Treating a President with COVID-19
According to The New York Times, The President is being treated (as of Saturday, October 3) with:
- REGN-COV2 (REGN10933+REGN10987) -- A cocktail of two monoclonal antibodies from Regeneron Pharmaceuticals of Tarrytown, NY targeting the ability of the SARS-CoV-2 virus to attach to cells via a spike protein. While the use of these two antibodies remains investigational, REGN-COV2 is a standardized product, which convalescent plasma is not.
- REMDESIVIR -- An antiviral agent that disrupts the replication of RNA chains in infected human cells.
- MELATONIN -- a relatively gentle anti-inflammatory thought to inhibit interleuken-1 production. Considered safe, melatonin is widely available in drug stores as a supplement / sleep aid.
- VITAMIN D -- Important for its anti-inflammatory properties, doctors increasingly test for vitamin D level as part of regular blood work when giving a physical exam. That vitamin D plays a role in the human immune response to COVID-19 is a possibility doctors and researchers have increasingly embraced. <Here's a recommended video with more information>.
- FAMOTIDINE -- Thought very promising and a possible safer alternative to hydroxychloroquine in late spring, an investigation suggesting OTHER stomach drugs are making people MORE susceptible to major COVID-19 caused reassessment in early summer. In light of that evidence it could be that famotidine, an H2 inhibitor, simply shines by comparison.
- ZINC -- The properties of zinc, a natural anode, are thought to promote the ability of cells to interact successfully with other elements and molecules, with antioxidant and anti-inflammatory results.
While the drugs above are all appropriate to treatment in the early, viral phase of the disease, there are some who counsel against the simultaneous use of so many agents, and it may be important that antivirals be discontinued when the president enters the next phase of the disease.
Earlier today, Dr. Sean Conley, The President's physician, spoke of the 7-10 day time frame being the most critical in determining the likely course of someone's illness. It's possible he means 7-10 days from onset of symptoms, which would correspond to days 12-15 on the graph above, and probably to days 14-17 from the date of initial infection. Dr. Conley spoke of its having been 72 hours since The President's first positive test result. A reporter asked a very important question to which Dr. Conley declined to respond: when was The President's last NEGATIVE test result? The timeline is a bit muddled, and confused press reports don’t help. At some point, The President will enter the inflammatory phase of the disease, when it will either be severe, or not. A combination of his own antibodies and white blood cells and the antibodies he is being given will have disabled most of the active virus by then, and what will be left is viral debris. His blood oxygen level may dip below 92-93%, the point at which most people are admitted to a hospital. If his blood oxygen continues to fall, and if doctors test his blood and see his cytokine levels rising, those are the markers that signal severe COVID-19 disease. It’s at that point that a corticosteroid is typically begun, along with anticoagulant if that hasn’t been started already. This is also when antivirals should be DISCONTINUED according to Dr. Paul Marik of Eastern Virginia Medical School, who has made a video explaining as much <view here>.
For those who are infected with the coronavirus and are not President of the United States, a few thoughts. If you or I enroll in a study of REGN-COV2, we will not know if we’re receiving the antibody drug or a shot of nothing, a placebo. We will not receive Remdesivir until we’re in the hospital and the viral phase is near done, because we will not be admitted to a hospital until our blood oxygen level is below 93%. Outside of a clinical trial involving a placebo, no pill or injectable antiviral will be available to us prior to hospitalization.