience and no medical training. If you read Stat News, you know more about medicine than I do.
I also conclude:
And:
That fact comes from a large (n = 4716) randomized controlled trial, which found that hydroxychloroquine is almost certainly unsafe for treating patients who have been hospitalized with COVID-19. The drug caused about a 7% relative increase in deaths.
Bear in mind that I redid some of the statistics from the studies because I thought they were incorrectly concluding that hydroxychloroquine had no effect. If you don’t trust my math (I wouldn’t trust a stranger’s math), you can see my work here. And I wrote the post for an audience who might not know what Bayes is.
I think this is unsafe advice, specifically using chloroquine and hydroxychloroquine without medical supervision.
These are not benign drugs (chloroquine being worse) and you are advising people use it while unwell with an emerging and poorly understood disease that could potentially alter its safety and pharmacokinetic/dynamic profile, and without any consideration for potential other health issues people have or medications people are taking (eg many antidepressants and anyone with diabetes).
If you have chloroquine/hydroxychloroquine, you should go see your healthcare provider before taking it do the baseline tests and discuss relevant side effects for your individual situation.
If you have COVID-19 and have chloroquine/hydroxychloroquine, you should not be taking them without medical supervision. If you are young and healthy, you are more likely to have side effects from the drugs than have a severe infection.
If you are unwell enough to be admitted to hospital, bring your drugs with you and ask the doctors to prescribe it while you are an inpatient, with appropriate monitoring, using your own supply (and keep it with you, rather than in the hospital’s drug cupboard—lots of theft of hospital supplies happening)
Edit: for formatting
I’ve added some information about possible side effects to my comment. Obviously “with medical supervision” would be preferable, so sure talk to your doctor on the phone about it first if you can. (I think visiting a doctor’s office is too risky at this point.) But if your doctor can’t or won’t talk to you about taking chloroquine/hydroxychloroquine, and you don’t have preexisting conditions that make chloroquine/hydroxychloroquine more dangerous for you, it seems to me safer to take it than not. Unfortunately I’m unable to find quantitative information about the risk of side effects (UpToDate says “Frequency not defined” under “Adverse Reactions”), so it’s hard to make a really informed decision about this. Perhaps to be safer, one could take chloroquine/hydroxychloroquine at home at a lower dosage than is recommended for severely sick hospitalized patients? Would you agree with that, or do you think “young and healthy” should refrain from taking any dosage, absent medical supervision? If so, what is that based on? (E.g., are you a doctor with first-hand experience or some other source of information about chloroquine side-effects?)
Hydroxychloroquine is pretty well tolerated from what I’ve seen (never seen chloroquine given we have a safer alternative). The most common side effect is nausea/vomiting/diarrhoea and this is the only thing I could find a rate on (~10%). There are also a collection of rare, severe side effects.
Some of my concerns are:
Most of our safety data would be targeted at use in relatively well patients with rheumatological or dermatological disease, not acutely unwell infective patients (I have no idea about its safety profile in malaria other than it’s not really used anymore due to resistance)
Unknown dosage—as you suggested a lower dose might be safer but could also be below the therapeutic dose (the studies DO seem to use a fairly high dose)
The chloroquines come with a risk of QT prolongation; coronavirus comes with a risk of myocarditis—I would expect one would have much higher rates of arrhythmias. Also worsened by the other QT prolonging medication one would be on by then (azithromycin), and electrolyte abnormalities present in critical illness/from GI side effects of the drugs and infection. Admittedly, myocarditis seems to be a late development and the patient would be in ICU already, rather than early in the disease
Most of this probably comes down to the unknown—this is extremely early days into the investigation of using hydroxychloroquine for COVID19. I don’t think we know enough about this to be using it outside of the medical setting. Maybe my risk threshold would be for its earlier use in those over 60 or those with isolated hypertension? I’m unsure. This could all change within 1-2 weeks as I’d expect there’ll be significantly more data.
Of the initial 26 in the treated group:
three patients were transferred to intensive care unit,
one transferred on day3 post-inclusion
one patient died on day3 post inclusion
one patient stopped the treatment
no one left the control group.
“We left out four patients who got definitively worse” seems like a big flaw in the analysis.
Note that antimalarial drugs seem to be bad for psoriasis.
BTW, the google doc appears to have been taken down due to a TOS violation.
It’s still available on the Internet Archive: https://web.archive.org/web/20200319023745/https://docs.google.com/document/d/e/2PACX-1vTi-g18ftNZUMRAj2SwRPodtscFio7bJ7GdNgbJAGbdfF67WuRJB3ZsidgpidB2eocFHAVjIL-7deJ7/pub
Huh, that’s quite weird. I wonder whether we can ping any of the people at Google we know about this, since I thought that document was quite good, and I linked to it a few times.
You can buy hydroxychloroquine here still (as of March 20th): https://fixhiv.com/shop/coronavirus-drugs/hcqs-400-hydroxychloroquine-400-mg/ which imports it from India. This site also lets you easily buy a prescription for it, FWIW.
Check for G6PD deficiency before taking chloroquine (can be done through the 23-and-me interface) as it can cause haemolysis. Apparently not an issue with hydroxychloroquine: https://www.ncbi.nlm.nih.gov/pubmed/28556555
The google doc seems to be down
See this comment thread: https://www.lesswrong.com/posts/F3q7eL7pdQqhWFTYh/what-should-we-do-once-infected-with-covid-19?commentId=yei98MRd4cjqcDYEp