6 ms·

One of the comments in the article: I prescribe Plaquenil extensively in patients with autoimmune conditions.The safety profile of this drug is excellent. It i

One of the comments in the article: I prescribe Plaquenil extensively in patients with autoimmune conditions.The safety profile of this drug is excellent. It is also still used for malaria prophylaxis in healthy individuals .it is not a new drug. I don’t see the reason of labeling it as dangerous. The question is : does it work for Covid19 prevention and treatment? The answer is “the current limited evidence suggests that it does”. What i can tell you that I am aware of a number of doctors in the US who are currently infected or waiting for results who are taking the drug. And I cannot blame them.

deleted 7y ago
[deleted]
paulmd 7y ago
This whole incident hasn't done much to shake my impression that US doctors are interested first and foremost in making sure they get their "cut" on every prescription, even when the drug is relatively innocuous. Like fine, we can have this discussion about chloroquine. It's behind-the-counter in the UK, so on par with sudafed in terms of access control, and OTC in a lot of countries that actually have to deal with malaria directly. But the same argument gets applied to stuff like oral contraceptives, which are straight-up OTC in a lot of countries too, and can simply be discontinued if you notice symptoms. At the same time, we allow drugs with insanely narrow theraputic ranges like tylenol/acetaminophen/paracetamol (seriously, almost as bad as the chloroquine people are freaking out about, a normal dose is 1-4g and a lethal dose can be as low as 5g) to be sold OTC here with no questions whatsoever. We allow combination products despite obvious risks for multiple dosing, we allow combination products to "dissuade addicts" from abusing opiods (like any addict has ever been dissuaded by a risk bodily harm). And doctors don't make a peep about that, because they're not accustomed to getting their cut on that one. That's also why the AMA resists nurse practitioners so hard. The truth is, a lot of those drugs really should be "behind the counter", a pharmacist should simply have to give you a quick rundown of possible symptoms and what to do if you notice them (discontinue and see a doctor or go to a hospital depending on urgency, same as you would do with a doctor-prescribed drug), but doctors won't allow that because they wouldn't get their cut, so we just call them "nurse practitioners" instead. US doctors really like playing gatekeeper, to a much greater extent than other countries (where coincidentally, money doesn't come into the picture as much).
- pkaye 7y ago
  Do doctors "get a cut" when their patients buy from a neighborhood pharmacy?
  - paulmd 7y ago
    They get a couple hundred bucks for a 5 minute office visit to write the prescription, yeah. I'm fine if there's a serious reason for a physical examination, but a lot of stuff the doctor is effectively filling the role of a pharmacist: telling you side effects and if you have this set of serious side effects then to stop it and/or go to a hospital, here's your script, pay at the front desk. A lot of stuff is unnecessarily shoehorned into Rx-only, and despite a lot of talk about "reducing costs" there is no real drive to actually do so. A great example is oral contraceptives. You may have to try a couple different blends before you find the right mix for your body. Some of them will be uncomfortable. Some may cause dangerous bleeding and you need to go to a hospital. There is not zero risk here, or with any drug. But the doctor has no way of telling which might be which for your particular body, they are there to tell you the risks, sign the paper and let you try it out. And that's why oral contraceptives specifically are being looked at as something that could be moved out of Rx only and to either OTC or pharmacist-prescribable - but the problem is there are really a lot of drugs that don't belong there. A pharmacist can read the risks to you just as easily and not charge you $250 for a 15 minute office visit and another $250 for a one-month followup 15 minute office visit. I have lots of 6-month maintenance visits that are literally 5 minutes. Everything going well? "Yup!" "OK, we'll call in your prescription, pay up front". They're just using their gatekeeping power to extract a check.
    - jac241 7y ago
      They don't make a couple hundred bucks. A 99213 established outpatient visit is worth 0.96 work RVUs * $36.0391 Medicare conversion factor = $34.59 for a standard outpatient visit. Even if you add the facility RVU = 0.48 + malpractice RVU 0.08 that is $54.78 for an outpatient visit. To make a couple hundred bucks, you need to do something like placing a stent for someone who is having a heart attack: CPT code 92941 - 12.31 work RVUs = $443.64. All this information is available online. You can look up the physician fee schedule straight from the CMS. https://www.cms.gov/apps/physician-fee-schedule/search/search-results.aspx?Y=0&T=2&HT=0&H1=92941&M=5 https://www.cms.gov/apps/physician-fee-schedule/search/searc... . Here are the cardiology codes - https://myheart.net/cardiology-coding-center/coronary-intervention-cpt-codes-and-rvu/ https://myheart.net/cardiology-coding-center/coronary-interv... To add an additional data point, doing a heart transplant is 89.50 wRVU * 36.0391 = $3225. I don't think doctors are living as well as you think. CPT code 33945.
aaavl2821 7y ago
Fwiw, Plaquenil is hydroxychloroquine, a less toxic derivative of chloroquine. It has a different safety profile than chloroquine The French study of HCQ had several limitations. Including that it was very small and some patients who got HCQ and progressed to go to the ICU were excluded from the study. Thus making the drug look better than it is HCQ is not likely to be a miracle cure. It may be useful in combo with other drugs It's easy to make not great data look like great data to untrained eyes. And it's tempting to cut scientific corners to bring forward a drug for covid-19. But if the drug doesn't work, we should be honest about that and look for better drugs Should at risk people take HCQ as a precaution until something better comes along? Definitely. but we need to be careful in talking about its potential
- zamalek 7y ago
  > It may be useful in combo with other drugs Weren't the first studies done in combination with azithromycin (which is bizzare, as that's an antibiotic)?
  - red-indian 7y ago
    The azithromycin was given to some of the patients with viral pneumonia as there is a chance of reinfection with bacterial pneumonia. Astonishing and unexpectedly, the covid19 virus was completely wiped out in all the HCQ+azithromycin patients but only in a bit over half the HCQ alone patients. So just as an antiparasite drug surprisingly once was found to also work as an antiviral, azithromycin has unexpectedly been found to have some sort of a complementary amplifying or catalyzing effect with the hydrochloroquine. Of unknown mechanism and no doubt this will be explored in great detail in future research. For now it's known that putting the two together looks to be a good thing to do.
    - paulmd 7y ago
      the problem is quite simple: the virus infects your body, damages your lungs, and fucks up your immune system. Then you get an opportunistic pneumonia The mechanism is also quite simple: administer them both together and the antimalarials kill the virus, the antibiotics kill the pneumonia.
treeman79 7y ago
Had a week long freak out from it. Apparently mild stimulant can magnify if your on other stimulants. Amazing drug otherwise. My autoimmune symptoms have greatly reduced on it. Wish I could take the full dose.

deleted 7y ago

[deleted]

paulmd 7y ago

This whole incident hasn't done much to shake my impression that US doctors are interested first and foremost in making sure they get their "cut" on every prescription, even when the drug is relatively innocuous. Like fine, we can have this discussion about chloroquine. It's behind-the-counter in the UK, so on par with sudafed in terms of access control, and OTC in a lot of countries that actually have to deal with malaria directly. But the same argument gets applied to stuff like oral contraceptives, which are straight-up OTC in a lot of countries too, and can simply be discontinued if you notice symptoms. At the same time, we allow drugs with insanely narrow theraputic ranges like tylenol/acetaminophen/paracetamol (seriously, almost as bad as the chloroquine people are freaking out about, a normal dose is 1-4g and a lethal dose can be as low as 5g) to be sold OTC here with no questions whatsoever. We allow combination products despite obvious risks for multiple dosing, we allow combination products to "dissuade addicts" from abusing opiods (like any addict has ever been dissuaded by a risk bodily harm). And doctors don't make a peep about that, because they're not accustomed to getting their cut on that one. That's also why the AMA resists nurse practitioners so hard. The truth is, a lot of those drugs really should be "behind the counter", a pharmacist should simply have to give you a quick rundown of possible symptoms and what to do if you notice them (discontinue and see a doctor or go to a hospital depending on urgency, same as you would do with a doctor-prescribed drug), but doctors won't allow that because they wouldn't get their cut, so we just call them "nurse practitioners" instead. US doctors really like playing gatekeeper, to a much greater extent than other countries (where coincidentally, money doesn't come into the picture as much).

pkaye 7y ago
Do doctors "get a cut" when their patients buy from a neighborhood pharmacy?
- paulmd 7y ago
  They get a couple hundred bucks for a 5 minute office visit to write the prescription, yeah. I'm fine if there's a serious reason for a physical examination, but a lot of stuff the doctor is effectively filling the role of a pharmacist: telling you side effects and if you have this set of serious side effects then to stop it and/or go to a hospital, here's your script, pay at the front desk. A lot of stuff is unnecessarily shoehorned into Rx-only, and despite a lot of talk about "reducing costs" there is no real drive to actually do so. A great example is oral contraceptives. You may have to try a couple different blends before you find the right mix for your body. Some of them will be uncomfortable. Some may cause dangerous bleeding and you need to go to a hospital. There is not zero risk here, or with any drug. But the doctor has no way of telling which might be which for your particular body, they are there to tell you the risks, sign the paper and let you try it out. And that's why oral contraceptives specifically are being looked at as something that could be moved out of Rx only and to either OTC or pharmacist-prescribable - but the problem is there are really a lot of drugs that don't belong there. A pharmacist can read the risks to you just as easily and not charge you $250 for a 15 minute office visit and another $250 for a one-month followup 15 minute office visit. I have lots of 6-month maintenance visits that are literally 5 minutes. Everything going well? "Yup!" "OK, we'll call in your prescription, pay up front". They're just using their gatekeeping power to extract a check.
  - jac241 7y ago
    They don't make a couple hundred bucks. A 99213 established outpatient visit is worth 0.96 work RVUs * $36.0391 Medicare conversion factor = $34.59 for a standard outpatient visit. Even if you add the facility RVU = 0.48 + malpractice RVU 0.08 that is $54.78 for an outpatient visit. To make a couple hundred bucks, you need to do something like placing a stent for someone who is having a heart attack: CPT code 92941 - 12.31 work RVUs = $443.64. All this information is available online. You can look up the physician fee schedule straight from the CMS. https://www.cms.gov/apps/physician-fee-schedule/search/search-results.aspx?Y=0&T=2&HT=0&H1=92941&M=5 https://www.cms.gov/apps/physician-fee-schedule/search/searc... . Here are the cardiology codes - https://myheart.net/cardiology-coding-center/coronary-intervention-cpt-codes-and-rvu/ https://myheart.net/cardiology-coding-center/coronary-interv... To add an additional data point, doing a heart transplant is 89.50 wRVU * 36.0391 = $3225. I don't think doctors are living as well as you think. CPT code 33945.

aaavl2821 7y ago

Fwiw, Plaquenil is hydroxychloroquine, a less toxic derivative of chloroquine. It has a different safety profile than chloroquine The French study of HCQ had several limitations. Including that it was very small and some patients who got HCQ and progressed to go to the ICU were excluded from the study. Thus making the drug look better than it is HCQ is not likely to be a miracle cure. It may be useful in combo with other drugs It's easy to make not great data look like great data to untrained eyes. And it's tempting to cut scientific corners to bring forward a drug for covid-19. But if the drug doesn't work, we should be honest about that and look for better drugs Should at risk people take HCQ as a precaution until something better comes along? Definitely. but we need to be careful in talking about its potential

zamalek 7y ago
> It may be useful in combo with other drugs Weren't the first studies done in combination with azithromycin (which is bizzare, as that's an antibiotic)?
- red-indian 7y ago
  The azithromycin was given to some of the patients with viral pneumonia as there is a chance of reinfection with bacterial pneumonia. Astonishing and unexpectedly, the covid19 virus was completely wiped out in all the HCQ+azithromycin patients but only in a bit over half the HCQ alone patients. So just as an antiparasite drug surprisingly once was found to also work as an antiviral, azithromycin has unexpectedly been found to have some sort of a complementary amplifying or catalyzing effect with the hydrochloroquine. Of unknown mechanism and no doubt this will be explored in great detail in future research. For now it's known that putting the two together looks to be a good thing to do.
  - paulmd 7y ago
    the problem is quite simple: the virus infects your body, damages your lungs, and fucks up your immune system. Then you get an opportunistic pneumonia The mechanism is also quite simple: administer them both together and the antimalarials kill the virus, the antibiotics kill the pneumonia.

treeman79 7y ago

Had a week long freak out from it. Apparently mild stimulant can magnify if your on other stimulants. Amazing drug otherwise. My autoimmune symptoms have greatly reduced on it. Wish I could take the full dose.