Since US President Donald J. Trump was diagnosed with COVID-19 late last week, he’s received an experimental antibody treatment, an antiviral available for emergency use, a dose of steroids, and supplemental oxygen.
The steroid, dexamethasone, powerfully tamps down the immune response that can lead to life threatening inflammation. A study in the UK shows it works best in people who are gravely ill from COVID-19, but could harm those with milder disease. Remdesivir inhibits viral replication, and though experts think could be useful in mild disease, it is currently only indicated for very sick COVID-19 patients. Meanwhile, the experimental treatment, a monoclonal antibody cocktail from Regeneron, so far only shows a benefit in a subset of people infected with the virus.
The combination of dexamethasone and remdesivir indicates severe disease, experts say,yet reports from Trump’s doctor, Sean Conley, suggest that the president’s oxygen levels haven’t fallen so low as to indicate severe disease. On Sunday, Trump left the hospital briefly in a car to see well-wishers and by Monday afternoon, tweeted that he would be discharged from the hospital that evening.
What the public is hearing and seeing is puzzling, says Ali Raja, an emergency room physician at Massachusetts General Hospital. The medications would indicate the president is really ill, the critical care expert notes.
Raja talked to C&EN about treating COVID-19, the possible state of the president’s health, and all the factors Trump’s doctors are likely weighing as they treat him. The interview has been edited for conciseness and clarity.
Given what we know about the president’s treatment to date, how severe or how serious do you think his illness is? Should he be discharged so soon?
It wouldn’t be unusual to discharge a patient with COVID-19 after 72 hours of treatment. What is unusual is that most patients who require remdesivir and dexamethasone are more severely ill, and are too ill to be discharged from the hospital so quickly.
If a patient with COVID-19 requires supplemental oxygen, we’re starting to consider that they might need to be intubated, and will have already started them on dexamethasone, and if possible, remdesivir. That might be what’s going on with the president. The other alternative is that he and his physicians have decided to lower the treatment threshold (prescribe the medicine even though he may not meet the guidelines for use) and use both remdesivir and dexamethasone in a patient who is not critically ill.
So his doctors might be throwing the kitchen sink at this to try and keep him from getting critically ill?
The president’s treatment demonstrates options that we didn’t have a few months ago. How has the treatment of COVID-19 changed since the early days of the pandemic in the US?
What we did then, for patients who were severely ill, was supplement oxygen to try and keep them off ventilators for as long as possible. But we ended up putting a lot of them on ventilators to keep their oxygen saturation up. We didn’t really have much else for many months.
Now there are a few different medications that we use. The first, and quite honestly, cheapest and most available is a low dose of steroids, prednisone, which is an oral medication, or dexamethasone, which is an IV medication that reduces the risk of death in seriously ill COVID-19 patients. We don’t use them for patients who are walking around with normal oxygen saturations and who happen to be infected.
The other thing we do for patients who have been hospitalized is to use remdesivir. Like steroids, it has been shown to work in patients who are critically ill, but not all. Even with an EUA (emergency use authorization) from the Food and Drug Administration, it’s still not widely available. The fact that it’s still an investigational agent means we admit them, and they get five days of remdesivir while they are in the hospital.
The president is getting an antibody treatment, but it’s not available yet. It’s experimental.
What about for people who arrive at the hospital with milder illness? What treatments do they get?
There’s just no evidence behind other treatments. When we were seeing lots of patients from nursing homes who were obese, so having the same mortality risk factors as the president, if they could maintain their oxygen saturation, and could eat and drink, we would send them to a facility that was caring for COVID-positive patients or home with a home health aide. An oxygen saturation in the low-to-mid 90s’s, as the president’s has been reported, doesn’t indicate a critically ill patient. I always send these patients home with instructions to go to the drug store and buy an oxygen saturation monitor and a thermometer, and if their oxygen saturation starts to fall or fevers come up, to come back.
What about the supplements that the president is reported to be taking, like zinc and vitamin D?
There’s some early evidence that low levels of Vitamin D might be associated with more severe disease. But in a first world country, with someone who is as healthy as the president appears to be, I doubt very much he has a low vitamin D level, so there’s no evidence that shows Vitamin D supplementation would help him. There’s no evidence that shows that zinc helps. So this is a decision that the president and his physicians have made together, but this isn’t something that I recommend to my patients, or that other physicians recommend to their patients.
The president has reportedly taken one dose of Regeneron’s monoclonal antibody cocktail, which is still in testing. Early data suggest the therapy helps lower the viral load in people who are infected, but whose immune systems have yet to switch on. But, so far, it doesn’t appear to dramatically effect progression of the disease. How will this fit into your practice? How will you talk to your patients about it?
I fully understand that he’s the president and he and his medical team are going to make different decisions than I make for my patients, but the president is using a medication that is still under investigation— I wouldn’t feel comfortable prescribing them to my patients because we don’t know if they work. It does make the discussions with my patients hard, if they come in with the list of medications the president is taking, and they aren’t all available to them.
In a future where both remdesivir and Regeneron’s antibodies are approved and widely available, would you use them both as the president’s doctors are doing?
In addition to availability of this monoclonal antibody cocktail potentially being a problem (it will take time for it to be approved and manufactured, and for many, the cost might be out of reach), we don’t have comparative effectiveness trials. We really need to compare them head to head. Those trials are a long time away. And like remdesivir, the monoclonal antibodies will likely only be beneficial for a certain group of patients, and that may not be the same as remdesivir. It needs to be defined more.