Geeta Nayyar, MD, MBA: How COVID-19 Affects Rheumatology Patients

Geeta Nayyar, MD, MBA

Coronavirus disease 2019 (COVID-19) has brought attention to 2 medications, hydroxychloroquine and chloroquine. Both medications are anti-malarial and can be used to treat rheumatology patients. As it stands, patients with arthritis have a hard time getting such medications. Now, the current state of healthcare is seeing a shortage of these medications.

In an interview with HCPLive®, Geeta Nayyar, MD, MBA, chief medical officer at Greenway Health, discussed how she has used the medications as a rheumatologist, why they’re being touted as “miracle drugs,” and how hydroxychloroquine and chloroquine can negatively affect patients.

Editor’s note: This interview has been lightly edited for style, length, and clarity.

HCPLive: Can you put into context what hydroxychloroquine and chloroquine are and how you've used them in the past?

Nayyar: That's a terrific question. These are anti-malarial medications and they're really mainstay therapy for lupus and rheumatoid arthritis patients, as well as a variety of other autoimmune diseases. So, we use these routinely in rheumatology for chronically ill patients who need to be immunosuppressed. This is like gold standard therapy for lupus and rheumatoid arthritis patients and some of the most vulnerable patients right now to the coronavirus. So, it's that much more important that we really judiciously think through who is going to get these medications because there's already a shortage with a lot of misinformation out there about using these drugs for prophylaxis.

HCPLive: Why are these medications being touted almost as “miracle drugs” for patients with COVID-19?

Nayyar: You know, I'm going to give you a really provocative answer to that one. Why do rumors get started? The very small anecdotal study that was done on these 2 medications everyone heard Anthony Fauci, MD, talk about, they're very small, bias studies. They’re not what we call a randomized clinical trial, which is how we validate any number of therapies for any number of diseases. So, it is surprising that there is so much weight being given to this when we just don't have enough information. It is really the equivalent to what I would say is a rumor, which is not to say that it shouldn't be explored, but it certainly doesn't add any validation to whether they may or may not work.

HCPLive: What are some ways in which these medications can be harmful for patients with rheumatology patients?

Nayyar: There are all kinds of side effects to anti-malarial medications. First of all, you have to have routine blood work. You have to monitor internal organs and you have to check your eyes. There are any number of side effects that can happen from any one of these medications that are not something that you would start without being overseen by a physician. We could actually do more harm than good. You can have nausea, vomiting, stomach pain, weight loss, hair loss. There's any number of side effects.

There’s also concern that it can affect the liver. So, if you have any history of liver disease or alcoholism, there's also something called Glucose-6-phosphate dehydrogenase. If you happen to have that enzyme deficiency, you should not be on plaquenil, which is the hydroxychloroquine. So, again, like any prescription medication, this is not something that you should be given without being overseen by a physician and continuing to be monitored on.

And not to mention, this is an immunosuppressive drug. So, when we think about coronavirus, and we think about the fact that it's an infection, it is somewhat counterintuitive that you would get an immunosuppressant—something that suppresses the immune system when someone has an infection. Now, there are many reasons why we might do that. It can relate to inflammation; it can relate to inflammatory markers. So, there are many reasons why that could be the case, but it is a balance. It is a balance and anything that's affecting the immune system is never something to be taken lightly.

HCPLive: What efforts are underway to test the efficacy of these medications?

Nayyar: My understanding is that there are trials underway abroad as well as domestically, but it's very early. I mean, again, with everything going on, this remains a very dynamic situation. So, the reality is, it's going to take some time. And in certain situations, perhaps similar to end of life, there are experimental medications that are given because there's thought to be a “there's nothing left to lose” type of approach.

I think in coronavirus, that's a lot of the situations where it's been used. The thought now from Dr. Fauci is to use this as an end of life situation as opposed to prophylaxis, meaning normal, healthy people taking chlorquine or hydroxychloroquine could in fact actually be to the detriment of patients such as those with lupus and rheumatoid arthritis, who are actually more susceptible to coronavirus and now are facing a shortage of getting their day-to-day medication.

HCPLive: How can COVID-19 affect high susceptible patients with arthritis differently than otherwise healthy individuals?

Nayyar: Very similar to anyone right now with any underlying chronic chronic diseases, so not just arthritis, but if you have diabetes, congestive heart failure, lung disease, asthma, COPD, you are going to naturally be predisposed to any kind of infection. And at this time, obviously coronavirus is top of mind with everything going on in the globe. But whether it was the general flu, whether it was a cough or cold, for those patients, by virtue, their baseline is going to be different than you and me. You and I are young, healthy women. Someone who is older or already has something that their body is fighting on a day to day basis, like lupus, asthma, or COPD, their immune system and body simply just is not as healthy to ward off any infection, whether it be coronavirus or any other run of the mill infection.

The way we talk about medicine with language of war, this very much is like a war, right? With the doctors and nurses being the soldiers and we're asking them now to go practice without shields, without masks without any kind of armor, there's no treatment, and without a strategy in many ways if you look at what's going on.

Then when we think about the human body, it's the same thing. Someone who has an underlying autoimmune disease or an underlying disease of any kind, their defense system is just not as strong as someone who doesn't have those issues. You can be old and healthy, but as we get older, our defense system naturally is just not the way it was when we were 25. Our kidney functions are just not the same as when we were 25.

So, this is just a natural human body and how it operates when dealing with a foreign antigen or an infection like the coronavirus.