San Antonio Express-News (Sunday)
Physician’s advice on COVID-19 questioned
Dear Dr. Roach: Is there a difference between COVID-19 treatment in academia vs. the real world? I had a telemedicine appointment the other day to see my internist, and he said to call right away if I developed symptoms consistent with COVID. He would order tests forme and start me right away on hydroxychloroquine, doxycycline and zinc. I told him I was surprised he would prescribe these, since everything I’ve read recently supports no benefit from hydroxychloroquine. Also, I thought doxycycline was not beneficial for viral infections. He said he uses it, and it works.
Your thoughts, please.
B.R. A: All physicians are obligated to stay abreast of current standards of care for the practice of medicine. Unfortunately, physicians both in academia and in private practices do not always stay as current as they should.
With COVID-19, it can be hard to keep abreast of all the changes and the sometimes-conflicting data that comes from clinical trials and expert recommendations. Although it might be easier for academic physicians to do so, my observation is that some private practice docs are really up to date while a few academic docs are behind on the latest updates.
Hydroxychloroquine appeared to show benefit in some early, uncontrolled studies, but the vast majority of the evidence, including the most reliable evidence from controlled trials, has shown no benefit and significant potential for harm from hydroxychloroquine, at least at the time of this writing.
Doxycycline is an antibacterial agent, and is used in people with COVID-19 and concurrent bacterial infections. It has been studied in early trials, as in addition to its antibacterial properties, it is anti-inflammatory as well and may have some antiviral effects. It may have a role in treatment, but it is not recommended for use until there are clear results from clinical trials, which at the time of this writing are lacking.
Similarly, there are theoretical reasons why zinc might be effective, and people with zinc deficiency have suppression of the immune system. However, there are no data showing benefit of zinc treatment in people with COVID-19, although zinc has shown modest benefit in some other viral illnesses.
Hydroxychloroquine has clear potential for harm, and some studies have shown worse outcomes in people with COVID-19 taking it. Zinc and doxycycline are both safe but unproven. Some physicians choose to use unproven but hopeful treatments when there is a low likelihood of harm, as is the case with zinc. Others prefer to have data showing that treatments are both effective and safe before using them.
At the beginning of the pandemic, I saw many doctors, frustrated at the lack of treatment options, choose to try unproven medications out of a feeling they need to be doing something. Fortunately, now there are at least two
treatments, remdesivir and dexamethasone, that have been proven helpful in people with moderate to severe COVID-19 infection.
I would not follow the recommendation of a physician who recommends hydroxychloroquine, whether he or she comes from academia or private practice. Wishful thinking that it helps can lead to bias, especially since most people with COVID-19 will do well. We need to practice what the best scientific evidence says, not what our gut tells us. A single physician’s observation that it seems to work is inadequate in the face of evidence saying the contrary.
Dear Dr. Roach: In your recent column referring to the shingles vaccine, you do not mention younger adults. My son had a very bad case of chickenpox when he
was only 6 months old. He is now 40 years old, and earlier this year had an attack of shingles that affected the area behind his ear. He wanted to get the shingles vaccine to hopefully avoid a repeat of this and was told he was too young and would have to wait until he is 50. Is he to remain susceptible to this for another 10 years? What is your opinion on this situation?
L.C. A: The shingles vaccine has only been tested in adults older than 50, and thus is not indicated for younger ages by the Food and Drug Administration. The vaccine is particularly important in older people because shingles is more common and has a higher risk of complications in older people. People in their 40s are at low risk for complications. People who have already had shingles are still recommended for the vaccine
once they are 50, but they are at lower risk from shingles than those who haven’t had shingles.
Giving the vaccine to a younger person would likely be effective. This is a new vaccine, and although it seems to confer longlasting immunity, it is not known whether it is lifelong. It would also not be covered by insurance and costs $155 for each of two doses on the Goodrx app. Personally, I wouldn’t recommend it, but it’s not out of the question. Beyond side effects of the shingles vaccine — which are often worse than a flu shot — there is little risk from the shingles shots.
Dear Dr. Roach: I am an 88-year-old woman. I have had excessive belching for nine months. I have tried many medications and home remedies, but nothing has helped. Have you heard of this problem? I have to ride 3 ½ hours to see a specialist.
C.M. A: I have seen this problem often. Eructation (we have Latin names for almost everything) or belching, is the expulsion of air from the esophagus or stomach. The average person belches 25 to 30 times per day. This normal body function is considered a problem only when it is excessive and causes distress.
Stomach gas is most commonly caused by swallowed air, so the treatment is to teach people how to swallow less air. This means no gum chewing or smoking; no carbonated beverages (which contain dissolved CO2 gas); and most especially slower, careful eating to reduce air swallowing during mealtimes.
Belching can also be associated with reflux disease; however, medications generally do not help the belching symptoms. Dietary treatment — that is, avoiding foods that make reflux worse (caffeine, chocolate, fatty foods, mints) — may improve the symptom.
Just reassuring people that belching is a benign condition often helps with the anxiety that can accompany the belching. Anxiety itself can make people swallow more air, so sometimes people get stuck in a vicious cycle of belching and worrying about it.
Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med. cornell.edu or send mail to 628 Virginia Dr., Orlando, FL 32803.
EachWuzzle is a word riddle which creates a disguised word, phrase, name, place, saying, etc. For example, NOON GOOD = GOOD AFTERNOON