Why the AIIMS/ICMR 2021 COVID guideline is wrong about hydroxychloroquine ?

On 22nd April 2021 in the midst of a crumbling health system the AIIMS/ ICMR-COVID-19 National Task Force/Joint Monitoring Group , Ministry of Health & Family Welfare has finally issued a revised “Clinical Guidance for Management of Adult COVID-19 patients” (* see post-publication note in end). In essence, it is not much of a guideline but a flowchart (much like the previous one). It does not adhering to any standards of a guideline, does not present any evidence (not even citations!), nor does it communicate anything around risk-benefits for any of the drugs. As such, it is impossible to understand how the guideline was developed and why some drugs were chosen and why it was not.

The article however focusses only on one aspect of the guidelines- the recommendation for hydroxychloroquine being recommended as a “may do” . However, this recommendation for hydroxychloroquine is contrary to data from randomized controlled trial. Between July 2020 (when the last guideline was issued) and now, there is a lot of trials that has been completed and we now have reasonable evidence to inform decision making. Evidence from randomized controlled trial shows that hydroxychloroquine does do not have any effect on mortality (based on data from 10859 patients ; 29 studies) in COVID=19 patients . In fact patients given hydroxychloroquine may have significantly more diarrhea , nausea and vomiting compared to those not given so.  Diarrhoea and vomiting are known to increase the risk of hypovolaemia, hypotension and acute kidney injury, additional health systems burdens which one should avoided at all costs in this phase of the pandemic.

Hydroxychloroquine for COVID19 clinically meaningful outcomes https://app.magicapp.org/#/guideline/5058/section/67027

Even if we look at health systems relevant outcomes (which are of course equally important to patients) which are of significance in the currently crumbling health system recommending the use of hydroxychloroquine does not make any sense – it increases the number of people who need mechanical ventilation(based on data from 6379 patients ;5 studies).

Hydroxychloroquine for COVID 19 on outcomes of health systems significance https://app.magicapp.org/#/guideline/5058/section/67027

It is high time that issues in the guideline development process that has been already identified are resolved such that lives of patients can be saved through evidence informed therapies .

*As of 10th May 2021 – another version of the AIIMS/ICMR guideline is being circulated in social media without hydroxychloroquine . I could not verify the veracity of this version of guideline being genuine considering the ICMR website https://www.icmr.gov.in/ still hosts the 22nd April 2021 version

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