If You Get Covid-19, Here Are the Current Treatments Available
Outcomes are improving, but many people don’t get the therapies they need
Scientists and doctors have made significant progress in treating Covid-19. But the available therapies are few, the evidence for each is at least somewhat mixed, and they all have considerable limitations. Meanwhile, many Americans at the greatest risk for the worst outcomes don’t have access to key therapies that only work early on to help prevent severe symptoms and hospitalization.
“We are much better off than we were last spring,” says Manish Sagar, MD, an infectious disease physician at Boston Medical Center and associate professor of medicine and microbiology at Boston University School of Medicine. “We have a number of proven treatments, and we have much more expertise about how to deal with the disease. If you were infected last March as compared to if you were infected today and you, unfortunately, were in the group that was likely to have severe complications, your likelihood of surviving is much higher now than it was back in March.”
Yet many hospitals don’t have the necessary equipment to administer some of the helpful therapies nor the range of specialists to share expertise in fields as diverse as infectious disease, pulmonology, hematology, and rheumatology, says Paul Sax, MD, clinical director of infectious diseases at Brigham and Women’s Hospital and a professor of medicine at Harvard Medical School.
One persistent challenge: As with other respiratory viruses like the flu, there’s been almost no progress treating Covid-19 on an outpatient basis — before a person is sick enough to go to the hospital.
“We’ve made most of the major progress on the inpatient side,” Sax tells Elemental.
Given Covid-19’s impact on multiple bodily systems and organs and with new research papers being published daily, no single doctor or researcher can fully grasp all the nuances of the proven and prospective therapies.
The rest of us can be excused for being totally bewildered. But armed with some basic facts, a Covid-19 patient or loved one can ask helpful questions to make sure all viable options are discussed.
“Having an educated patient is always a good thing,” says Todd Rice, MD, an intensive care physician and associate professor of medicine at Vanderbilt University Medical Center.
Treatments that can prevent hospitalization
Three of the most compelling Covid-19 therapies target the coronavirus only in the days immediately after symptoms appear, helping the immune system fight Covid-19 before it worsens and a person ends up in the hospital.
People who’ve recovered from Covid-19 have antibodies in their blood that the immune system made to fight the disease. When they donate blood, plasma containing these antibodies can be separated out. This so-called convalescent plasma has been used to treat many illnesses, including polio and chickenpox, so it is presumed safe.
But not all plasma is created equal, experts say. It must be screened to ensure it’s got high levels of antibodies. Studies have yielded mixed results on the therapy, with the strongest positive evidence suggesting it may work best for people at greater risk of complications due to age or underlying health conditions.
And there’s another catch: The therapy works only if started within a few days of symptom onset. When treatment starts within three days of a Covid-19 diagnosis, people 65 and older getting convalescent plasma were 48% less likely to develop severe symptoms compared with those receiving a placebo, according to a recent study in the New England Journal of Medicine.
“If it’s going to work, it has to be given very early,” Sax says.
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These synthetic antibodies mimic the real thing and target coronavirus particles’ spike proteins, which latch onto receptors on human cells to gain entry.
There are two versions approved by the Food and Drug Administration: bamlanivimab (from Eli Lilly) and a mix of casirivimab and imdevimab (from Regeneron). The evidence suggesting they work is based on small studies, and more research is underway.
“The logistics of getting people to a place where they get monoclonal antibodies is hard. It’s a pretty heavy lift.”
Again, timing matters greatly: For people 12 and older with mild to moderate symptoms but at risk for severe outcomes due to age or preexisting medical conditions, monoclonal antibodies can reduce the risk of severe symptoms if treatment begins within about seven days of a positive test. “Monoclonal antibodies, in the symptomatic patient, have been shown to decrease the need for hospitalization,” Rice says.
Monoclonal antibodies may be among the most effective treatments that have been shown to work early on, Rice says. However, they have not been shown to be effective for people already hospitalized or who are receiving oxygen therapy.
Meanwhile, monoclonal antibodies are not being fully utilized. The people who could benefit from the treatment may not be offered the drug until it’s too late and they’re already hospitalized. Further, the therapy is administered in specialized IV infusion centers that isolate Covid-19 patients from others, and a patient has to stay for a couple of hours after an infusion to make sure they don’t have an adverse reaction. The majority of hospitals are not set up for it, Rice explains.
“The logistics of getting people to a place where they get monoclonal antibodies is hard,” he says. “It’s a pretty heavy lift.”
Sagar, the Boston University professor who also treats Covid-19 patients, calls Remdesivir’s clinical trial data “quite a mixed bag.” In fact, he says, all the above therapies have “a lot of caveats.”
This antiviral drug developed for Ebola was shown to block replication of SARS and MERS, two coronaviruses that caused outbreaks in the past. Some studies suggest that the drug also modestly shortens recovery time among people hospitalized with Covid-19. More recent research has been less promising. Vanderbilt University Medical Center uses quite a bit of Remdesivir, but not all hospitals favor it.
“It probably does have some benefit in getting people better, faster, and getting people out of the hospital,” Rice says.
Treatments that calm the immune system after hospitalization
When symptoms become severe, treatment shifts from thwarting the virus to calming an overactive immune system and battling organ damage. Progress on this front has been substantial, in part because patients by then are hospitalized and receiving watchful care, leading to a wealth of data contributing to ongoing research about the therapies and outcomes.
Improvements include smarter use of using oxygen therapy without the more invasive mechanical ventilators and putting patients in the prone position, face-down, to relieve pressure on the lungs and allow for easier breathing.
In addition, three medications show particular promise.
Dexamethasone and other steroids
Cytokines are molecules released by the immune system to battle infections. In severe Covid-19 cases, the immune system may release too many cytokines, causing a so-called cytokine storm that can lead to failure of the lungs and other organs.
In these severe cases, specifically among people who are on supplemental oxygen or ventilators, common, inexpensive anti-inflammatory medications called corticosteroids, including dexamethasone, have been found to reduce the risk of death. Dexamethasone is one of the best Covid-19 treatments, Sagar says.
“It looks like any of the steroids probably decrease mortality and improve outcomes in people who are hospitalized and need oxygen,” Rice says. Conversely, he notes, giving these drugs to people who are not yet so sick could be harmful.
“There are a number of providers out there who maybe aren’t fully up to date on all of the treatments and who should be offered the treatments. If you don’t like the answer that you get, you may even get a second opinion.”
Interleukin 6 inhibitors
One type of cytokine, called interleukin 6, is a key molecule of the immune system. It’s also one that’s prone to running amok during severe infections. Clinical studies of interleukin 6 inhibitors to treat Covid-19, particularly the drugs tocilizumab and sarilumab, have had mixed results.
Rice calls this a really promising therapy but says its effectiveness remains unclear. Initial studies suggested that maybe it wasn’t that helpful, he explains, but a more recent study, which has not yet been peer-reviewed, indicates it reduces mortality but only when given to patients once they end up in ICU. “We’re still trying to fully understand that data and whether that is really a treatment that we should be using,” Rice says.
The risk of blood clots rises with severe Covid-19 cases, so most people admitted to a hospital for the disease get low doses of blood thinners — anticoagulation medications such as heparin or enoxaparin. Patients who have a history of blood clots or who are at high risk may get full doses. Anticoagulants come with the risk of excessive, potentially dangerous internal bleeding, however. Even regular aspirin, known to reduce the risk of blood clots but also increasing the risk of bleeding, has shown promise for lowering the risk of death in severe cases.
Given the numerous complexities, the need to administer some treatments soon after an infection begins, and the evolving knowledge on these and emerging therapies, anyone who tests positive for Covid-19 and has symptoms should at least talk to a medical provider right away to learn what treatments might be available and appropriate, Rice says.
Armed with knowledge, you can now go into the conversation with, at least, a list of questions.
“There are a number of providers out there who maybe aren’t fully up to date on all of the treatments and who should be offered the treatments,” Rice says. “If you don’t like the answer that you get, you may even get a second opinion.”