COVID Care: Beyond IVM and HCQ

by | Mar 1, 2021 | COVID-19 | 0 comments

Many patients have remarkable results with Ivermectin and the FLCCC protocol of vitamins, but some patients arrive late and very sick and often need additional medications. Others have significant comorbidities and are much higher risk and warrant more aggressive treatment.

Thankfully there are a number of experimental off-label, adjunctive treatments available to front line physicians, some with very promising research backing them up, and others that are considered likely to work. None of them are considered dangerous and all have been used safely for decades in other conditions.

FLUVOXAMINE

The only comorbidity that lowers the risk of COVID-19 is depression. Scientists postulated that this was due to the protective effect of a common class of antidepressants called selective serotonin reuptake inhibitors (SSRIs).

Platelets hold 95% of the entire bodies serotonin stores and in COVID-19 the serotonin is released into the bloodstream where it becomes a large part of the problem – SSRIs deplete serotonin levels in platelets and prevent the damage that can occur to the vascular walls when serotonin levels skyrocket in the blood. They also activate the Sigma 1 receptor which inhibits inflammation and helps prevent the COVID-19 induced cytokine storm.

Retrospective cohort studies showed that patients on SSRIs like fluvoxamine had much lower rates of COVID-19. In one psychiatric hospital the staff was 3.5 times as likely as the patients to be diagnosed with COVID-19.

Based on this data a randomized controlled trial was conducted in the summer of 2020 by Lenze et al which showed a 100% protective effect of fluvoxamine – none of the patients who took it got worse vs 8% deterioration in those who were on placebo.

This result was repeated in a trial by Seftel et al showing once again:

Dr Seftel did not formally keep track of time to improvement, but reported in a personal communication that in most cases COVID-19 symptoms resolved completely within 3 days of starting fluvoxamine – in fact he said this was the most amazing effect he’d seen in the 25 years he’d been practicing medicine.

Fluvoxamine may also turn out to be useful for long COVID symptoms – especially when affecting the brain. This could prove very important as there is evidence in a mouse model to suggest that COVID-19 may sequester itself within neurons in the brain and this may be the source of many patients’ long COVID symptoms.

Dr. Drew, the famous physician and media personality, took fluvoxamine for long COVID and his tinnitus resolved within 30 minutes of taking it. Overall he was 80% better within hours of the first dose and 100% better within 12 days.

The 50 mg dose being used by many physicians is lower than that normally used for OCD and has no side effects for the vast majority of patients. Also there are usually no psychiatric effects with a short 2 week course.

Some considerations when taking fluvoxamine:

Avoid caffeine because it is not properly metabolized while on fluvoxamine and sticks around about 5 times longer than expected. Though this is not dangerous it can cause some very troublesome symptoms like insomnia and anxiety.

Selected more common side effects of fluvoxamine include constipation (≤6%), nausea (≤12%), vomiting (≤11%), confusion (≤11%), dizziness (2% to 15%), drowsiness (6% to 63%, may be transient), headache (2% to 11%), hypotonia (2% to 35%), hypotension (≤9%), urinary retention (≤8%), insomnia (≤7%), pain (≤4%), paresthesia (≤7%), seizure (≤10%),

Rare side effects (<1%) can include: abdominal pain and bleeding into the bowels, amnesia, blurred or double vision, elevated blood sugar, hallucinations, hypertension and others.

COLCHICINE

Colchicine is an old stand-by for treating acute attacks of gout and in one form or another the active ingredient has been known and used for more than 3000 years.

The COLCORONA trial in 4488 patients showed colchicine may be effective at preventing progression to severe COVID-19. In 4159 patients with proven COVID-19 it reduced the risk of death by 44%, mechanical ventilation by 50% and hospitalization by 25%.

Colchicine prevents inflammation in a specific way by blocking certain cytokines like IL-6 that are involved in the COVID-19 cytokine storm.

Dr. Darrell Dimello of India has treated more than 20,000 patients in the last year and noted that colchicine often prevented even high risk patients from developing clinical illness. In one cohort of about 30 dialysis patients who were given thrice weekly colchicine after dialysis, all turned antibody positive to COVID-19 and only one developed any clinical illness.

In Dr Dimello’s experience taking colchicine three times a day for the first month, then twice a day for the second month and daily for the 3rd month and possibly longer will prevent the development of long COVID. He also recommends an aspirin daily, or stronger blood thinner like plavix for the first 1-2 months.

Colchicine has some stomach side effects that can be mild to severe including nausea, vomiting, diarrhea and stomach pain in some patients, it can also cause liver, heart and kidney problems in patients who already have problems in those organs. In all patients taking it long term for many weeks to months labs (CBC, CMP) should be checked after a month and then every 3 months.

Colchicine used to cost a few cents a pill, but after it became an “on-label” treatment for gout about a decade ago the price skyrocketed and it is now about $4 a pill, even for the generic form. Many insurance companies do not cover this except for gout, so the expense as well as side effects can limit it’s use.

STEROID INHALERS

One interesting observation in the last year has been that asthmatics on average were not coming down with severe COVID-19 symptoms. It was hypothesized that this might be due to the protective effect of steroid inhalers which are widely prescribed in asthma moderate to severe asthma.

Now we have some trial data out of England confirming that the early use of the steroid inhaler budesonide prevents progression to severe lung disease in COVID-19.

The STOIC study was a phase two randomized trial done with 146 patients who all entered the study within 7 days of symptom onset and took either 800mcg of the inhaled steroid budesonide twice a day or were given no particular treatment.

The inhaled steroid group showed a 90% relative risk reduction for requiring hospitalization or urgent care and at 14 days only 10% of the steroid group still had persistent symptoms compared to 30% of the “usual care” group.

A steroid inhaler can be started either at the first sign of symptoms and taken twice a day, or patients can choose to wait and if they begin to have a cough or wheezing they can then start using the inhaler then.

The greatest benefit is likely to accrue when starting within the first 7 days before inflammation really gets going.

One theoretical risk of steroid inhalers is they could predispose to developing a bacterial lung infection, but over a short course of a couple weeks this is unlikely. They can also cause thrush in some people, which is more annoying than anything else and easily treated.

Another drawback is that, if paying out of pocket, they usually cost $200 – $300 even at goodrx.com. An alternative for people who happen to have a nebulizer machine handy, or can get one, is to get the same medication in ampules for the nebulizer, in which case you can often get it at a quarter of the cost of an inhaler.

LOW DOSE STEROIDS

Dr Mobeen Syed of DrBeen.com reports that after treating 400 patients with ivermectin and a short course of low dose steroids during their acute illness, none but one progressed to long COVID, and that patient started treatment relatively late in his disease course. Even that patient’s long-hauler symptoms resolved after repeating the course of low dose steroids.

This therapy is cheap and has a low incidence of side effects, but despite the very suggestive clinical experience the drawback is we don’t have any confirmatory studie yet.

The protocol is dexamethasone 0.5mg starting around day 7 of acute illness and taken three times a day for 2 days, then twice a day for 2 days then daily for 2 days.

Steroids strongly suppress the immune system, so we avoid starting in the first week when the immune system is usually fighting off the infection in a normal manner.

The second week is when the immune system often goes into overdrive producing the deadly cytokine storm that often wipes out lung function and puts patients on ventilators. So at that point in the infection the virus has usually completed it’s replication and we are just dealing with the after-effects of infection – the acute inflammation at risk of becoming chronic.

HIGH DOSE STEROIDS

If patient’s deteriorate clinically and a CRP blood test (marker of inflammation) shows significant elevation then high dose steroids are often very beneficial and for this reason they are part of the FLCCC inpatient protocol.

From relatively early in the pandemic their benefit has been obvious, especially in the ICU, and various studies have backed up clinical experience.

The NIH COVID-19 treatment guidelines include the use of steroids, particularly dexamethasone, in certain clinical situations.

BLOOD THINNERS

Acute COVID-19 infection often leads to microscoping clotting throughout the body and because of this many protocols being studied around the world include blood thinners ranging from aspirin and plavix to eliquis and even injection blood thinners AKA low molecular weight heparins (LMWH) like Lovenox.

Dr. Dimello reports that in his clinical experience if the oxygen saturation drops below 95% and there is significant inflammation present on a lung CT scan, rapid initiation of full dose lovenox treatment every 12 hours is often a life and lung saving intervention, and if started immediately the oxygen saturation often bounces back up within hours to days. I have seen this myself in a number of cases.

Again anecdotal evidence like this is certainly limited, but this is how off-label treatments usually get started and has been a mainstay of modern medical practice for generations.

VITAMIN D

Vitamin D, AKA the sunlight hormone, has long been known to boost immunity to viral infections, however much controversy has swirled around vitamin D and COVID-19.

Various studies showed remarkable effects when vitamin D was given early on to patients.

Other studies, seemingly designed to fail (reminds one of the HCQ controversy), used vitamin D far too late for it to be beneficial, especially considering it can take up to 2 weeks to become activated by the body when administered in its inactive form as has been the rule in all vitamin D studies thus far.

In my own practice everyone who comes with severe COVID-19 and is tested for vitamin D turns out to be low. And of those who come with mild disease, most have been on vitamin D for months.

Since it takes so long for vitamin D to be fully activated and available to your body, the time to top up your vitamin D levels is before you get sick and if you have not been taking at least 3000 IUs of vitamin D3 for a couple months you should either get tested and supplement accordingly or immediately take 100,000 IU of vitamin D3 and then start on at least 3000 – 5000 IU per day.

Such a high one time dose is not dangerous, even if you already have normal vitamin D levels and will help ensure that you reach vitamin D sufficiency within 2 weeks.

For patients who are already sick, do not know their vitamin D levels and have not been supplementing for long enough to be sure they are at a normal level an experimental prescription option is the synthetic activated vitamin D analog called calcitriol.

For hospitalized patients this can be given IV, but even when taken orally it is well absorbed and reaches peak blood levels within a few hours. There is one in vitro study showing significant activity against COVID-19, but no one has yet studied it in patients.

SUMMING UP

The ideal patient is low risk, has a normal vitamin D level and has been on the other recommended supplements for months. They might even be on an SSRI already. They show up on day 1 of symptoms and the pharmacy has ivermectin in stock and the pharmacist doesn’t balk at the weird dosing, so they start treatment right away.

This patient is often observed to improve and return to normal within 1 to 3 days of starting ivermectin and the FLCCC protocol supplement regimen.

Not all patients fit this mold.

Higher risk and late presentations may call for promising adjunctive treatments including fluvoxamine, colchicine, oral and inhaled steroids, stronger blood thinners and vitamin D.

And if in doubt assume it’s COVID – time is lung and time is brain and time is not on your side. Anywhere from 20-90% of patients develop some form of long COVID lasting weeks to months and I have seen it even in young children and healthy young adults. It can be debilitating and even knock off up to 8 IQ points.

My advice to all patients is to treat every COVID-like illness as COVID until proven otherwise.

Proof can be hard to come by, some blood groups (B) test false negative more often, One patient in the hospital tested negative multiple times over multiple days right up until they were intubated and a lung aspirate finally tested positive for COVID-19.

One silver lining to this pandemic is that we have come to appreciate that we have many cheap broad spectrum antivirals available. I would be surprised if similar treatments did not work for the flu and other viral illnesses.

When the proposed treatments are cheap old generic drugs and supplements that are generally safe and well tolerated there is little to lose assuming it’s COVID-19 and treating accordingly.

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Dr. Syed Haider