So, what would you do if you get COVID?

So, what would you do if you get COVID? - Printable Version

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So, what would you do if you get COVID? - M T - 12-14-2020

On Friday, within an hour, two of my relatives (in separate areas of California) called us to say each had tested positive for COVID.

In dealing with them, I realized for all the time I've spent understanding this pandemic, I didn't have a current plan on what to do if I, or someone close to me, got sick. Early on, I knew that there was no treatment. Somehow, I've let that cloud my thinking. Now, most of us (me too) are only thinking about the vaccine as what will help.

But we've got 2+ months of winter ahead of us, and several months until even half the population are vaccinated. Frankly, I'd guess we are at about the halfway point on total cases, and maybe the halfway point on deaths.

So, I am reviewing what I'd do if I got sick and what I'd recommend for family. One clear thing I'd recommend is to figure out what you'd do BEFORE you get sick.

We've come a long way in the last 11 months. We're seeing that the vaccines appear to be real. But vaccine development has not been the only progress going on. On this board, we've seen several touted drugs not help much. We've heard mixed reviews on some of the others (may reduce hospitalization time but not serious outcome). But, medicine has been marching forward.

There have been several drugs approved by the FDA for clinical trials. Maybe some won't help. Maybe some will.

My age group has a 5% CFR. The decade younger than me has 1.3% CFR (1 death out of 76 confirmed cases). The older age groups have more grim numbers. You can adjust these numbers based on exact age, blood group, this comorbidity or that, gender, or whatever, but it is higher than probably any of us are willing to accept.

So, I will fight if I get COVID. Yes, I will be willing to try unproven methods, if I believe they might work, and even if it is only a chance that I might get a drug versus a placebo. Maybe I'd prefer one drug more than another, but I'll try to find something.

So, now what? Do I wait to get sick and then find out what my physician or hospital might offer? That's a problem. Suppose I wait until I feel bad, then I go and get a test, and then get the results back, and then go to the doctor, and then hear what he/she has to say, and then research it, and then choose what I want, and then try to find a way to get it, and then apply, and then find out I took too long. For one relative who took a test on Friday, his last chance to be in the trial was Monday.

Now is the time to look around and think about whether there's a clinical trial out there that you want to join. Your decision might well be "No thanks" but I hope it doesn't wind up "I would have, if I had been prepared." I also hope it won't be "I was in a rush and didn't really think it through."

I hope the various medical professionals will help me out here. I'm sure they know better than me.
To find the list of studies, you can go to https://clinicaltrials.gov/
Click on "Recruiting and not-yet-recruiting" radio button, enter "Covid19" (no dash) for "Condition or disease", skip the next line ("Other terms"), and then fill in your location, and the distance you're ready to go (say, 50 miles), and Search.

I turned off "Not yet recruiting" and get 48 studies within 50 miles of Stanford. You can add your age, whether you're looking for one while healthy (one study is for people living in the household of those with COVID), and gender. There are more options to restrict the results. If you want to see more info about each study, you can add columns (for instance, you might want to see what phase the study is in)

Only some of the studies will have treatments for the infection. Some are about testing, psychological support, COVID-19 and <other condition>, etc.

If you ever get to a point where you think you may have COVID, while you're quarantined, waiting for your test to come back, talk to your physician and then, if appropriate, contact the trial.

The relative that I was most worried about got a positive test on Friday in the absence of anything but maybe a sore throat or a bit of a stuffy nose and a cough due to one of his medicines, got a negative result on Monday from a second swab taken on Friday. He was the one I was trying to get into a trial. The other relative is 7 days into her COVID at home. O2 acceptable but feeling tired, muddled, queasy. She didn't quarantine despite going in for a test, so those at work and home are still at risk.

RE: So, what would you do if you get COVID? - BostonCard - 12-15-2020

Also remember that several treatments have been made available by EUA, and it is worth knowing whether they would be indicated for you. For example, the Regeneron antibody cocktail is indicated for:

"mild to moderate COVID-19 in adults and pediatric patients (12 years of age or older weighing at least 40 kilograms [about 88 pounds]) with positive results of direct SARS-CoV-2 viral testing and who are at high risk for progressing to severe COVID-19. This includes those who are 65 years of age or older or who have certain chronic medical conditions."

(generally mild means outpatient, moderate means hospitalized but not in the ICU).

The indication for the Eli Lilly cocktail is similar. If you fall into this category, think about whether you would want to get the infusion, even if you aren't sick enough to go to the hospital.

Remdisivir is indicated for "the treatment of adults and pediatric patients ≥12 years old and weighing ≥40 kg requiring hospitalization for COVID-19. VEKLURY should only be administered in a hospital or healthcare setting capable of providing acute care comparable to inpatient hospital care."

Dexamethasone does not have an EUA for COVID-19 but can be prescribed by a physician off-label and is probably considered standard of care at this point for patients with moderate (hospitalized, requiring oxygen) to severe (in the ICU) patients. Here are the guidelines:

https://www.covid19treatmentguidelines.nih.gov/immune-based-therapy/immunomodulators/corticosteroids/

There are other drugs as well, some of which have been granted an EUA, and some of which are approved for other indications and may be beneficial in COVID-19.

BC

RE: So, what would you do if you get COVID? - Snorlax94 - 12-15-2020

BC thanks for this helpful information but are these treatments widely available? My understanding from a WaPo article was that there isn't enough of the proven medicines -- whether remdesivir or the antibody cocktails -- for most people. It's helpful to know that these drugs exist and people can ask for them, but it sounds like the vast majority of people would be out of luck unless they have some personal connection to the Trump administration, and even then, only *some* of theme seem to get the VIP treatment (certainly not Herman Cain).

From the WaPo:

Giuliani, 76, joins a group of other Trump confidants who have received special care that is not widely available.

“The treatment given to Mr. Trump’s allies is raising alarms among medical ethicists as state officials and health system administrators grapple with gut-wrenching decisions about which patients get antibodies,” the New York Times reports. “Some top officials at the F.D.A. — both career employees and political appointees — have privately expressed concern in recent months that people with connections to the White House appeared to be getting access to the antibody treatments. … The antibody treatments are so scarce that officials in Utah have developed a ranking system to determine who is most likely to benefit from the drugs, while Colorado is using a lottery system. … The scarcity is such a problem that the National Academies of Sciences, Engineering and Medicine is holding a session next week to help medical professionals sort their way through rationing questions.”

Former New Jersey governor Chris Christie got the Eli Lilly antibodies before the FDA granted an emergency use authorization for them. The 58-year-old was offered participation in a Regeneron clinical trial but turned it down because he feared he might receive a placebo, the Times notes.

RE: So, what would you do if you get COVID? - BostonCard - 12-15-2020

This is a good question, and the answer is I don't know. I think remdisivir is increasingly available (but unfortunately, demand is also up). Manufacturing for the two monoclonal antibodies is ramping up, and now that there is an EUA, I expect availability to be patchy but no longer uniquely available to the well-connected. If I were to get COVID-19, and be eligible for one of the drugs, I might ask around about availability. For example, it looks like UCSF has a treatment algorithm for when to give Bamlanivimab, which is the Lilly antibody:

https://infectioncontrol.ucsfmedicalcenter.org/sites/g/files/tkssra4681/f/UCSF_Bamlanivimab.pdf

UCSF's treatment algorithm is here:
https://infectioncontrol.ucsfmedicalcenter.org/sites/g/files/tkssra4681/f/Executive_Summary_UCSF_Adult_COVID_Inpatient_Management_Guidelines.pdf

Based on that, it looks like bamlanivimab and remdisivir may be available for patients who qualify; the Regeneron cocktail is not. Dexamethasone is widely available. UCSF's treatment documentation is here:

https://infectioncontrol.ucsfmedicalcenter.org/coronavirus/algorithms?title=&field_covid_19_audience_tid_selective=All&field_covid_19_sub_section_tid_selective=All

(kudos to UC for being transparent about this)

I looked up Stanford, but their online documents are less up-to-date (for example, their treatment algorithm is dated May, 2020, which in this pandemic is eons ago)

BC

RE: So, what would you do if you get COVID? - dabigv13 - 12-15-2020

Remdesivir is not in short supply. The mAbs however are very limited (if you are not a friend of POTUS). The vast majority of people who meet the indications will not be given that medication. Maybe in a few months it will be more common, but hopefully by then enough people will be vaccinated that we'll be on tail end of this thing.

RE: So, what would you do if you get COVID? - M T - 12-15-2020

The trial I was trying to get my relative in had just 10% as many people signed up at Stanford as at Modesto.
It may be a bit dated, but Kaiser has COVID-19 research studies.

On Nov. 23, Operation Warp Speed listed a number of therapeutics that had been distributed across the country.
"The investigational monoclonal antibody therapeutic cocktail of casirivimab and imdevimab, [EUA Nov. 21] from drug maker Regeneron, is not for COVID-19 patients who are already hospitalized, but instead for patients who have mild to moderate COVID-19 symptoms and who are at high risk of disease progression." 30K doses distributed initially (Nov 24). I believe 300K doses were purchased.
By Dec. 15, over 5700 courses have been distributed to California. Over 38K have been delivered to the country.

"With bamlanivimab, [another monoclonal antibody] distribution is now in the third week [EUA Nov 9]. Already, Redd said, more than 120,000 patient courses for that drug have been allocated across the nation, and over 85,000 patient courses of bamlanivimab have been delivered to nearly 2,500 care sites across the nation."
By Dec. 15, nearly 200K courses have been distributed.

Let me emphasize that you don't need to have a bad case of COVID to get these therapeutics. If you wait that long, you may be out of luck.

RE: So, what would you do if you get COVID? - akiddoc - 12-15-2020

I haven't read most of the therapeutic studies, but my impression is that you want one of the monoclonals and you want it early. My friends who work in ICU's aren't very enthusiastic about Remdisivir. On the other hand, most of the people I know are in Pediatrics. My only other word of advice: steroids. Dexamethasone may be responsible for saving more lives than every other therapy available put together.

Anecdote: I saw a 3 year old who was wheezing 2 weeks ago. She is a known asthmatic, so just about anything could have set her off. We generally treat asthmatic kids who have active wheezing with oral steroids, so I prescribed that (a relative of Dexamethasone). Of course, in today's environment, you always wonder if the precipitant for the asthma attack is Covid, so I ordered the PCR. She was symptom free in 18 hours. Her test came back positive in 48 hours. Of course kids generally don't get very sick from Covid, but that was a darn fast response. I'm guessing that early treatment with steroids will turn out to be more efficacious than late treatment when it comes to Covid. Someone must be doing that study.

RE: So, what would you do if you get COVID? - BostonCard - 12-16-2020

(12-15-2020, 11:38 PM)akiddoc Wrote: I'm guessing that early treatment with steroids will turn out to be more efficacious than late treatment when it comes to Covid. Someone must be doing that study.

In adults, that is probably not going to be the case. The recovery trial showed that the people who benefit the most are the sickest.

[Image: nejmoa2021436_f3.jpeg]

Obviously, that is not the same as early treatment, but I think you are going to want to see how patients declare before giving them steroids. If I were seeing someone newly diagnosed with COVID-19 in an outpatient office, the data shows that unless they are sick enough to need oxygen, they won't benefit (and there's a hint they may do worse). But I would probably give them a shot of dexamethasone as soon as their sats drop below 93 and I am hooking them up to the nasal canula. And certainly if they are sick enough that I am even thinking about intubating they better already be on dexamethasone.

BC