As cases of COVID-19 tick up in many states and President Donald Trump now is fighting the illness, doctors still have no cure, but better drugs and therapies are helping more COVID-19 patients survive the deadly virus.
Some of the therapies that Trump received also are being used for seriously ill COVID-19 patients in Colorado and elsewhere, including the corticosteroid, dexamethasone, and, to a lesser degree, the antiviral drug, remdesivir.
Trump also has received an experimental antibody cocktail made by Regeneron. The federal Food and Drug Administration has not approved the Regeneron therapy yet for most COVID-19 patients, but clinical trials are underway in Colorado and elsewhere.
So, which therapies work best and what are the go-to treatments now that frontline doctors have learned more about how to treat patients with COVID-19? Are the treatments that Trump received standard for most seriously ill patients? And which patients are most at risk for faring poorly if they get COVID-19?
COVID-19 treatment: Dexamethasone and remdesivir helping, doctors no longer using hydroxychloroquine
Care for patients who need to be hospitalized for COVID-19 has improved. In April, based on small, preliminary studies, hospitalized patients were being given hydroxychloroquine, a repurposed antimalarial, and the antibiotic azithromycin, says Dr. Josh Douin, a University of Colorado School of Medicine anesthesiologist and critical-care medicine specialist.
Those treatments didn’t pan out, Douin said.
“That’s the issue with a brand-new disease,” he said. “You learn as you go along.”
“The biggest breakthrough has been dexamethasone, which showed a pretty significant improvement for survival for folks who require ventilation,” Douin said. “Everyone who’s admitted and requires intubation is getting dexamethasone.”
Some patients are also getting therapies as part of clinical trials. Trials involving hydroxychloroquine have stopped because of the therapies’ questionable effectiveness with COVID-19. Trials involving convalescent plasma and specific monoclonal antibodies – man-made proteins like the Regeneron therapy – that could theoretically bind to the virus and alert the immune system to its presence are continuing. There’s also a clinical trial of tPA (tissue plasminogen activator) for patients with abnormal blood clotting, something that’s been widely reported among COVID-19 patients. That’s in addition to prophylactic doses of anticoagulant given to all ICU patients, says Douin.
Along with dexamethasone and remdesivir for COVID-19, doctors avoid ‘the vent’
In addition to drugs that have been proven to help patients, including dexamethasnoe and remdesivir, doctors have discovered other ways to improve outcomes. Physicians at UCHealth University of Colorado Hospital were the first to describe the broader respiratory disease under which COVID-19’s serious cases fall – acute respiratory distress syndrome, or ARDS – back in 1967. But the coronavirus’s version of ARDS has its wrinkles. While seriously ill coronavirus patients often need mechanical ventilation, physicians have learned to delay it as long as possible and even avoid mechanical ventilation entirely. One way they do that is with heated high-flow systems that deliver many liters of oxygen per minute through nasal cannulas, said Dr. Marc Moss, head of the Division of Pulmonary Sciences and Critical Care Medicine at the University of Colorado School of Medicine.
All that said, and despite thousands of academic papers about the virus and the disease it causes, the biological mechanisms through which the SARS-CoV-2 does its damage remain poorly understood.
“It hits every patient in variable ways. It’s still difficult to predict with an admitted patient who will do well and who will do poorly,” Douin said. “We do feel more confident in our ability to treat these patients safely.”
Even as the infection demographics shift and the months grind by, we’re still in the infancy of COVID-19 treatment, Moss says, and there’s a reason for optimism.
“I just think it’s really remarkable how much progress has been made understanding the virus and how we can help people, all in a relatively short period of time,” he said. “I think that’s because the medical community has worked collaboratively and avoided previous hurdles to make sure we can really care for patients. It’s unprecedented.”
COVID-19 now: Greatest risk factors, highest case numbers
Demographics – in particular, age – matter. Older patients continue to fare poorly if they get the illness. The U.S. Centers for Disease Control and Prevention (CDC) reports that those ages 75-84 have eight times the risk of being hospitalized with COVID-19 than young people in the 18-29 age bracket; among those 85 and up, the risk jumps to 13 times higher than the younger cohort’s. And the younger you get, the less likely it is that you will end up hospitalized: youths ages 5-17 are nine times less likely to be hospitalized than those ages 18-29. In other words, while COVID-19 can put anyone in the hospital, younger people fare much better.
And it’s younger people who are being increasingly diagnosed with the coronavirus in Colorado. Back in the spring, during the week of April 19, those under 40 accounted for 32% of cases; by the week of Sept. 13, they accounted for 68% of them. The percentage of cases among those over 60 fell from 28% to 10% over that same period. Critically, those over 80 – for whom COVID-19 death rates hover around 65% – saw their percentage of confirmed Colorado cases fall from about 10% to just 1.7%. Experts attribute these trends to behavior. Many older adults have quarantined themselves and have been very cautious about socializing. Meanwhile, young adults have returned to colleges and universities where parties have spread the virus.
Testing & prevention
Those numbers don’t paint a full picture of actual case counts, though. People with mild or no symptoms (The CDC’s current best guess is that 40% of COVID-19 patients are asymptomatic) largely weren’t being tested early in the pandemic. Testing was scarce enough that many who were quite sick didn’t get tested at all. That shows in the data, too: on April 19, a whopping 22.4% of 1,477 coronavirus tests statewide came back positive. On Sept. 13, 10,485 tests yielded 2.75% positives. More testing across a broader sample of people led positivity numbers closer to – if surely still higher than – the actual assumed infection rates. (The Colorado COVID-19 Modeling Group estimates that about half the new infections in the state are being detected through testing).
Prevention efforts – hand washing, social distancing, mask-wearing – have also helped keep hospital admissions down. We know now that lingering aerosols from talking, singing, or just breathing are a factor in COVID-19 transmission, and, with that knowledge, can do something about it. Masks, in addition to protecting the wearer and those nearby from those aerosols and larger respiratory droplets, may even lower the dose of viruses inhaled to provide a degree of inoculation.