COVID19…Amidst the conundrum and the chaos . Weekly musings of an ID Doc. June 17, 2020.

This past Monday June 15th, the US FDA revoked the EUA (emergency use authorization) for hydroxychloroquine sulfate aka Plaquenil and its parent drug chloroquine phosphate. We could pretty much say that the concept of Plaquenil therapy with COVID-19 is dead as a doornail. We have removed that as part of our regimen in our hospital.

We added Dexamethasone (DEX) in our regimen based on the results of RECOVERY (randomized evaluation of COVID-19 therapy) trial that were published yesterday June 16th by University of Oxford in UK. This is just a prepublication manuscript, it has not been validated yet nor peer-reviewed. It showed that DEX (a low cost systemic steroid that could be given either IV or PO) reduced deaths by up to one third in hospitalized patients with severe respiratory complications of COVID-19. These are patients who are sick enough to require supplemental oxygen treatment, not those with mild disease. According to that study, DEX is the first drug to be shown to improve survival in COVID-19. That’s a total paradigm shift from what we knew or thought we knew few months ago during the start of pandemic. Back then, we were trying to avoid any use of systemic steroids in the fear that giving such would promote viral replication and/or decrease viral clearance. Anyhow, this particular study involved more than 11,000 patients in the UK and studied/tested multiple treatment arms including Lopinavir-Ritonavir (we used to use this as part of HIV regimen), low-dose DEX, Hydroxychloroquine (which has now been stopped due to lack of efficacy), Azithromycin (a commonly used macrolide antibiotic), Tocilizumab (Interleukin-6 receptor antagonist indicated for the treatment of chimeric antigen receptor T cell-induced severe or life-threatening cytokine release syndrome), convalescent plasma (collected from donors who have recovered from COVID-19 and contains antibodies against the SARS-CoV-2 virus) or no additional treatment.

Overall, DEX reduced the 28-day mortality rate by 17% with a highly significant trend showing greatest benefit among those patients requiring ventilation. They found no evidence of benefit for patients who did not require oxygen. They did not study patients outside the hospital setting. It did not include Remdisivir, an antiviral agent that was used for SARS, EBOLA, MERS.

Which brings me to Remdisivir (RDS). We have given RDS to one patient at RMC. This affable 77 year old true Southern gentleman initially tested positive through a local urgent care where he presented with mild symptoms and was advised to self quarantine. He had to go to our ER because of worsening symptoms but did not want to be admitted as he wanted to be with his wife. He was subsequently prevailed upon to be admitted after few days. He had coronary artery disease, hypertension and was a lymphoma (non Hodgkin’s) survivor. I started him on RDS right away and even gave him Tocilizumab. Unfortunately, he passed away after the 3rd RDS dose. He was critically ill even prior to the 1st RDS dose but I thought I could get him through this. He passed away 3 hours after his wife of 53 years died. She had metastatic lung cancer and was on home hospice. He kept on asking me when he can go home as he really wanted to be with his wife. I made it known to all the nursing staff taking care of him that I wanted him alive and well so that he can go home and take care of his wife.

Love really does last forever, even beyond death.

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