I wanted to provide everyone with an update on the Coronavirus 2019 pandemic. As we predicted the rate of infection continues to increase over time. The elderly and those with compromised immune systems or chronic disease remain at greater risk of severe infection. Young people are at low risk but remind them that they play a vital role in preventing spread of the virus to vulnerable patients.Please stay home if you are sick, over the age of 60, have a compromised immune system, or a chronic disease.
Slowing Down a Pandemic
There are several ways to slow down a pandemic.
- Find a treatment
- Develop a vaccine to prevent the disease.
- Contain or mitigate the disease through social distancing, frequent hand washing, sanitizing solid surfaces, avoiding touching your face and following quarantine orders.
- Herd immunity(also known as community*immunity) is defined by the Centers for Disease Control and Prevention (CDC) as “a situation in which a sufficient proportion of a population is immune* to an infectious disease (through vaccination and/or prior illness) to make its spread from person to person unlikely.”
Hydroxychloroquine Treatment of Coronavirus 2019
In my original email on March 7, 2020 I mentioned that an anti-malaria drug Chloroquine had shown some promising results in China. I have since reviewed data from South Korea and yesterday reviewed a controlled clinical trial from France. In these studies, most patient’s symptoms improved and the presence of virus in the nasal cavity resolved after 6 days. In the control group virus persisted beyond 20 days. Although both studies are limited due to small sample size, in the absence of any other treatment during this pandemic I am comfortable that in certain patients the benefits of Hydroxychloroquine therapy for Coronavirus 2019 infection outweighs the risk.
Chloroquine is a medication that was developed in 1945 to treat and prevent malaria. Hydroxychloroquine was developed to reduce the side effects of Chloroquine. Hydroxychloroquine is widely available and inexpensive. In this country we use Hydroxychloroquine mainly for the treatment of autoimmune diseases such as lupus and rheumatoid arthritis. It modulates the immune system reducing inflammation without suppression. In vitro studies with the SARS virus revealed that Chloroquine had potential broad spectrum anti-viral effects. It is these anti-viral and anti-inflammatory effects that may account for its potential efficacy against Coronavirus 2019 infection. Hydroxychloroquine is well tolerated. Side effects are not common but include nausea, vomiting, headache, ringing of the ears, rash, loss of appetite and diarrhea. Patients with prolonged QT syndrome or the enzyme G6PD deficiency should avoid Hydroxychloroquine. Short courses of Hydroxychloroquine is safe for patients with eye disease. Hydroxychloroquine has a few drug interactions that need monitoring.
Hydroxychloroquine Recommendations for Coronavirus 2019
When I was in medical school in the 1980’s at the University of California San Francisco (UCSF), I cared for and watched many young patients die of AIDS. We treated their rare infections and cancers, but we had nothing to help their immune systems. I am reminded of those days scouring the medical literature for answers and trying different therapies without adequate research to prove benefit and safety.
These recommendations are limited by the lack of comprehensive clinical trials. These recommendations are not approved by the FDA. These recommendations would be an off-label use. I prescribe Hydroxychloroquine frequently for autoimmune disease. I feel comfortable that with appropriate patient screening, the benefits of short courses of Hydroxychloroquine for Coronavirus 2019 infection outweigh the potential risks. I will consider each case individually and review your prior electrocardiograms for prolonged QT syndrome as well as any potential drug interactions prior to starting therapy.
- Healthy patients with no symptoms or mild symptoms of short duration do not need to take Hydroxychloroquine unless the patient lives with a vulnerable family member.
- Healthy patients with moderate or severe symptoms or mild symptoms of prolonged duration can take Hydroxychloroquine 200 mg twice a day for 10 days.
- Elderly patients or patients with compromised immune systems or chronic disease can take Hydroxychloroquine 200 mg twice daily for 10 day.
- Preventative therapy has not been studied yet may be considered on a case by case basis. For example, a health care professional on the front lines or an elderly patient in an exposed nursing home may benefit from Hydroxychloroquine 200 mg daily to prevent an infection.
- Should you have mild side effects reducing your dose to 200 mg daily will often help. Patients with severe side effects will need to stop therapy.
Ideally, I would like to confirm a Coronavirus 2019 infection prior to starting treatment. The turnaround time for test results can be up to 4 days. Empiric therapy will need to be started right away while test results are pending.
Azithromycin Treatment for Coronavirus 2019
The French study combined Hydroxychloroquine with Azithromycin and found a synergistic effect. Primary outcome of viral clearing was superior when compared to Hydroxychloroquine alone. Azithromycin or Zithromax is an antibiotic with anti-inflammatory effects. Both Azithromycin and Hydroxychloroquine can prolong long the electrocardiogram QT interval and potentially lead to abnormal electrical heart disturbances. This risk outweighs the benefit for most patients. Should patients develop a secondary bacterial infection I would recommend a different antibiotic.
Other Treatments of Coronavirus 2019
Remdesivir is believed to be the most promising of the other antivirals. Remdesivir was developed by Gilead Sciences Inc., as an investigational broad-spectrum antiviral. It was previously tested in humans with Ebola virus and showed promise in animal models with Middle East Respiratory Syndrome (MERS) and SARS. MERS and SARS are other types of coronavirus. Hospitalized Coronavirus 2019 patients at the University of Nebraska were enrolled in an NIH clinical trial of Remdesivir. Results are pending. It will take time to manufacture the necessary supply of Remdesivir.
Vaccine for Coronavirus 2019
On March 16, 2020 a messenger RNA COVID-19 vaccine developed by Moderna Inc began testing in 45 healthy Seattle adults. This is unprecedented that a vaccine started testing in just 63 days and that animal testing is being done concurrently with human testing.
Blood Type and Coronavirus 2019
I received a lot of questions about the Chinese study indicting that patients with blood type A are at greater risk of Coronavirus infection than patients with an blood type O. This studied some 2700 Coronavirus 2019 patients in China. The study was considered small for a blood type population risk study and will need to be validated by a larger study. My advice, if you are type A do not panic. If you are type O do not let your guard down. I do not routinely do blood types so please do not call for your type.
Testing for Coronavirus 2019
I am scheduled to receive 50 test kits this week. If this shipment does arrive, I can begin to test patients with mild symptoms. We will continue to do testing at home to prevent community spread. After speaking with me a kit will be left outside of my office door with detailed instructions. The sample is then returned in the lockbox outside of my door.
Symptomatic Treatment for ADULTS with Coronavirus 2019
- Fever and body aches: There is some evidence that Tylenol (acetaminophen) is superior to reduce fever and body aches than Ibuprofen. The dose of*Tylenol is 500 mg 2 caplets every 6 hours as needed for fever or Tylenol 325 mg 2 tablets every 4 to 6 hours as needed for fever*.
- Cough: Products with Dextromethorphan suppress cough. I recommend*Delsym 10 ml twice a day as needed for cough*. Mucinex DM or Robitussin are other options. If Dextromethorphan does not help, I can phone in a codeine-based cough syrup.
- Congestion: Products with Guaifenesin suppress cough. I recommend*Mucinex 600 mg twice a day as needed for congestion.*
- Wheezing: An Albuterol inhaler (Ventolin or Proair) two inhalations four times a day will be prescribed for patients who are wheezing. If you have asthma, make certain that your inhaler has not expired.
- Secondary bacterial bronchitis, sinusitis or pneumonia: Cefdinir 300 mg twice daily for 7-14 days or Levaquin 500 mg daily for 7-14 days will be prescribed for a secondary bacterial infection
- Probiotics: Probiotics are your first line of defense in your gut.
- Vitamin D: You should be taking Vitamin D3 2,000 to 5,000 units daily to support your immune system.
- Zinc: There is some evidence that zinc 30 to 50 mg daily reduces viral replication. Diarrhea is a side effect of taking zinc.
I apologize about the long email. I know everyone is getting bombarded with emails and information about the Coronavirus 2019 pandemic. I hope you continue to find this information useful. I remain hopeful that our scientific and medical community will continue to find solutions.
Charles H. Miranda, MD, FACP
South Denver Internal Medicine
Denver Concierge Medicine
10103 RidgeGate Pkwy, Suite 114
Lone Tree, CO 80124