The coronavirus pandemic has been about change. The virus has mutated, occasionally in unpleasant ways. Some of the best vaccines ever created have changed our most potent front-line defenses from distancing and masking to jabs in nearly six billion shoulders and counting. But what about the treatment of those who end up sick with COVID-19?
Given the lofty hospitalization numbers in Colorado and, much more so, in Texas and across the southern United States, it might not look like the treatment for COVID-19 has changed all that much in the past year or so.
The big improvements in care involved the steroid dexamethasone and the antiviral remdesivir becoming standard treatments for hospitalized coronavirus patients in mid-2020 and the Regeneron monoclonal antibody cocktail’s emergence that fall. But, in fact, treatment for COVID-19 has improved, if more incrementally than vaccine-fueled prevention.
The case of Juliette Morrow offers an example of how. Morrow, 61, had been fully vaccinated for months when, after a family gathering in Texas in late July, sniffles became congestion, her headache grew unrelenting, and a fever and nasty cough persisted. Back home in Denver, she tested positive for the coronavirus on a Friday. As Morrow’s physician at UCHealth Internal Medicine – Anschutz Medical Campus, Dr. Mindy Lam of the University of Colorado School of Medicine, was checking in on test results, she saw the breakthrough COVID-19 test. She called her patient.
New treatment options for COVID-19
A year ago, there would have been nothing to do but watch, wait, and hope. Now there was an alternative: based on an expanded U.S. Food and Drug Administration approval and state of Colorado guidelines, UCHealth can administer the aforementioned Regeneron monoclonal antibody cocktail – a combination of casirivimab and imdevimab called REGEN-COV – to certain outpatients. (The combination of bamlanivimab and etesevimab and the solo monoclonal antibody sotrovimab have also been FDA-approved for outpatients.) These are all lab-produced proteins that hook onto coronavirus-causing SARS-CoV-2 viruses and keep them from invading human cells.
A subsequent FDA emergency use authorization expanded the use of REGEN-COV to certain high-risk patients who had merely been exposed to COVID-19 in the past 10 days. But UCHealth follows state of Colorado rules that limit REGEN-COV to those showing symptoms in that time frame and who are at high risk of developing severe COVID-19.
Among the risk factors include being 65 or older, pregnancy, chronic kidney disease, diabetes, immunosuppression, cardiovascular disease, and chronic lung disease. Morrow’s cardiovascular disease qualified her, Lam recognized, and suggested REGEN-COV. The patient agreed that it was a good idea, and Lam signed her up though a state website. (Those lacking a primary care provider can sign up here for virtual visits through UCHealth Virtual Urgent Care.)
On the upswing
The following Monday, Morrow sat in an infusion chair at UCHealth Broomfield Hospital, one of about 30 sites statewide offering REGEN-COV infusions. It’s free for patients thanks to the federal government spending about $2,100 per dose. About an hour and a half later, of which 20 minutes constituted the actual monoclonal antibody infusion, Morrow was on her way. One can’t know whether REGEN-COV is to thank. But, Morrow says, after days of feeling miserable, “I felt like I was on the upswing by the next day or two. I worked from home that week.”
Among the others at that Texas family gathering who fell ill with COVID-19 included Morrow’s mother-in-law. Also vaccinated, she’s 85, and her COPD has her on oxygen to start with, Morrow says. The family feared the worst. But she also got a REGEN-COV infusion and pulled through. Lam, who has prescribed REGEN-COV to several patients since early August, is a strong proponent of monoclonal antibodies for her high-risk patients. “I think it’s great,” she said. “It’s helpful to have an outpatient treatment (for COVID-19) that can potentially prevent hospitalization and severe disease.”
New inpatient-care options for treating COVID-19
Patients sick enough to be hospitalized also have more options than a year ago, says Dr. Thomas Campbell, a CU School of Medicine and UCHealth virologist and infectious-disease specialist. As before, he says, the antiviral remdesivir and the steroid dexamethasone remain cornerstone inpatient treatment for COVID-19.
The REGEN-COV that Lam prescribed Morrow, in contrast, has shown little benefit to seriously ill patients and rarely given to UCHealth inpatients. The understanding that an immune response gone haywire is often at play in serious coronavirus cases has added immune-system modulators to the inpatient and ICU armamentarium. Campbell says they come into play when patients get worse despite receiving remdesivir and dexamethasone. These drugs include IL-6 receptor antagonists such as tocilizumab and sarilumab. Those who can’t tolerate or don’t respond to IL-6 receptor antagonists may receive a Janus kinase inhibitor such as baricitinib, he says.
Despite better inpatient treatment for COVID-19, hospital stays for serious cases tend to be long and the recoveries difficult. Campbell is far from alone in advising a far more efficient means of harnessing the medical advances of the past 18 months. “We talk about monoclonal antibodies like the Regeneron combination being helpful. But the thing that is most helpful, the thing that is most effective in keeping people from getting sick enough to be hospitalized, is vaccination,” he said. “The vast majority of people who are admitted to our hospitals are people who are not vaccinated.”
Morrow has fully recovered. She feels that, while the monoclonal antibodies may have helped and highly recommends the treatment to those who find themselves in her position, the coronavirus vaccine was decisive in her body’s ability to fight off the disease’s worst outcomes. “I don’t know how I would have reacted had I not been vaccinated,” she said.