An algorithm for managing QT prolongation in coronavirus disease 2019 (COVID-19) patients treated with either chloroquine or hydroxychloroquine in conjunction with azithromycin: Possible benefits of intravenous lidocaine

We developed and provided a flow chart to manage the risk of QT prolongation and TdP while treating these patients in the hospital with combination therapy. Introduction The rapid spread of the coronavirus disease 2019 (COVID-19) pandemic owing to a newly identified coronavirus, SARSCoV-2, originating in Wuhan, China, has resulted in significant morbidity and mortality around the world. Early reports have shown improved clinical outcome and viral clearance with the use of chloroquine and hydroxychloroquine. The results of a recent open-label nonrandomized clinical trial by Gautret and colleagues suggest that the addition of azithromycin to hydroxychloroquine significantly reduced polymerase chain reaction detection of SARS-CoV-2 in nasopharyngeal samples by 6 days in 6 patients compared to 14 patients treated with hydroxychloroquine alone. Patients with baseline prolonged QT intervals were excluded from this study, since both drugs are known to prolong the QT interval, which may increase the risk of torsades de pointes (TdP). Despite the drugs’QTc-prolonging effects, several reports suggest the risk of TdP is very low when either of these agents is used alone or in combination. Nonetheless, these risks may be higher in critically ill, hospitalized COVID-19 patients with metabolic derangements, with organ failure, and on other medications, increasing the risk of drug-drug interactions. If this combination, however, proves to be lifesaving for COVID-19 patients, “managing” the QT interval to allow patients to receive combination therapy will be critical.