How Treatable Is COVID-19?

The Wuhan epidemic has exposed a rift between the academic medicine types who dominate the Centers for Disease Control and similar agencies in the states and practicing physicians who are actually treating COVID patients. The former have generally been unhelpful; CDC in particular has performed poorly. Meanwhile, doctors on the front line have developed effective treatment regimens for the virus–regimens which apparently would save many lives if they were broadly publicized and implemented.

A group of critical care physicians representing the University of Tennessee, the University of Wisconsin, Eastern Virginia Medical School, the University of Texas and a number of other institutions have formed the Front Line COVID-19 Critical Care Consortium and released a bulletin setting out a recommended treatment protocol. The protocol is based largely on the fact that it is not the virus, but the body’s reaction to the virus, that kills patients:

[I]t is the severe inflammation sparked by the Coronavirus, not the virus itself, that kills patients. Inflammation causes a new variety of Acute Respiratory Distress Syndrome (ARDS), which damages the lungs.

Practicing doctors are highly familiar with inflammatory conditions and a number of known treatments have been adapted to COVID-19. The linked bulletin advocates early intervention–the key–using Vitamin C, heparin, Methylprednisolone and Hydroxychloroquine.

Dr. Paul Marik, Chief of Pulmonary and Critical Care Medicine at the Eastern Virginia Medical School, published a Critical Care COVID Management Protocol along similar lines. As a preventive measure, Dr. Marik recommends a combination of Vitamin C, Vitamin D, zinc and melatonin. Dr. Malik notes that “[w]hile there is no high level evidence that this cocktail is effective; it is cheap, safe and widely available.” For what it is worth, I have been following this regimen for some time.

Other protocols are suggested for patients who are sick but at home, hospitalized but with mild symptoms, patients with respiratory symptoms including shortness of breath, and so on. This is the critical text:

Three core pathologic processes lead to multi-organ failure and death in COVID-19:

1) Hyper-inflammation (“Cytokine storm”) – a dysregulated immune system whose cells infiltrate and damage multiple organs, namely the lungs, kidneys, and heart. It is now widely accepted that SARS-CoV-2 causes aberrant T lymphocyte activation resulting in a “cytokine storm.”

2) Hyper-coagulability (increased clotting) – the dysregulated immune system damages the endothelium and activates blood clotting, causing the formation of micro and macro blood clots. These blood clots impair blood flow.

3) Severe Hypoxemia (low blood oxygen levels) – lung inflammation caused by the cytokine storm, together with microthrombosis in the pulmonary circulation severely impairs oxygen absorption resulting in oxygenation failure.

The above pathologies are not novel, although the combined severity in COVID-19 disease is considerable. Our long-standing and more recent experiences show consistently successful treatment if traditional therapeutic principles of early and aggressive intervention is achieved, before the onset of advanced organ failure. It is our collective opinion that the historically high levels of morbidity and mortality from COVID-19 is due to a single factor: the widespread and inappropriate reluctance amongst intensivists to employ anti-inflammatory and anticoagulant treatments, including corticosteroid therapy early in the course of a patient’s hospitalization. It is essential to recognize that it is not the virus that is killing the patient, rather it is the patient’s overactive immune system. The flames of the “cytokine fire” are out of control and need to be extinguished. Providing supportive care (with ventilators that themselves stoke the fire) and waiting for the cytokine fire to burn itself out simply does not work… this approach has FAILED and has led to the death of tens of thousands of patients.

This all appears to make sense. So why have not these lifesaving techniques been more widely adopted?

The systematic failure of critical care systems to adopt corticosteroid therapy resulted from the published recommendations against corticosteroids use by the World Health Organization (WHO), the Centers for Disease Control and Prevention (CDC), and the American Thoracic Society (ATS) amongst others. A very recent publication by the Society of Critical Care Medicine and authored one of the members of our group (UM), identified the errors made by these organizations in their analyses of corticosteroid studies based on the findings of the SARS and H1N1 pandemics. Their erroneous recommendation to avoid corticosteroids in the treatment of COVID-19 has led to the development of myriad organ failures which have overwhelmed critical care systems across the world.

Our treatment protocol targeting these key pathologies has achieved near uniform success, if begun within 6 hours of a COVID19 patient presenting with shortness of breath or needing ≥ 4L/min of oxygen. If such early initiation of treatment could be systematically achieved, the need for mechanical ventilators and ICU beds will decrease dramatically.

It seems to be increasingly clear that both the World Health Organization and the Centers for Disease Control have been worse than useless in the present epidemic. Happily, front-line doctors are learning from experience what treatments can be helpful. As they continue to share information, it is reasonable to expect that fatalities associated with the Wuhan virus will decline. A consensus as to effective treatment is likely to reached long before a vaccine is available.

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