Coronavirus Basics Too Many People Never Learned

As a nation and a society, we found ourselves not fully prepared for the sudden global pandemic of the SARS-CoV-2 virus that causes COVID-19.  One of many ways that our society is struggling to keep up is for the public to understand basic concepts about medication and how to battle this new virus.  

We heard about the couple in Arizona who drank a fish tank cleaner designed to kill parasites in fish aquariums.  This was somehow blamed on President Donald Trump — even though the wife is alleged to be a Democrat donor, not a Trump fan. 

There are some basic concepts that professionals take for granted that everyone knows.  Apparently, some things should be better explained.  Your author reviewed these issues with doctors, including a preeminent physician among the top ten finalists for the Nobel in medicine.

First, no one should take medication without being screened by his physician and advised to take it.  Too much criticism about COVID-19 is based on the assumption that everyone might run out and start popping hydroxychloroquine pills like candy.

President Donald Trump recently announced that he has been taking hydroxychloroquine together with zinc supplements for almost two weeks now.  Speaker of the House Nancy Pelosi, always classy, then called Trump "morbidly obese" as a risk factor and gave her medical advice that the medication would be dangerous for Trump.

But medications that are not over the counter require a doctor's prescription.  A physician evaluates a patient and screens for risk factors, allergies to medications, and other "contraindications."  In Trump's case, the White House physician, Sean Connolly — not Pelosi — would decide if Trump's weight argues against the medication or whether hydroxychloroquine makes sense in decreasing the president's chance of coronavirus infection. 

For every drug or therapy, the medical community identifies "indications" — signs that it may benefit a patient.  But there are also "contraindications."  Those are times when a pill or shot should be avoided because of likely adverse side-effects in spite of possible benefits.  In pharmacology, this is the "benefit/risk ratio."  These are individualized decisions.  It is not a "do it yourself" project.

Second, we should not be looking for only one solution.  Doctors need to select the best medication for each individual, often trying one and then trying another.  The antiviral remdesivir looks the most promising at the moment.  We would celebrate that great news if remdesivir is unequivocally proven.  But we should hope to have several treatments that allow physicians to select the best answer for each individual patient, at different stages of the disease, different symptoms, and different severity.  We should not be looking to shut down any lines of research.

Remdesivir is an antiviral that targets specifically an enzyme in the viral genome (RNA-dependent RNA polymerase; RdRp).  Directly targeting the virus would seem to be the most rational approach, rather than treating the subsequent inflammatory responses caused by the virus.  Also, remdesivir has fewer risks than hydroxychloroquine for severe side-effects.

Hydroxylchloroquine is an anti-rheumatoid drug, often used when combined with the antibacterial azithromycin (AZT, or Z-pack).  It can fight inflammation and/or help transport zinc into cells, which reduces viral reproduction. 

Other medications being worked on are targeting completely different phases of COVID-19, such as trying to treat the "cytokine storm," which happens in many of the most severe infections.  COVID-19 often produces only moderate flu-like symptoms, but sometimes it generates a catastrophic collapse, sometimes unexpectedly.  It is believed that a cascading overreaction of the immune system can causes mass death of cells, including in the sensitive tissues of the lungs, leading to death by oxygen starvation.  Researchers are hoping to directly target the genesis of a cytokine storm, which should blunt the worst symptoms of the disease.

Third, treatment is not "set it and forget it."  Even with the best decisions, a patient may not respond as expected; monitoring and making changes are what the treating physicians do.  Medications can affect different people differently.  Some people actually experience an opposite effect compared to other people.  Some have allergies.  Genetic differences can change how people respond to any medication.

Fourth, we are seeing a steady march forward of clinical trials.  These are being rushed because of the worldwide crisis against what would normally be a 12- to 24-month timeline.  These accelerated efforts involve smaller study groups seeking quicker partial answers than would normally be used.  Our modern culture is impatient for quick answers.  As is to be expected in quick, small trials, results can be controversial. 

But one purpose of such clinical trials is to discover when in the life cycle of a disease a treatment might help, and under what circumstances.  So does a drug prevent a disease from becoming severe?  Or can it beat back a disease that has already flared up with the worst symptoms?

There is a serious concern when — sometimes — the worst symptoms of COVID-19 dramatically overwhelm a patient, leading quickly to death.  One drug may be able to prevent the disease from getting bad in the first place.  A different drug might (or might not) be able to pull a victim back from COVID-19's final death spiral.  It is the wrong question to ask if a drug is a "one-size-fits-all" therapy under all circumstances.

In clinical trials we hear criticism of bad results with some patients.  But that's what doctors do — in cooperation with medical researchers.  Clinical trials help improve our understanding of who should take which drug and who should avoid which drug.

Doctors informed by this growing body of research decide who should get a prescription and who shouldn't.  There are reasons why a doctor's prescription is required.  This is not just "make work" to make doctors practice their handwriting.  Some people are not the right candidates for a particular drug.

Fifth, medications are actually complicated.  Virtually all drugs exhibit no effect in some people, are beneficial in most patients, and can be toxic to an unfortunate subset of people.  Therefore, early quick and sloppy trials might not be able to delineate all the nuances of any test drug.

We hear that patients are pulled from some study due to adverse reactions.  This information can help physicians in prescribing a balance of several medications, taken together and at the right dosage. 

Sixth, there has been confusion about the word "cure."  Our information so far is that COVID-19 runs its course, on its own, in apparently 2 to 8 weeks.  We don't talk about a "cure" for the flu.  We just manage it until the body's immune system defeats the infection.

The real challenge is whether symptoms become so severe that the body cannot overcome the virus — so that the patient dies before the immune system can win the battle.  Therefore, treating symptoms matters.  If the body can be protected and strengthened from the worst effects of the disease, the body will gain the time and resilience to kill the infection on its own.  Some treatments might not be a "cure," but still very important.

As a nation and a society, we found ourselves not fully prepared for the sudden global pandemic of the SARS-CoV-2 virus that causes COVID-19.  One of many ways that our society is struggling to keep up is for the public to understand basic concepts about medication and how to battle this new virus.  

We heard about the couple in Arizona who drank a fish tank cleaner designed to kill parasites in fish aquariums.  This was somehow blamed on President Donald Trump — even though the wife is alleged to be a Democrat donor, not a Trump fan. 

There are some basic concepts that professionals take for granted that everyone knows.  Apparently, some things should be better explained.  Your author reviewed these issues with doctors, including a preeminent physician among the top ten finalists for the Nobel in medicine.

First, no one should take medication without being screened by his physician and advised to take it.  Too much criticism about COVID-19 is based on the assumption that everyone might run out and start popping hydroxychloroquine pills like candy.

President Donald Trump recently announced that he has been taking hydroxychloroquine together with zinc supplements for almost two weeks now.  Speaker of the House Nancy Pelosi, always classy, then called Trump "morbidly obese" as a risk factor and gave her medical advice that the medication would be dangerous for Trump.

But medications that are not over the counter require a doctor's prescription.  A physician evaluates a patient and screens for risk factors, allergies to medications, and other "contraindications."  In Trump's case, the White House physician, Sean Connolly — not Pelosi — would decide if Trump's weight argues against the medication or whether hydroxychloroquine makes sense in decreasing the president's chance of coronavirus infection. 

For every drug or therapy, the medical community identifies "indications" — signs that it may benefit a patient.  But there are also "contraindications."  Those are times when a pill or shot should be avoided because of likely adverse side-effects in spite of possible benefits.  In pharmacology, this is the "benefit/risk ratio."  These are individualized decisions.  It is not a "do it yourself" project.

Second, we should not be looking for only one solution.  Doctors need to select the best medication for each individual, often trying one and then trying another.  The antiviral remdesivir looks the most promising at the moment.  We would celebrate that great news if remdesivir is unequivocally proven.  But we should hope to have several treatments that allow physicians to select the best answer for each individual patient, at different stages of the disease, different symptoms, and different severity.  We should not be looking to shut down any lines of research.

Remdesivir is an antiviral that targets specifically an enzyme in the viral genome (RNA-dependent RNA polymerase; RdRp).  Directly targeting the virus would seem to be the most rational approach, rather than treating the subsequent inflammatory responses caused by the virus.  Also, remdesivir has fewer risks than hydroxychloroquine for severe side-effects.

Hydroxylchloroquine is an anti-rheumatoid drug, often used when combined with the antibacterial azithromycin (AZT, or Z-pack).  It can fight inflammation and/or help transport zinc into cells, which reduces viral reproduction. 

Other medications being worked on are targeting completely different phases of COVID-19, such as trying to treat the "cytokine storm," which happens in many of the most severe infections.  COVID-19 often produces only moderate flu-like symptoms, but sometimes it generates a catastrophic collapse, sometimes unexpectedly.  It is believed that a cascading overreaction of the immune system can causes mass death of cells, including in the sensitive tissues of the lungs, leading to death by oxygen starvation.  Researchers are hoping to directly target the genesis of a cytokine storm, which should blunt the worst symptoms of the disease.

Third, treatment is not "set it and forget it."  Even with the best decisions, a patient may not respond as expected; monitoring and making changes are what the treating physicians do.  Medications can affect different people differently.  Some people actually experience an opposite effect compared to other people.  Some have allergies.  Genetic differences can change how people respond to any medication.

Fourth, we are seeing a steady march forward of clinical trials.  These are being rushed because of the worldwide crisis against what would normally be a 12- to 24-month timeline.  These accelerated efforts involve smaller study groups seeking quicker partial answers than would normally be used.  Our modern culture is impatient for quick answers.  As is to be expected in quick, small trials, results can be controversial. 

But one purpose of such clinical trials is to discover when in the life cycle of a disease a treatment might help, and under what circumstances.  So does a drug prevent a disease from becoming severe?  Or can it beat back a disease that has already flared up with the worst symptoms?

There is a serious concern when — sometimes — the worst symptoms of COVID-19 dramatically overwhelm a patient, leading quickly to death.  One drug may be able to prevent the disease from getting bad in the first place.  A different drug might (or might not) be able to pull a victim back from COVID-19's final death spiral.  It is the wrong question to ask if a drug is a "one-size-fits-all" therapy under all circumstances.

In clinical trials we hear criticism of bad results with some patients.  But that's what doctors do — in cooperation with medical researchers.  Clinical trials help improve our understanding of who should take which drug and who should avoid which drug.

Doctors informed by this growing body of research decide who should get a prescription and who shouldn't.  There are reasons why a doctor's prescription is required.  This is not just "make work" to make doctors practice their handwriting.  Some people are not the right candidates for a particular drug.

Fifth, medications are actually complicated.  Virtually all drugs exhibit no effect in some people, are beneficial in most patients, and can be toxic to an unfortunate subset of people.  Therefore, early quick and sloppy trials might not be able to delineate all the nuances of any test drug.

We hear that patients are pulled from some study due to adverse reactions.  This information can help physicians in prescribing a balance of several medications, taken together and at the right dosage. 

Sixth, there has been confusion about the word "cure."  Our information so far is that COVID-19 runs its course, on its own, in apparently 2 to 8 weeks.  We don't talk about a "cure" for the flu.  We just manage it until the body's immune system defeats the infection.

The real challenge is whether symptoms become so severe that the body cannot overcome the virus — so that the patient dies before the immune system can win the battle.  Therefore, treating symptoms matters.  If the body can be protected and strengthened from the worst effects of the disease, the body will gain the time and resilience to kill the infection on its own.  Some treatments might not be a "cure," but still very important.