By William G. Bain, Georgios D. Kitsios and Tomeka L. Suber
A year ago, when U.S. health officials issued their first warning that COVID-19 would cause serious ‘disruption to daily life’, doctors had no effective treatment to offer beyond supportive care .
There is still no cure, but thanks to an unprecedented global research effort, several treatments are helping patients survive COVID-19 and stay completely out of hospital.
COVID-19 treatments target two main issues: the ability of the coronavirus to spread throughout the body and damage caused by the body’s immune system response. When the virus enters the body, it takes over the cells and uses them to replicate. In response, the body sends inflammatory signals and immune cells to fight the virus. In some patients, this inflammatory response may continue even after the virus is under control, resulting in damage to the lungs and other organs.
The best tool is prevention, including the use of face masks and vaccines. Vaccines train the immune system to fight off attackers. With less risk of uncontrolled infection, they can reduce the risk of death from COVID-19 to near zero. But vaccine stocks are limited, even with a third vaccine now licensed in the United States, so treatments for infected patients remain crucial.
As physicians working with patients with COVID-19, we have followed drug trials and successes. Here are six treatments commonly used today for COVID-19. As you will see, timing is important.
Keep you out of the hospital
Two promising types of treatments involve injecting antiviral antibodies into patients at high risk for COVID-19 before the person becomes seriously ill.
Our bodies naturally create antibodies to recognize foreign invaders and help them fight them. But natural antibody production takes several days, and SARS-CoV-2 – the coronavirus that causes COVID-19 – replicates rapidly. Studies show that injecting patients with antibodies soon after symptoms appear can help protect patients from serious infection.
Monoclonal antibodies: These lab-designed antibodies can bind to SARS-CoV-2 and prevent the virus from entering and infecting cells. They include Bamlanivimab and the casirivimab / imdevimab combination therapy developed by Regeneron. The United States Food and Drug Administration has granted emergency use authorization for these therapies because they have been shown to protect high-risk patients from hospitalization and death. Once patients are sick enough to require hospitalization, however, studies have found no proven benefit.
Convalescent plasma: Another way to deliver antibodies involves blood drawn from patients who have recovered from COVID-19. Convalescent plasma is primarily administered in research settings as the clinical evidence to date is mixed. Some trials show benefits early in the disease. Other studies have shown no benefit in hospitalized patients.
Convalescent plasma may play a role as a complementary treatment for some patients due to the growing threat of mutated variants of SARS-CoV-2, which may escape treatment with monoclonal antibodies. However, careful research is needed.
If you are hospitalized
Once patients become so sick that they need to be hospitalized, treatments change.
Most hospital patients have difficulty breathing and low oxygen levels. Low oxygen levels occur when the virus and the corresponding immune response injure the lungs, causing the pulmonary air sacs to swell which restricts the amount of oxygen entering the blood. Patients hospitalized with COVID-19 generally need supplemental medical oxygen to help them breathe. Doctors frequently treat patients on oxygen with the antiviral agent remdesivir and anti-inflammatory corticosteroids.
Remdesivir: Remdesivir, originally designed to treat hepatitis C, prevents the coronavirus from replicating by interfering with its genetic components. It has been shown to shorten the length of hospital stays and doctors can prescribe it to patients on oxygen soon after arriving at the hospital.
Corticosteroids: Steroids calm the body’s immune response and have been used for decades to treat inflammatory disorders. They are also widely available, inexpensive, and well-researched drugs, so they were among the first treatments to enter clinical trials for COVID-19. Several studies have shown that low-dose steroids reduce deaths in hospital patients on oxygen, including sicker patients in the intensive care unit or ICU. Following the results of the historic RECOVERY and REMAP-CAP COVID-19 studies, steroids are now the standard of care for hospital patients with COVID-19 who are treated with oxygen.
Anti coagulants: Inflammation during COVID-19 and other viral infections can also increase the risk of blood clots, which can cause heart attacks, strokes, and dangerous clots in the lungs. Many patients with COVID-19 are given heparin or enoxaparin anticoagulants to prevent clots from forming before they appear. Early data from a large trial in patients with COVID-19 suggests hospital patients benefit from higher doses of anticoagulants.
Some patients with COVID-19 become so sick that they need an intensive care unit for high levels of oxygen support or a ventilator to help them breathe. There are several therapies available for ICU patients, but ICU patients do not benefit from high doses of anticoagulants.
Treat the sickest patients
Critical care patients with COVID-19 are more likely to survive if they are given steroids, studies show. However, low dose steroids alone may not be enough to curb excessive inflammation.
Tocilizumab: Tocilizumab is a lab-generated antibody that blocks the interleukin-6 pathway, which can cause inflammation during COVID-19 and other illnesses. New results from the REMAP-CAP trial that have not yet been peer reviewed suggest that a single dose of tocilizumab given within one to two days of being placed on Respiratory support reduced the risk of death in patients already receiving low dose steroids. Tocilizumab was also found to be beneficial for patients with high levels of inflammation in the first results of another trial.
These innovative therapies can help, but neat supportive intensive care unit care is also crucial. Decades of extensive research have defined basic management principles to help patients with severe lung infections who need ventilators. These include avoiding underinflation and overinflation of the lung by the ventilator, treating pain and anxiety with low levels of sedating drugs, and periodically placing some patients with low levels. oxygen levels on their stomachs, among many other procedures. The same key principles likely apply to patients with COVID-19 to help them survive and recover from serious illness that can last for weeks or months.
The medical progress since the start of the pandemic has been impressive. Doctors now have vaccines, antiviral antibodies for high-risk outpatients and several treatments for inpatients. Further research will be crucial to improving our ability to fight a disease that has already claimed the lives of more than 2.5 million people worldwide.
William G. Bain, Georgios D. Kitsios, and Tomeka L. Suber are Assistant Professors of Medicine at the University of Pittsburgh
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