An ampoule of remdesivir is pictured in Hamburg, Germany. Photo: Ulrich Perrey/Pool via Reuters
New Delhi: As India’s COVID-19 cases skyrocketed during the second wave, the demand for drugs such as remdesivir, tocilizumab and favipiravir among others has also seen a proportional increase. Reports have found that prices of these drugs have skyrocketed, selling for more than 100 times their base price.
Although there is no evidence to suggest these drugs – especially remdesivir, which is one of the most widely used to treat COVID-19 – prevent the disease from worsening or reduce mortality, they continue to be prescribed.
Indeed, the health ministry’s latest guidelines to treat mild COVID-19 suggest the use of ivermectin and hydroxychloroquine and remdesivir, the last one only by a medical professional in hospital settings.
If the drugs haven’t demonstrated any positive outcomes in trials or are feebly effective at best, why do doctors still prescribe them?
IndiaSpend spoke to Gunjan Chanchalani, a consulting intensivist at the Cumballa Hill Hospital and St Elizabeth Hospital in Mumbai, and Sumit Ray, head of the department of critical care at the Holy Family Hospital in New Delhi, on the issue. The doctors said in no uncertain terms that routinely prescribed drugs like ivermectin, hydroxychloroquine, itolizumab, lopinavir, ritonavir and favipiravir, apart from experimental treatments using remdesivir and convalescent plasma, have shown no benefit in treating COVID-19 patients.
However, doctors are pressured into prescribing these drugs because “people are scared of COVID, they want some prescription,” they told IndiaSpend. There are also some doctors and physicians who prescribe many drugs because “they feel that probably patients feel they will get better with this bunch of medicines”.
Dr Chanchalani explained that COVID-19 is a viral disease that the body itself “learns to take care of”, and that doctors may need to give enough antipyretics to control the fever. “It is only in the second week, when there is a more inflammatory response or an immune response, do we need to intervene and give medications like maybe steroids and remdesivir,” she said, “when people have a drop in [oxygen] saturation. Otherwise, there is no need to really go for any over-the-counter drugs or medicines that are ineffective against COVID.”
Dr Ray concurred, saying antivirals like Fabiflu have shown no effects in the early phases of COVID-19. “We need antipyretics that reduce fever. But having said that, if high-grade fever persists and there is a more inflammatory response, we need to intervene,” he said.
Remdesivir is not a life-saving drug, he said, and has shown to reduce hospital stay in a very specific subgroup of patients. “Those who are not on oxygen do not benefit [from] reduction in the length of stay in hospital. Those on high oxygen support or on ventilators – [for them] this is not a life-saving drug. So do not run around trying to find it and waste your energy, time and money if your loved one is critically ill,” Dr Ray told IndiaSpend.
Dr Ray also referred to an article written by Dr Samir Malhotra published by The Wire Science, titled ‘Remdesivir – a Drug in Search of a Disease‘. He said:
There was an interesting article that said ‘Remdesivir – a drug in search of a disease’, because it failed against Ebola, it failed against MERS, it failed against SARS. But unfortunately, even we are sometimes pushed to prescribe it because the pressure is so high. And if the patient is not doing well, the pressure is even more in spite of explaining to families, so we end up having to do it. Some families accept [medical advice] and some families say, give it my loved one [who] is very sick, please give it. And medicine, unfortunately, doesn’t work like that but we are almost forced to do it.
A few weeks ago, in an interview to Scroll.in, Dr Lancelot Pinto, a consultant pulmonologist at Mumbai’s P.D. Hinduja Hospital, also said that remdesivir does not save lives but desperate families are advised by multiple sources to try therapies involving remdesivir, tocilizumab and plasma.
“The patient is often critically ill, the families desperate for something to be done, and they are often advised by multiple sources to try one of these therapies. Doctors themselves often suggest these therapies, and if the said therapy isn’t accessible to the treating physician, the family is given a prescription and asked to procure the drug (or donated plasma),” he said.
Dr Pinto added that while the families’ desperation, the need to “do something” shouldn’t overwhelm the caution associated with using drugs and treatments that have been clearly proven to be ineffective, and could in fact carry debilitating side-effects.
Dr Chanchalani also said doctors are “under pressure to treat, under the pressure of lack of resources and poor healthcare in our country”. When a patient comes for a consultation and is not prescribe any antibiotics, doctors are asked: “What was the consultation for?”
These doctors’ wisdom may also apply to some non-healthcare actors in India. For example, officials of the Bharatiya Janata Party in Delhi and Gujarat stocked their own supplies of remdesivir and Fabiflu to distribute among their constituents, after preliminary checks. Independent experts have asked how the party could stockpile these drugs when doing so requires a license that only hospitals – and not party offices – have, thus risking their use outside hospital settings as well.
In a separate instance, the Delhi high court upbraided the Indian government in late April after patients complained stocks of the drug were running low in the national capital. “This is wrong. This is a complete non-application of mind. Now people who do not have oxygen will not get remdesivir either. It appears you want people to die,” Justice Prathiba M. Singh told the Centre.
Dr Chanchalani told IndiaSpend that during the first wave, she prescribed ivermectin, but has since stopped. “And believe me, I have not seen any extra worsening after not giving these medicines. I have used Fabiflu as I said in the first phase [and] so many patients did complain of high uric acid; they had a lot of nausea, gastritis, and I think life was difficult for them,” she added. “Now, all my patients are eating well and they do well.”
Dr Chanchalani also said that patients recover better if they aren’t prescribed too many antibiotics, simply because they avoid side effects like gastritis and vomiting. “Some doctors are prescribing all of them together – whether it is ivermectin, fabiflu, everything. With that, your body definitely undergoes some change, but here, when we just advise them some supplements and a good diet and maybe good hydration, they are quite happy.”
According to her, patients shouldn’t panic when they test positive because 95% of COVID-19 patients don’t need to be hospitalised. As she put it: “Follow your doctor, monitor yourself, monitor your own oxygen, monitor your oxygen on exertion, which is a six-minute walk test.” If oxygen saturation drops, a doctor should be informed and, if necessary, admission to a hospital should be sought. “People are using all these over-the-counter medicines or comparing [their medication] with others because they are panicking.”
Dr Ray agreed, but added that since the number of cases have become “overwhelming”, hospitals have become choked. “Patients who go into the ICU don’t move out for almost three weeks… Actually, to tell you honestly, there are not enough hospital beds. What we have to do is look at it as a disaster at this point. One end is to say, ‘do not panic’, but yes, people will panic in this condition when beds are not available,” he said.