The Department of Internal Medicine (my home) at the University of Michigan Medical Center devoted its weekly Grand Rounds to a discussion of the first 30 days of COVID-19 here.
Just last week, the hospital opened a new ward – the 32 bed RICU (Regional Infectious Containment Unit) – devoted to the care of COVID-19 patients, featuring negative pressure to keep materials from spreading beyond the unit. The unit quickly filled and now encompasses 50 beds, devoted now only to the most serious cases. The second patient ever encountered was a middle aged woman with lupus, Sjögren’s and preexisting lung disease who was already on Plaquenil plus some more potent immunosuppression. In anticipation of compassionate use of the experimental antiviral remdesivir, she had her Plaquenil held, and she became rapidly worse, only to have the Plaquenil reinstated. Despite continued Plaquenil, remdesivir, Actemra and steroids she remains on the ventilator at maximum support, still alive.
One huge leap forward was getting our own high throughput lab testing for coronavirus, not having to rely on sendouts or the low capacity CDC test.
Treatments pretty much follow the guidelines I’ve shared with you out of China on my blogs. They do start Plaquenil a little higher, 600 mg twice daily vs. 400 mg, but otherwise dose it the same. One new drug to creep onto the list of options is nitazoxanide (Alinia), approved by the FDA in 2004 for treatment of protozoal infections (cryptosporidiosis and giardia, both water borne buggers that can cause diarrhea, with crypto having become a particular problem in HIV patients). It works by interfering with the pyruvate ferredoxin/flavodoxin oxidoreductase dependent electron transfer reaction, which is essential to anaerobic energy metabolism. As such, it markedly modulates the survival, growth, and proliferation of a range of extracellular and intracellular protozoa, helminths, anaerobic and microaerophilic bacteria, in addition to viruses. Nitazoxanide exhibited activity against the MERS coronavirus in the test tube, but there have been no reports of its clinical efficacy.
Three clinical trials are in progress at U of M. Two employ remdesivir, one for moderate illness and one for severe illness. Another employs sarlilumab (Kevzara), an anti-interleukin-6 monoclonal antibody, very similar to tocilizumab (Actemra), which I’ve discussed before.
So we plug along at U of M, looking to face a flood of new cases over the next 2 weeks. They haven’t yet begun trying to coax the retirees back into harness, at least yet. Stay tuned.