Category Archives: Coronavirus

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From Diabetes Metab Syndr in Sept 2020:

The clinical efficacy and utility of ivermectin in SARS CoV-2 infected patients are unpredictable at this stage, as we are dealing with a completely novel virus. However, repurposing existing drugs as possible COVID-19 treatment is astute usage of existing resources, and we await results of well-designed large scale randomized controlled clinical trials exploring treatment efficacy of ivermectin to treat SARS-CoV-2.

The authors of this letter mention current clinical trials (~38) with a dose [presumably by mouth] ranging from 200 to 1200 mcg/kg body weight, for a duration of 3–7 days, which is showing promising results both in terms of symptoms as well as viral load reduction. Another article mentioned the usual treatment dose is 0.2mg/kg on day 1 and day 3 followed by Days 6 and 8 if not recovered.

The authors cite the Broward Health hospital system study from South Florida. In this small pilot study, hospitalized patients treated with ivermectin had a better survival rate compared with “standard care,” whatever that was back in Spring 2020. The ivermectin-treated patients received “at least one dose” of the drug at 200 mcg/kg, by mouth. Has this report been peer-reviewed and published yet? If not, why not?

Moving on…

One small study (probably 60 each in the treatment and placebo groups) found that 12 mg ivermectin by mouth once a month impressively protected healthcare workers against COVID-19.

Another study: “Two-dose ivermectin prophylaxis at a dose of 300 μg/kg with a gap of 72 hours was associated 73% reduction of COVID-19 infection among [hospital] healthcare workers for the following one-month. Further research is required before its large scale use.”

After hydroxychloroquine, azithromycin, and ivermectin, will nitazoxanide be the next panacea? You heard it first here!

A small study in Barcelona found no benefit from a single standard dose (200 mcg/kg) of ivermectin in patients hospitalized with severe disease. They suggest that a higher dose might be useful.

I’ve spent about 90 minutes on my day off trying to figure out if I should prescribe ivermectin to my hospitalized patients. My conclusion is that we need more and better data before it’s ready for prime time. I agree with Dr Ananda Swaminathan, who probably spent many hours more on the subject:

Evidence for the use of Ivermectin is based on in vitro [lab studies, not living animals], prophylaxis, clinical, safety, and large-scale epidemiologic studies (heterogenous populations in multiple different settings) BUT…

Many of the trials thus far are methodologically flawed without enough information about baseline demographics, multiple primary outcomes, soft/subjective outcomes, convenience samples, and unclear definitions, just to name a few

Additionally, a valid concern in evaluating the literature is that many of the trials have not yet passed the peer review process and are in pre-print format

Although Ivermectin is cheap, readily available, with a fairly safe side effect profile, based on the evaluation of the literature above, at this time, Ivermectin should not be recommended outside of a clinical trial to ensure we get a true answer of effect

Ivermectin is interesting, there is certainly signal to evaluate further, but in our desire to want a treatment option, let’s not continue to do the same thing over and over again, as we saw play out with Hydroxychloroquine

Like they say, “more studies are needed.”

Steve Parker, M.D.

PS: Something you can do to help prevent and survive COVID-19 is to get and stay as healthy as possible. Let me help:

In July, the CDC published data on the characteristics of 50,000 U.S. residents who died of COVID-19 between mid-Feb and mid-May, 2020.

Some points:

• 55% were male
• 80% were aged ≥65 years
• 14% were Hispanic/Latino (Hispanic)
• 21% were black
• 40% were white
• 4% were Asian
• 0.3% were American Indian/Alaska Native (AI/AN),
• 3% were multiracial or other race
• race/ethnicity was unknown for 18.0%
• median decedent age was 78 years (median means half who died were over 78, half were under 78)

CDC didn’t have much clinical data on all 50,000 decedents. But they were able to collect supplementary data on close to 11,000 of them;

• 61% were male
• 75% were aged ≥65 years
• 24% were Hispanic
• 25% were black
• 35% were white
• 6% were Asian
• 3% were multiracial or other race
• race/ethnicity was unknown for 6%
• decedent age varied by race and ethnicity; median age was 71 years among Hispanic decedents, 72 years among all nonwhite, non-Hispanic decedents, and 81 years among white decedents. The percentages of Hispanic (35%) and nonwhite (30%) decedents who were aged <65 years were more than twice those of white decedents (13%)

What about underlying conditions among these 11,000 decedents for whom supplementary data was available?

At least one underlying medical condition was reported for 8,134 (76%) of decedents for whom sup­plementary data were collected, including 83% of decedents aged <65 years. Overall, the most common underlying medical conditions were:

• cardiovascular disease (61%)
• diabetes mellitus (40%)
• chronic kidney disease (21%)
• chronic lung disease (19%)
• among decedents aged <65 years, 83% had one or more underlying medical conditions
• among decedents aged ≥85 years, 70% had one or more underlying medical conditions
• diabetes was more common among decedents aged <65 years (50%) than among those aged ≥85 years (26%).

From the CDC report

 

From Diabetes Care:

In summary, the findings of our study suggested that COVID-19 patients with diabetes had worse outcomes compared with the sex- and age-matched patients without diabetes. Diabetes was not independently associated with in-hospital death, while hypertension, cardiovascular disease, and chronic pulmonary disease played more important roles in contributing to the mortality of COVID-19 patients. In-hospital death among COVID-19 patients with diabetes was associated with hypertension and advanced age, whereas only older age was independently associated with death among matched patients without diabetes. The need for early monitoring and supportive care should be addressed in these patients at high risks.

Source: Clinical Characteristics and Risk Factors for Mortality of COVID-19 Patients With Diabetes in Wuhan, China: A Two-Center, Retrospective Study | Diabetes Care

Recall that the coronavirus itself uses the ACE2 protein as an entry point into cells. One worry has been that the use of antihypertensive drugs [specifically angiotensin converting enzyme inhibitors or angiotensin receptor blockers] might well cause ACE2 expression to increase, which seems as if it could be a bad idea, providing more targets for the virus to latch on to. But this survey of the literature found little evidence that these expression changes even happen. The animal data that show these effects, they report, tend to be via acute injury models or doses that are much higher than human patients encounter, and there seems to be no good evidence that it happens in humans. So that’s one thing to think about: a big part of the worry about antihypertension drugs may not be even be founded on a real problem.

We also have some clinical data: this preprint from a multicenter team in Wuhan retrospectively evaluates 43 patients with hypertension who were taking drugs in these two classes versus 83 hypertension patients who were not taking ACE inhibitors or ARBs, versus. 125 age- and gender-matched controls without hypertension at all. They also compared hospital admission statistics in general to patients’ medical histories. They first confirmed what others have found, that hypertension itself is a risk factor: the patients admitted for treatment had higher levels of hypertension than the general population, and once admitted those patients had higher death rates and longer hospital stays. But when they looked at the hypertension patients who were taking either ACE inhibitors or ARBs, their numbers were better. They had comparable blood pressure numbers to those taking other drugs, but they were a lower percent of critical patients (9.3% versus 22.9%, near miss on statistical significance) and had a lower death rate (4.7% versus 13.3%). The ACE/ARB cohort also had lower inflammation markers (c-reactive protein and calcitonin). So while the data are noisy, there may be a trend towards protection in those taking angiotensin-targeting drugs. All the more reason to heed the advice not to change therapies for people with hypertension.

Source: Angiotensin and Coronavirus Infection: The Latest as of April 7 | In the Pipeline

 

I propose a four-point plan to prevent a prolonged economic recession or depression in the U.S. caused by unjustified fear and panic about coronavirus:

1. Young and middle-aged healthy adults go back to work now.
2. Young and middle-aged healthy adults and children return to usual social interactions and school, using 6-foot distancing and face masks if desired.
3. Extreme social distancing for those at risk for serious illness from COVID-19 for the next 2–3 months, then re-evaluate the situation. The goal is NO EXPOSURE  to those who may transmit the virus to them. Protect the medically frail who are over 60, particularly if over 70 or 80.
4. Continued isolation of COVID-19 cases until they’re no longer infectious.

My presuppositions:

• A large majority of the COVID-19 deaths and serious illness will be in the elderly (over 60-65) and/or those with risk factors for serious illness, as we’ve seen in Italy, China, and South Korea.
• Those under 60-65 will have less severe illness and be much less likely to require hospitalization.
• The pandemic in the U.S. is not going to be as bad as predictions you may have heard or read (e.g., 500,000 to 2.2 million deaths), in part due to actions already taken: isolation of cases, self-quarantine or mandated quarantine, social distancing, education on infection prevention, etc).
• The recent $2 trillion relief package passed by Congress is unlikely to be very effective, particularly after the bureaucrats, politicians, major banks, and Big Business take their usual lions share. There won’t be much left for little guys like you and me.
• “Relief packages” passed by politicians are not the answer. Government is more of a problem than a solution.
• GM and Ford, et al, can’t make 50,000 ventilators in 3–4 weeks. By the time they’re ready, they won’t be needed.
• The situation is quite fluid and helpful medical information arrives daily. So we need to stay light on our feet and ready to incorporate it.
• The role of quarantine isn’t clear even now. We need more information. If a nurse treat a COVID-19 patient at the hospital, should she be on quarantine for two weeks or can she keep working? At what point do folks without symptoms start shedding virus that can infect others?
• We’re seeing a power grab by federal and state governments that is unjustified and unprecedented in our lifetimes. For instance, a Florida pastor was arrested for holding a church service in violation of social distancing. Doesn’t the first amendment to the U.S. Constitution give us the right to peaceably assemble and freely exercise our religion? Once grabbed, government does not readily relinquish power. For more on this issue, read Peter Grant’s April 1 blog post.
• Behavior of those living in COVID-19 hot spots like New Orleans or New York city may need to be different from those living elsewhere.
• Extreme social distancing of those at risk or serious illness from COVID-19 may well require them to withdraw from the workforce for several months (or longer), but that’s much less harmful than what is essentially “house arrest” of 80–90% of the population.
• Our list of conditions that increase serious risk from COVID-19 may well change over time as we learn more.
• Increased testing to identify those infected with coronavirus will help us devise better containment measures. Containment will also be easier when we can identify—via antibody testing—those who have already been infected and are cured and (hopefully) immune to the current strain of the virus.

The problem with state-mandated or encouraged social distancing is that it’s strangling our economy.

Physicians, virologists, and epidemiologists who are advising our politicians are typically focused on medical aspects of the coronavirus epidemic. Economics is on the back burner, naturally, since that’s not their area of expertise. But the economy matters!

In the U.S. in February 2020, 165 million people were in the labor force. For the week ended March 21, 2020, the U.S. set a record for unemployment benefits applications: 3.3 million. The very next week, a new record was set: 6.6 million. Economists are predicting a drop in 2nd quarter Gross Domestic Product of at least 20%.

In good times, most folk don’t apprehend the web of connections among various parts of the economy. They will soon find out.

From LexisNexis:

Unemployment has been linked with a number of psychological disorders, particularly anxiety, depression, and substance abuse; dangerous behaviors including suicide and violence toward family members or others also correlate with unemployment. These associations hold true not only in surveys of those already unemployed but also in studies that follow one or several individuals with no psychological difficulties into a period of unemployment. Such findings have been reported from many industrialized nations and, with some minor variations, apply to workers of both sexes and all ages.

Research regarding the consequences of unemployment may be confounded by a commensurate loss of income in subjects being studied. However, some studies try to account for this phenomenon of drop in socioeconomic status. Although an alert health care system may provide some needed assistance, resolution of the problem lies outside the field of medicine.

For example regarding suicide, among the unemployed aged 26 to 64 suicide was two-and-a-half times more likely than those who had jobs. Worldwide, one in five suicides is linked to unemployment. In 2017, suicide was the 10th leading cause of death in the U.S., with over 47,000 victims. At the time of this posting, the U.S. has reported 5,137 deaths from COVID-19.

Bankruptcies and unemployment will lead to an epidemic of despair.

Additionally, the stock markets in the U.S—S&P 500 and Dow Jones Industrial Average—are already down by 20–30%, depending on the day you check. I wouldn’t be surprised if it drops another 20% or more from here. Imagine how that affects folks approaching retirement, or in it already, who are depending on their 401k’s to live.

Laid-off workers without a paycheck can’t pay their mortgages or car payments or other loans. In most jurisdictions, unemployment benefits are woefully inadequate: in Arizona it’s $240/week. This is a set-up for massive loan defaults. One silver lining: If you have cash, it may soon be buyer’s market for homes and new or used cars.

Panicking is rarely good. Let’s stop.

Expect more from me on Extreme Social Distancing in a future post.

Steve Parker, M.D.

PS: A few other sources that question the mainstream media’s and government narratives…

• How Deadly Is the Coronavirus? It’s Still Far From Clear at The Spectator
• Is Our Fight Against Coronavirus Worse Than the Disease? at The New York Times
• On the lighter side: Submarines, Star Trek, and the Economic Collapse by John Wilder

PPS: The history of the Coronavirus Pandemic will be written in the the next few years. I have no doubt it will look different than what we’re seeing now.

On March 12, 2020, I published a list of conditions that increase the risk of a bad outcome from pandemic Coronavirus infection. I told you to be extra careful around Coronavirus if you had risk factors for serious illness. What I failed to do is tell you how to take precautions if you have risk factors. I rectify that today, although this may be well-known to you already.

By the way, physicians are calling the disease caused by Coronavirus, “COVID-19.”

Like the U.S. Centers for Disease Control, I mentioned that age 60–65 or higher is a risk factor.

Is Age Really Important?

Yes. Here’s a chart from the report of UK’s Imperial College COVID-19 Response Team dated March 16, 2020:

TL;DR version: The need for hospitalization and ICU (intensive care unit) admission starts to rise dramatically for patients aged 50-59 and shoots up from there. If you make it into the ICU with COVID-19, you’ll quite likely have a tube down your throat and be on a ventilator (a mechanical “breathing machine”), or getting ECMO.

BTW, the Response Team figures you have only a 50:50 chance of surviving if you end up on a ventilator.

If You Have One or More of the Listed Conditions, What Does “Being Extra Careful Around Coronavirus” Mean?

Avoid the virus if at all possible. The U.S. Centers for Disease Control and state governments have been issuing guidelines. One major issue is that the virus incubates in the body without symptoms for 5–7 days, and the affected individual may be infectious—shedding the virus that could get into you if you’re nearby—for 24 hours or so before the virus carrier even knows they’re sick. For folks that get sick with the virus, symptoms last for 1–2 weeks, and their oral or respiratory secretions (and feces? tears?) could infect you if the they enter your body via the mouth, nose, or eyes (or gastrointestinal tract?). Even after recovery, infected individuals can shed infectious virus for about a week. Further complicating the situation is that infected individuals may just have mild symptoms like a cough (or runny nose or sneezing?), and won’t be quarantining themselves or avoiding other people. They won’t know they have the virus. Other people can harbor the virus in their bodies and never feel sick—we don’t know how infectious these folks are. So what specifically can you do if you have risk factors for serious disease?

• Monitor your local news reports to know how common is the virus in your community. If there’s an outbreak there or where you’re going…
• Avoid crowds (0f 10 people? 50?)
• Stay home as much as possible.
• Don’t be around people with symptoms of possible COVID-19: c0ugh, shortness of breath, fever, ?sneezing, ?runny nose. Sure, they could just have common illnesses like bronchitis, pneumonia, hay fever, allergies, the common cold, or a sinus infection. You just don’t know. The virus won’t get into your residence unless you allow an infected person in.
• Avoid touching high-touch surfaces in public places, like hand rails, elevator buttons, door handles, handshakes, etc. If you must touch, cover the surface with a tissue or disinfect it first.
• Wash your hands frequently with soap and water. Particularly after touching high-touch surfaces in public places.
• Avoid cruises, mass transit, air travel. Again: crowds.
• If you can’t avoid someone who’s coughing or sneezing, offer them a surgical mask.
• Don’t touch your mouth, nose, or eyes. That’s how germs on your hands can enter you.

Steve Parker, M.D.

PS: It’s still very early in this pandemic and there’s much we don’t know. Some of the above information is probably wrong. Stay tuned.

Steve Parker, M.D.

 

The U.S. Centers for Disease Control website notes that the you are at risk for serious—even life-threatening—illness from Coronavirus if you are over age 60–65 or have a serious chronic medical condition, like…

• heart disease
• diabetes
• kidney disease
• lung disease

Well, there are at least a couple hundred heart diseases, a couple hundred kidney diseases, a couple hundred lung diseases, and at least three kinds of diabetes. There are entire thick medical textbooks written specifically for heart disease, lung disease, and kidney disease. All of those individual diseases don’t make you particularly vulnerable to Coronavirus.

And what’s a “serious condition?” Doctors don’t always tell you how serious a disorder is, and patients don’t always hear and remember when the doctor does. So you have a heart murmur. It’s likely chronic but is it serious? It depends.

I’ve even seen hypertension listed as a risk factor for serious flu complications, but I don’t believe it.

And what’s chronic? Say five years ago you had a mild heart attack, a stent was put in the only blocked artery, you take your prescribed drugs, and your doctor told you last month you’re doing great. Do you still have a serious chronic medical ailment?

How Do I Know If I Have a Serious Chronic Medical Condition?

If you’re uncertain, the answer should come from your personal medical specialist or primary care physician. I know many of you will be unsure.

Here’s a simple test you can do to see if you might have a serious chronic medical condition:

• Walk up two flights of stairs without stopping

If you can’t do that without stopping to rest and without much shortness-of-breath (you should be easily able to carry on a conversation): you flunk. Possible explanations (among many) include serious heart or lung disease, being badly overweight, or just “out of shape” from lack of regular exercise. A couple of those conditions you can rectify, and should.

If You Have One of the Following Conditions, You Need to Be Extra Careful When Coronavirus Is Around

Having practiced medicine for over three decades—and I’ll keep practicing until I get it right—here’s my current list of conditions that raise your risk of serious disease if you contract Coronavirus:

• age over 60–65 (may not be much of a risk factor if you are otherwise healthy, physically fit, and eat well)
• needing supplemental oxygen at home, whether continuously, at night only, or just as needed
• moderate or severe valvular heart disease, whether the valve is leaky or blocked
• a weak heart muscle called cardiomyopathy with left ventricular ejection fraction under 50% or on home oxygen
• history of congestive heart failure with current left ventricular ejection fraction under 50% or on home oxygen
• moderate to severe diastolic heart failure (sometimes call “heart failure with preserved ejection fraction”)
• serious coronary artery disease (e.g., frequent chest pains, multiple heart attacks, residual blockages in arteries)
• asthma that requires daily drugs or that has frequent or severe exacerbations
• COPD (chronic obstructive pulmonary disease) or emphysema requiring daily scheduled drugs or frequent “as needed” drugs or home oxygen
• chronic liver disease (such as cirrhosis) with serum bilirubin over 2.0 mg/dL or albumin under 3.0 g/dL or elevated prothrombin time
• serious active cancer, particularly if on chemotherapy that suppresses the immune system
• prior organ transplant requiring immunosuppressive drug therapy to prevent organ rejection
• immunoglobulin deficiency
• very sedentary lifestyle
• poor nutrition and/or malnutrition
• morbid obesity
• body mass index over 35
• on chronic corticosteroid therapy
• end-stage renal disease on dialysis
• chronic kidney disease with serum creatinine over 2 mg/dL
• nephrotic syndrome
• diabetes mellitus, especially if poorly controlled and/or concomittant chronic organ impairment such as nephropathy, neuropathy, or retinopathy
• active autoimmune disease (e.g., systemic lupus erythematosis, rheumatoid arthritis, Crohn’s disease), particularly if on drug therapy that impairs immune system function
• chronic low white blood cell count
• chronic active infection (e.g., tuberculosis, hepatitis, AIDS)
• you “always catch what’s going around” (possible immune system disorder or poor hygeine?)

Why Do These Conditions Increase Risk of Serious Illness?

Many of these infirmities impair your immune system and increase your risk of serious complications from any infection, whether viral, bacterial, or fungal. Just as importantly, these disorders may impair your body’s ability to respond to the increased physical stress of infection. Clearly, the more of these ailments you have, the greater your chance of a bad outcome.

Here’s the problem when you come down with flu or any other infection. The infection increases the workload on various organ systems that keep you alive day in and day out. Even if you take an antibiotic or anti-viral drug, you still need various organ systems to keep you alive. I’m thinking particularly about your lungs, cardiovascular, and immune systems, working together at maximal capacity. You heart, for example, pumps about five liters of blood every minute while you’re at rest, blood that’s carrying life-preserving oxygen to all your other organs in addition to the heart muscle. That blood also carries a waste product—carbon dioxide—to your lungs for delivery to the outside world. If you exercise vigorously your heart increases it’s pumping output to twenty liters a minute, if you’re young and healthy. By the same token, your lungs have a certain but limited capacity to take up oxygen from the air and blow off carbon dioxide both at rest and during exercise. As we age, the capacity the heart and lungs to do their jobs diminishes no matter what. Same with the immune system. That’s why folks over 60 are at risk for serious complications from viral and other infections. Because infections increase the workload on the heart, lungs, and immune system. When Coronavirus infects your lungs, fluid and inflammatory debris builds up in the gas-exchanging tissues, impairing your ability to absorb oxygen from the air. So your lungs and heart have to work harder, and long enough for your immune system to eradicate there virus.

I hope you find this list more helpful than CDC’s. Nevertheless, I’m sure it’s incomplete. I’m not trying to scare you. I’m trying to help you survive the pandemic, as most of us will. Forewarned in forearmed.

Steve Parker, M.D.

PS: It’s still very early in this pandemic and there’s much we don’t know. Stay tuned.