Coronavirus II

We are in unprecedented times.
The COVID-19 strain of coronavirus is spreading quickly through the United States and many other countries. Everyone is desperate for reliable information.

With so many sources out there, it’s hard for us to know what to believe. I work in a medical system and we get multiple updates just about every day. We have conference calls several times per week. The protocols and recommendations are in constant flux. As I write this, I’m aware that new information may come in tomorrow that will alter our focus and priorities.

Some aspects of the COVID-19 pandemic are unchanged from the beginning. This is a real threat especially for those who are older and with chronic health conditions. The virus is extremely contagious with a relatively long incubation period. Many who are infected have minimal if any symptoms.

This means almost any person might right now be carrying a virus that they can unknowingly spread to others. Young people with no symptoms at low risk of can still pass the virus on to someone who can then pass it to someone else at higher risk of harm.

Positive Developments in Society:
There have been many positive developments in the society. The majority of people are under relative self-quarantine maintaining social distance whenever possible.  Those approaches, however, are only effective if adopted by a strong majority of people.

I’m going to delve now into some of the reports ping ponging across the Internet.  

  • The first is the idea that a person infected with COVID-19 who takes non-steroidal anti-inflammatories (NSAIDs) like ibuprofen (Advil, Motrin) and Naprosyn (Aleve) is at greater risk of death. I’ve searched and searched for something that confirms this idea, but have not found a solid source.Most scientists, doctors, and researchers are familiar with the phrase “correlation is not causation.” What that means is that something can be associated with a certain condition, but is coincidental and does not necessarily represent the primary cause or even a contributor to that condition. Perhaps the patients that are the sickest are more likely to take ibuprofen to relieve their symptoms and that’s why it seems to increase their risk?People, including public health officials that should know better, don’t always represent data and statistics properly.A definitive answer to whether ibuprofen increases risk will probably not come soon. The ultimate way to prove or disprove a theory is for someone to go to the effort and expense of a double-blind placebo controlled trial. In this case, the study would provide half of those positive for COVID-19 a certain dose of ibuprofen and half a placebo to be taken over some period of time. For many reasons, this standard is impractical.

    When things are changing so rapidly and we are trying to make the best decisions, we often have to work with incomplete or imprecise facts.  For any specific question, what is our best judgment using the best information available to us at a given moment in time such that we can weigh the potential benefits against potential harm.

    NSAIDs are known to have a variety of potential negative impacts including potential damage to the lining of the gastrointestinal tract and adverse effects on the kidneys. These risks generally come into play for older, more vulnerable people especially if they take higher doses over extended periods of time.

    With so many factors in play, it’s hard to be definitive. I have come to mistrust absolute answers. When it comes to ibuprofen, we cannot say at this time based on the state of evidence available to us that it is causing grave harm to those infected with the COVID-19 virus.

    But it’s possible.

    So, the best approach is to discuss your concerns and options with an experienced healthcare professional. That person will weigh the risks and benefits for you as an individual.

  • Next up is the potential benefit of melatonin supplementation: The argument in favor of melatonin supplementation at 0.2mg to 0.5mg at bedtime made in the article is intriguing and persuasive. But not definitive. To know for sure, we would need the same double-blind placebo controlled trial.
    Will that trial be done any time soon? No.
    Is there potential benefit from melatonin assuming her argument is credible? Yes.
    How about potential harm? Unlikely.
    Cost? Fairly low.She also recommends high doses of vitamin C. This option has, of course, been around for many years especially relative to the potential benefits of stimulating the immune system.Is there potential benefit? Yes, of course.
    Is there potential harm?

    Vitamin C is water-soluble, so it shouldn’t build up in tissue. It can cause loose stools and increase iron absorption, but otherwise should be safe.

  • In terms of pharmaceuticals, there are many getting attention that might be used for the prevention of a serious COVID-19 infection or for treatment of an ongoing infection or both. At the top of the list is hydroxychloroquine (name brand Plaquenil) with or without the antibiotic azithromycin. Hydroxychloroquine was originally developed for malaria and has also been used for certain autoimmune conditions and for chronic Bartonella infections.For this medication, there are limited studies with relatively small numbers of patients including one from France that suggested benefit and a controlled study from China presented last week that did not. As of now, we do not have enough information to recommend for or against this option.

    The option with the highest potential benefit might be a medication currently in development called remdesivir. This, compared to the other options above, is designed specifically as an antiviral. It’s not clear when this drug will be available and what threshold the FDA will use to approve its use for COVID-19. Its also uncertain as to what the drug company will charge, but hopefully they will keep the cost reasonable in these difficult times. For reference, the breakthrough drug that clears almost 100% of Hepatitis C cases is about $1,000 per pill or $100,000 for one course of treatment.

    There are other supplements that have potential to support the immune system and/or inhibit viral activity including zinc, l-lysine, astragalus, elderberry, echinacea, andrographis, umcka and my personal favorite, the combination supplement from Pure Encapsulations called Daily Immune. We have no concrete evidence to support any of these options in terms of benefit for COVID-19, but many people will decide to take one or more of these non-pharmaceutical options based on the principle that there is enough potential benefit with minimal chance of harm at relatively low cost.

  • On to the situation of test kit availability. For someone on the front lines, this process has seemed incredibly slow and inefficient. One article commented that the COVID-19 pandemic is exposing the United States for our lack of a coordinated public health policy. It feels like that, but this situation is so unique in our history, it’s hard to come to any firm conclusion. We can certainly compare our response to those of other countries like China, South Korea and Italy.In our healthcare system, and presumably most of the systems around the United States, we went from no kits to having kits with a lack of the swabs needed to do the testing and now we have both kits with swabs. We still have a relatively limited supply of these items and, to that end, there is a protocol in place for who should be tested or not. Healthcare workers with symptoms are a priority because they can infect many other people. Those over 60 or 65-years old are a priority especially if they have chronic heart or lung conditions.

    I’ve had my first two patients go for testing this past week. The turnaround time was reported to be 4 or 5 days, but one of the results came in on day two. Surprisingly, I got a negative result for my 40-year-old symptomatic police officer with exposure to multiple co-workers who had previously tested positive.America, for all of its issues and struggles, can still be impressive in terms of fortitude and innovation. A company has developed a COVID-19 test with a result that comes back in about an hour.

    Knowing who has COVID-19 and who doesn’t will obviously be a tremendous benefit to our efforts. It will help reduce spread. It will help us identify those that have had the infection. For a person who has COVID-19 and clears the infection, we presume they will have long-term immunity against reinfection. Many in that group can then step up and do work on the front lines knowing they are unlikely to get anyone else sick. Click here to read an article about coronavirus antibody certification.

Overall, stay isolated, avoid social contacts unless necessary, and consider wearing a mask in public. Masks significantly reduce the chances a person can spread the virus to others. The masks are, however, in short supply so they may be difficult to acquire. If you’re trying to decide about medications and supplements or if you have other questions or concerns, its best to contact your primary care office or discuss with another qualified professional.

Andrew Lenhardt, MD