Coronavirus Update: April 27
As we enter the last week of April, people are getting restless with continued sheltering behavior. The good news is that the numbers of those hospitalized and dying are going down. Our social distancing efforts are working. But at least in the New York region, we are not ready to let down our guard. We need to see a significant reduction in new cases before we can begin slowly normalizing activity. That will take another several weeks. In other parts of the US, where the coronavirus numbers have been relatively low, we will see what happens as these communities begin reopening.
Predictions, Modeling, and Projections
If we have learned anything from this pandemic crisis, it is that as excellent as our scientific leaders are, they cannot accurately predict what will happen. They have done a great job of educating us about how to protect ourselves, our neighbors, and loved ones, but they cannot tell us what will happen in the future.
So far, there are tragically, over 50,000 deaths in the US. But this is a lot better than the prediction just 2 weeks ago that as many as 250,000 Americans would die. And in many regions, the number of those hospitalized and dying is going down. It seems clear that the risk of infection is significantly greater in densely populated areas, which is why we see so many cases in New York.
The news media often makes things worse by intensifying our fears and politicizing the crisis. Be careful with these outlets and the digital media platforms which really increases our anxiety. As more testing is done and more data emerges, the picture of how the pandemic will play out will become clearer. Many of our questions will be answered, in time.
Treating Viral Infections
It has always been difficult to find medication to treat viral infections. Viruses differ from bacteria, for which we have numerous antibiotics to help fight infection. Antibiotics directly kill pathogens and help our natural immune system defenses. But we do not have many antibiotics against viruses and instead, depend upon our own immune systems to defeat infection. That’s a good thing, otherwise, we would become deathly ill from the common cold!
Sure, there are a few antiviral medications available, such as those used to treat herpes, some types of hepatitis and HIV–but for most viruses, we simply do not have good drugs. Instead, we rely on vaccines to “fool” our immune systems to think that it has previously encountered the virus and thus developed antibodies and other specific immune strategies to fight it. This is the case for measles, mumps, chickenpox, and even flu vaccine.
It is unlikely that a unique medication will be found to treat Covid-19 infection. We need a vaccine against this coronavirus, and the race is on to develop a safe one–hopefully soon.
Coronaviruses have been around for a long time. There are 4 subtypes which are responsible for about 25% of common colds. They are seasonal viruses and usually emerge in the fall and dissipate by mid-Spring (this is one reason that experts tell us that the novel coronavirus, SARS-Cov2 is likely to die down and return later in the year).
SARS and MERS were also coronaviruses and were a great concern a few years ago. Those coronaviruses were quite deadly, with a high mortality rate, but were less contagious and fortunately died down in a matter of months. The coronavirus that causes Covid-19, however, is very contagious and thus spread rapidly and led to the pandemic. The rapid and sudden spread in a vulnerable population is what has resulted in the tremendous stress on our health care systems and hospitals.
The spectrum of illness caused by SARS-Cov2 is very variable; some people experience no symptoms at all, while others develop life-threatening illnesses. The classic symptoms of fever, cough, and shortness of breath do not always develop–a Covid-19 infection can seem like a cold for some people, a flu-like illness for others.
As more testing is done, we are learning that the infection is much more widespread than initially realized. As many as 15-20% of people living in New York may have been infected, the vast majority of whom get better with little consequence.
Indeed, the mortality rate overall is much lower than previously believed. There appears to be a 0.5-1% risk of dying if you contract Covid-19 infection. But for the elderly or those with chronic diseases like diabetes, obesity, and hypertension, the risk is higher.
Ethical Issues and Controversies Regarding Proposed Treatments for Covid-19
Ordinarily, when a new drug is developed, properly designed clinical studies are carried out to demonstrate safety and effectiveness. This leads to FDA approval for its use and general acceptance by the medical community. But we currently face an evolving pandemic in which more and more people across the globe are becoming infected and we simply haven’t the time to conduct studies in the usual fashion. Some consider it unethical to expose people to unproven drug treatments that may or may not work without first performing the proper research. Others feel that we have no choice but to try some medications in the face of critically ill patients for whom we have no other treatment options. A compassionate need approach such as this recognizes that the medications could have adverse effects or even make things worse, but feel the risk is worth taking.
Another issue is that if a drug is widely used before proven to be effective, adverse effects will emerge when given to large populations and some people will be hurt by a treatment that may later be found ineffective.
What about established drugs that are being “repurposed” for use against Coronavirus? Hydroxychloroquine (Plaquenil) is used for treating rheumatoid arthritis, lupus, and malaria. Many patients who need this medication cannot obtain it due to a run on prescriptions for hydroxychloroquine for unproven use against Covid-19.
Proposed Treatments for COVID-19 illness and prevention
There is no medication currently available that has been proven to treat Covid-19. Quite a few have been proposed–over 25 drugs are under investigation with over 150 ongoing therapeutic trials, so we will have answers to our questions hopefully soon. Reports of success are considered anecdotal, meaning small case reports or limited trials. We must be certain any drug protocol is both safe and effective. In my April 13 blog, I discuss nutraceutical and vitamin approaches that may be helpful for prevention.
Hydroxychloroquine (Plaquenil) and Chloroquine
These antimalarial drugs, commonly used to treat rheumatic diseases, have been suggested to be useful for Covid-19. They were also tried in the fight against SARS and Ebola viruses but were proven ineffective. A number of small reports of possible benefit emerged from China and France suggesting benefit in early Covid-19 disease. More recent reports in hospitalized patients have been disappointing. But those reports have been criticized for not meeting scientific criteria for properly controlled research and are considered insufficient from which to draw conclusions.
Some doctors recommend using azithromycin, a common antibiotic with no antiviral activity, with the HC. The combination of these 2 drugs is potentially dangerous because it can cause a heart rhythm disturbance in some patients. When these drugs are taken individually, this problem is extremely rare.
Because proper studies evaluating the effectiveness of HC in Covid-19 have not been completed, many experts, like Dr Fauci, warn against its use. In New York, Governor Cuomo has issued a rule that pharmacies may only dispense HC to those with conditions like arthritis or lupus and it is not to be used for Covid-19 in the outpatient setting. Hospital use is permitted and is being offered to sick Covid19 patients, while research is ongoing.
Other Antiviral Agents
Several antiviral agents used for treating other viral illnesses are under investigation for use in Covid-19 patients.
Remdesivir, Lopinavir/Ritonavir, Ribavirin, and Oseltamivir (Tamiflu) have all been tried in small studies and more are ongoing. So far, these have not shown many benefits, though Remdesivir did show some value in patients with severe respiratory failure on a ventilator.
Favipiravir (Avigan) is an antiviral drug, used in Japan to treat influenza, which has shown some promise in treating Covid-19. Currently, studies are ongoing in Japan, Italy, and the US.
Sarilumab (Kevzara) and Tocilizumab (Actemra) are biologic drugs used to treat rheumatoid arthritis which have shown promise in treating advanced Covid-19 patients. These drugs work to dampen down the immune system activation (“cytokine storm”) which is a major cause of injury in Covid-19 patients with severe disease. Other antirheumatic drugs are also being studied, including baracitinib (Olumiant) and tofacitinib ( Xeljanz). Auranofin, an oral gold formulation, also used for treatment of rheumatoid arthritis is also under study.
Anti-inflammatory drugs, like ibuprofen (Advil and others) and naproxyn (Aleve) are useful in reducing fever and musculoskeletal aches and pains, which are common symptoms of Covid-19 illness. Warnings against their use have been all over social media, based upon the opinion of a French governmental agency suggesting that these agents make the illness worse. This is simply untrue and without evidence. NSAIDs do have potential side effects and should be used with caution, however. Tylenol may be preferred in this setting, but some find it less effective.
Of course, these agents treat symptoms and have no antiviral activity.
A number of other drugs have been proposed to be useful in combating Covid-19 and are under study. Many of these have been circulating on the internet. Famotidine ( Pepcid), Ivermectin (used to treat parasitic infections), losartan ( blood pressure drug) are a few examples. Because men do worse than women with Covid-19, studies are underway using female hormones for treatment. Some of these agents have antiviral activity in the test tube, but that does not mean that they work in “real life”. Others have a specific use in treating patients with severe disease on ventilators and have a limited role in disease prevention or early treatment. It is wonderful that so many investigators are seeking solutions and conducting good research, but right now, no recommendations can be made about using any of these medications for treatment or prevention of Covid-19.
Please do not start taking any of the aforementioned products in an effort to treat or prevent Covid-19! If you feel comfortable taking some of the vitamins and supplements previously discussed, that is fine. Continue your social distancing efforts, handwashing and the use of face covers. Slowly, but surely, we are getting through this calamity. Stay safe!
If you’d like to talk in more depth, please schedule an appointment with my office.