Ivermectin was originally developed by William Campbell and Satoshi Omura as an anti-parasitic medication in humans. It was so successful against diseases such as river blindness that its inventors received the 2015 Nobel Prize in Medicine. It first came into the public spotlight when Australian researchers found that, in a laboratory setting, it could remove all COVID viral RNA within 48 hours, essentially killing the virus. This led to small preliminary studies which initially showed some promise. The Front Line COVID-19 Critical Care Alliance, comprised of critical care physicians, then included it in a protocol for treating COVID patients called I-MATH. One of the physicians in the alliance, Dr. Pierre Kory, touted the drug at a Senate hearing in December 2020. He clearly expresses enthusiasm for promising results of vaccines, yet he is labeled “anti-vaccine” for the unforgivable crime of proposing that there may be other preventative options in addition to vaccines that ought to be investigated. Indeed, media outlets have consistently tried to link ivermectin use to anti-vaxxers, a group that much of the country loves to hate and an easy scapegoat for the pandemic.
When podcaster Joe Rogan contracted COVID-19, he was prescribed ivermectin by a physician, along with monoclonal antibodies and supplements such as vitamin C and NAD, and he recovered, whether on his own or due to all or part of his treatment. This produced a baffling response from numerous media outlets, which reported the incident as a “vaccine skeptic” taking a “horse dewormer,” calling the medication unsafe, despite its excellent safety profile, and ineffective (more on that later).
Ivermectin has also been developed for horses, and people have indeed resorted to ingesting the horse paste, as demonstrated by a viral video called “Ivermectin Horse Paste” released shortly after the Senate hearing. The video has since been taken down, likely fueling more conspiracy theories. What are they trying to hide from us? After all, ivermectin is cheap, and if it really works against COVID, that would destroy the profits of pharmaceutical companies. Few can deny the strong influence of the pharmaceutical industry on our health care system. The FDA’s smug, condescending, and immature tweet response certainly did not help matters: “You are not a horse. You are not a cow. Seriously, y’all. Stop it.”.
At the same time, the issue of widespread consumption of horse paste appears to be exaggerated to some degree. RollingStone published an article about Oklahoma physician Dr. Jason McElyea claiming emergency rooms are so backed up with patients overdosing on ivermectin that they are unable to take care of gunshot victims. One hospital where he worked denied the claim, stating that they had not treated any ivermectin overdoses, and the National Poison Data System reported only 459 cases in the entire country in the month of August. This information was added by RollingStone as an “update” instead of what it should have been: a retraction.
However, these points are irrelevant in the case of Joe Rogan, who did not in fact ingest horse paste. Media reports on the issue are at best negligent and at worst an alarming misframing and distortion of the truth. It is difficult to definitively assign motives, but in a rating-driven news business model that is increasingly threatened by alternative media outlets, this type of reporting should not come as a surprise, and neither should the resulting widespread mistrust of so-called reputable sources.
So what does the evidence say about ivermectin? Results have been mixed. A meta-analysis of 15 trials published by Bryant et al over the summer found a significantly reduced risk of death in COVID patients. Another similar meta-analysis of 14 trials published by Popp et al shortly thereafter, however, was inconclusive, deeming the trials too small or poor quality. It can be difficult to interpret what this means. Perhaps we would be able to have a clearer picture of what the drug does if we had a larger set of patients, or perhaps we haven’t identified the right dosing or the right types of patients that would benefit, or perhaps it really isn’t effective against COVID. Bryant et al’s hopeful findings may be the result of poor study design, “comparing apples and oranges” according to some. As stated by the CDC, “There is insufficient evidence for the COVID-19 Treatment Guidelines Panel (the Panel) to recommend either for or against the use of ivermectin for the treatment of COVID-19. Results from adequately powered, well-designed, and well-conducted clinical trials are needed to provide more specific, evidence-based guidance on the role of ivermectin in the treatment of COVID-19”. In other words, we simply do not know yet.
In my own field of neuro-oncology, glioblastoma is a devastating disease that does not have a cure, or particularly effective treatments that can offer more than an extra few months. When the disease comes back with a vengeance, the “kitchen sink” approach is not unreasonable. “Repurposed” medications are medications that were originally developed for other reasons but have shown some benefit. For example, valproic acid (antiseizure medication), metformin (diabetes medication), mebendazole (antiparasitic medication), doxycycline (antibiotic), and statins (cholesterol-lowering medication) have all shown some promise in treating glioblastoma. Although there have not been randomized trials to prove their efficacy, the small possibility of benefit is thought to outweigh the risks. It is important to make it clear that we simply do not know yet if it will work, but many patients’ families take comfort in the fact that we did everything we could.
This type of individualized care, humility, nuance, and careful weighing of risks and benefits appears to be lost when it comes to certain discussions surrounding COVID. Multiple physician and pharmacy groups have been cracking down on ivermectin prescriptions. The AMA, APhA, and ASHP put out a joint statement strongly opposing ivermectin outside a clinical trial. The Arizona Medical Board is investigating a physician for prescribing it to his patients. The Washington Medical Commission is considering disciplinary action for any physician who prescribes it. All this for a medication that is deemed safe by the FDA, simply because it has not yet proven itself in a large, robust randomized trial.
Physicians ought to have the freedom to prescribe approved medications off label based on their clinical judgment, as they have always had. Instead, our institutions, perhaps out of frustration over the protracted course of the pandemic, are trying to forcibly take control of the situation. This should be a wake-up call and a cause for reflection. Why are people not trusting the authorities? Why can’t people afford to see a doctor, instead resorting to seeking medical advice from YouTube and ingesting horse paste? Why are we really failing to put the pandemic behind us?
Written by Ramya. Artwork by Dhanya.
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