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Why home treatment of COVID-19 with several drugs is crucial

Why home treatment of COVID-19 with several drugs is crucial
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We are more than nine months into the consequences of the COVID-19 pandemic in the United States and as the months wear on, it is becoming apparent that there is no single drug that can be considered a “silver bullet” for SARS-CoV2. In almost all other viral infections — including HIV, hepatitis C and zoster, or shingles — multiple drugs are needed to treat the infection and its complications. COVID-19 in many ways is more complex than these other infections, since the virus does direct organ damage, triggers an immune cytokine storm, and stimulates excessive internal blood clotting.   

Worldwide, doctors have learned that a rational approach to treating COVID-19 is using in combination appropriate non-labelled, off-target antivirals (zinc, favipiravir, hydroxychloroquine, azithromycin, doxycycline, ivermectin), steroids (oral dexamethasone, prednisone, inhaled budesonide) and antithrombotics (low-molecular weight heparin, oral anticoagulants). My colleagues and I, a consortium of U.S. and Italian physicians, offered American physicians and patients important guidance and support in the Aug. 7, 2020, issue of the American Journal of Medicine — a treatment algorithm, according to age and underlying medical problems, based upon the pathophysiological principles of what has been learned from 58,000 scientific publications on SARS-CoV2 infection cited in the National Library of Medicine.   

If a healthy individual under age 50 contracts COVID-19, no medical treatment is advised.  However, for someone 50 years and older or anyone with one or more underlying medical conditions, treatment should be started at the onset of symptoms before the results of testing are known. This is important, since the treatment of any infection is always most effective when started as early as possible in the course of illness. Because each medication by itself has a modest effect, two or more drugs must be used early to slow down viral replication.   

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In 30 countries, including China, Japan, Saudi Arabia and Russia, the lead medication is favipiravir, an oral polymerase inhibitor that can be considered like a pill form of remdesivir, the only drug approved by the Food and Drug Administration (FDA) for inpatient treatment of COVID-19. Favipiravir is being tested in a clinical trial by Stanford University, but the trial started late and the results and pathway for regulatory approval may be too slow to help any American in 2021 or beyond. After five days of combination antivirals, or if any pulmonary symptoms develop, then oral corticosteroids are recommended. The most familiar form to most Americans is prednisone, which is commonly used for asthma and other acute pulmonary conditions. 

The final phase of treatment addresses the most damaging and deadly aspect of COVID-19: blood clots that develop in the small vessels of the lungs, as well as larger ones that can form in arteries and veins. Many patients with COVID-19 experience chest heaviness and shortness of breath, which could be from micro-blood clots in the lungs. Older patients, in general, have risks for blood clots with many medical illnesses, so it is not uncommon to be placed on blood thinners (for hospitalization with pneumonia, for example). Hence, the extension of anticoagulants, available by injection or orally, in the home is not far from adjunctive treatment in hospitalizations for other acute conditions. 

Currently, the average American with COVID-19 shelters in illness and fear without home treatment for about two weeks. Some may then need hospitalization. Once in the hospital, the treatments discussed above are variously deployed — but far too late in the course of illness.   Intravenous remdesivir and convalescent plasma are used in a minority of hospitalized patients and are probably far less effective than they could be because the patients have been ill for so long. Thus, there is strong rationale for early treatment of COVID-19 at home with available drugs used in a sequenced combination, with the intent of shortening the course of illness and reducing the risks of hospitalization and death. 

It is certainly not too late for the U.S. to catch up to other countries regarding home treatment. We rank among the 10 worst countries for COVID-19 mortality per million population, despite having first-class hospitals. The common theme of these countries is the lack of government agency and medical community support for home treatment for COVID-19.

The report of AstraZeneca halting its large vaccine trial because of a safety event has given the academic medical community concern over the timing and certainty of our rescue by COVID-19 vaccination. The return to school and the tepid reopening of restaurants and businesses means a likely third wave of COVID-19 cases, building upon a large base. In my view, this strengthens the call for physicians to develop the confidence — and patients, the expectations — for prompt home treatment of available medications for COVID-19 based upon currently available medical science.  

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There are no signs that single drugs in randomized trials are going to be proven efficacious alone, and large randomized trials of combination drugs at home are years away. The medical community must act now to provide combination therapy to COVID-19 patients to reduce Americans’ suffering, and unnecessary hospitalizations and deaths. 

It is worth placing a phone call now to ask one’s doctor whether he or she is willing and prepared to manage COVID-19 by telemedicine in the patient’s home. If the answer is no, it is prudent to have a referral to a practice that offers ambulatory COVID-19 treatment. The same advice applies to relatives of senior home patients. Does the facility provide early in-center treatment for COVID-19, and if so, to what extent?   

No American should have to wait two weeks through progressive illness and succumb to hospitalization before receiving their first treatment in isolation and without support from their doctor and family members.  

Peter A. McCullough, MD, MPH, is an internist, cardiologist and epidemiologist, and the editor-in-chief of “Cardiorenal Medicine” and “Reviews in Cardiovascular Medicine.” He has authored more than 500 cited works in the National Library of Medicine and lectured across the world on contemporary medical issues.