COVID-19: Illness, Prevention, Severity Reduction

March 24, 2020

This is an update to the post that we placed on our website on March 17.  Several things have changed – these are highlighted in bold font.   

Q:  Is COVID-19 a more serious illness than the usual yearly influenza?

A:  The virus that causes COVID-19 is SARS-CoV-2.  It is like the coronavirus that during the 2002-2003 SARS epidemic infected 8000 people worldwide, with a 10% mortality rate.  The earlier virus has continued at a very low level of infection, with a mortality rate over a year’s time that is twice that of the usual flu.  The mortality rate of COVID-19 is unclear, but is estimated between 1 and 4%.  Currently the US mortality rate is running around 5%; this is based on a restricted denominator based on testing that has been limited.  As most adults have limited or no immunity to the disease and those who have immune or respiratory disease are at increased risk, there is the potential for the pandemic to overwhelm existing capacity for treatment, as has occurred in China and Italy.

Q:  What symptoms raise suspicion of the COVID-19?

A:  Although there may be illness that is caused by this virus and is typically not recognized, generally COVID-19 presents with mild illness for a few days that is followed by more severe symptoms that includes fever, myalgias, and lower respiratory symptoms (cough and shortness of breath); a few people have diarrhea only.  At this later stage, patients may become very ill and require hospital care.  Mortality results typically from ARDS – respiratory distress and damage caused both by the virus and by the immune response to it.

Q:  How is the disease transmitted and how can transmission be reduced?

  • A:  Although there is controversy, it appears that transmission occurs mostly based on large droplets from the lower respiratory tract, rather than via small droplets that are airborne, which is the usual mode of transmission with the flu.  As such, if a mask is used, a standard mask (rather than the special N95 mask) is likely to be sufficient to interrupt transmission outside the hospital.  Because the droplets survive for a week on surfaces, and are capable of being picked up by manual contact and then cause infection if transmitted by touching the mucous membranes of the face.  For this reason, de-infecting surfaces, hand-washing, and avoiding touching the face is recommended.  Furthermore, the amount of person-to-person spread of the illness is also important.  When on average a patient with the disease spreads it to more than one other person, the disease spreads rapidly in the population, so restricting contact (“social distancing”) may slow or reduce transmission and as a result reduce the likelihood of overwhelming hospital treatment capacity or the number of deaths that the pandemic is responsible for, although the effectiveness of this strategy is a subject of discussion (see, e.g. a recent post arguing that this “horizontal” containment strategy should be replaced by a more targeted “vertical” strategy:  https://www.nytimes.com/2020/03/20/opinion/coronavirus-pandemic-social-distancing.html
  • On March 17, The President issued a new document with new guidelines on preventing the spread of the illness,  The following people are urged to stay home:  those who are ill, those with family members who test positive for COVID-19, those who are “older”, and those who have a serious underlying health condition (affecting the heart, lungs, or immune system).  The link to this statement is here:  https://www.whitehouse.gov/wp-content/uploads/2020/03/03.16.20_coronavirus-guidance_8.5x11_315PM.pdf
  • On March 22, Maryland Governor Larry Hogan ordered non-essential businesses to close, and the Maryland Department of Health ordered medical providers to seek to see patients virtually rather than in person to limit the amount of physical exposure of patients with each other and with providers.

Q:  How can the disease be prevented, severity be reduced, or severe infection be treated?

A:  Points to consider:

  • The antiviral prescription medications have not been shown to be effective.
  • There is work being done to test vitamin C and other substances given by IV infusion, and to test other prescription medications including hydroxychloroquine and azithromycin – it is unclear if this is effective in prevention, severity reduction, or treatment of severe disease.

Q:  What should I do to reduce the likelihood of getting the illness?

A:  Points to consider in preventing the illness:

  • Follow the national prevention guidelines: disinfect surfaces that might have been exposed to the virus, wash hands, avoid touching the mucous membranes if there might have been exposure, and stay home if you are ill, exposed to a documented case, older, or have a serious underlying condition (affecting heart, lungs, or immune system).  If you are in the presence of someone with possible illness, wear a standard mask.  A challenge here is obtaining disinfectants or masks.  You can make your own disinfectant with a mixture of 2/3 rubbing alcohol and 1/3 aloe gel (see https://www.cbsnews.com/news/hand-sanitizer-coronavirus-make-your-own/ ), or use any commercial product (multi-surface cleaner or sanitizer) that is at least 60% alcohol (see https://www.wtae.com/article/here-s-a-list-of-disinfectants-you-can-use-against-coronavirus/31250157 ).
  • Avoid contact with people who may be infected—people with respiratory symptoms, or situations in which you might have exposure to those who may have the virus; this may include large public gatherings or travel to areas where the illness is prevalent, or public (e.g. air) travel in which other passengers may be coming from areas of prevalence.

Q:  Are medications, nutrients, herbs, and supplements helpful?

A:  Points to consider:

  • Medications have not been shown to be helpful, and the current influenza vaccine is not effective against COVID-2.
  • We don’t know whether nutrients, herbs, or supplements are helpful in prevention, reduction in severity, or treatment of the illness, although Vitamin C has been used in treatment of patients with resulting pneumonia in China. IHP patients might consider an approach that includes the following:
    • An antioxidant such as Vitamin C 2000 mg two to three times daily; and lipsomals such as Quicksilver Liposomal Vitamin C 1000 mg twice daily – many of these products are currently out of stock; IHP has no access to them
    • As an alternative, supplements that increase availability of glutathione, a much more powerful antioxidant than Vitamin C, such as Avmacol Immune (includes both sulphoraphane from broccoli sprout and reishi mushrooms for immune support) which IHP has
    • One or more antiviral herbs such as elderberry, olive leaf extract, or monolaurin; IHP has both of the latter two, and they and other products are on Fullscript (reachable on our website at: https://integrativehealthpractices.org/portal/)
    • IV Vitamin C 25-50 g; IHP provides Vitamin C infusions ($180 for 25 g, $230 for 50 g) – patients must not have active disease and must have a prior lab test for G6PD

Q:  Should I come in to IHP for appointments or urgent care visits?

A:  If you are ill with symptoms that are suggestive of the flu (fever, achiness, cough/shortness of breath), call us and we’ll give you guidance on whether and how to be seen; current COVID testing is in short supply but is being done in some urgent care and emergency rooms.  If you have a scheduled appointment with us, we encourage you to see us virtually using telemedicine, which most insurers are now covering.  We are calling patients prior to appointments to arrange this, or to confirm an in-office visit, or to reschedule for another time.  You may also confirm or make changes to your appointment by calling our office (410-648-2555).

 

 

Osteoporosis and Low Bone Density

Bone is a dynamic structure, constantly being remodeled by cells that remove it (osteoclasts) and renew it (osteoblasts).  Once adulthood is reached, these two processes should stay in relative balance, but as hormonal status changes over time, the removal process predominates.  For some people, hormonal-mediated bone removal may be predated or augmented by other conditions.

Predominance of bone removal results in low bone density (sometimes referred to as osteopenia).  When bone density declines, the structure of bone is altered and it loses some of its strength and flexibility.  Severe bone loss is referred to as osteoporosis; osteoporotic bone has thinner outer cortex and trabecular supporting structure.

Low bone density and osteoporosis are associated with increased risk of fracture.  Other factors, however, are also important in predicting fracture risk:  age, smoking status, body size, alcohol use, etc.  The FORE Fracture Risk Calculator (https://americanbonehealth.org/bone-health/introducing-the-fore-fracture-risk-calculator/) can be used to calculate fracture risk.  Importantly, the radiographic assessment of bone density by DXA scanning, which is the most widely used method of predicting fracture risk, does not take into account all of the factors that are relevant to this prediction.  The quality of bone (how it is structured and what its mineral composition is), as well as its density, is also important.  Bone quality is not generally assessable through non-invasive testing.

It is common for patients to undergo DXA scanning, be told that their bone density is low, or that it is declining rapidly based on serial scans, and that as a result prescription medications are recommended to reverse the process of bone loss.  Although for some patients this may be appropriate – particularly when the risk of fracture is very high – for others it may not be for several reasons:

  • DXA scanning is subject to error, particularly if the patient is not properly positioned during the scan
  • Factors that are causing the imbalance of bone resorption and bone renewal have not been identified and addressed
  • Risks resulting from the use of the medications may be significant, particularly with bisphosphonates, which are associated with osteonecrosis of the jaw, and with spontaneous fractures owing to their effect on bone, which is to block the removal process such that bone formation predominates, which increases bone density but alters its quality (making it structurally more brittle).

When a DXA scan shows low bone density, it is appropriate to do lab testing to assess for conditions that are associated with bone loss (imbalance between removal and renewal).  Testing includes the general assessment that we use for most patients in integrative care (for hormonal status, nutrients, gut health/celiac status, and inflammation), as well as assessment of factors that are more specific to bone, including PTH, serum calcium, Vitamin D levels, 24 hour urine calcium, C Telopeptide (CTX) and osteocalcinin.  The latter three factors assess balance between bone removal and renewal, and are used in initial assessment of causes of low bone density and to monitor impact of treatment over the short run, with biannual DXA scanning and fracture risk prediction over the long run.

There are multiple causes of low bone density from imbalance between resorption and formation of bone:

  • Nutrient deficiency, either dietary or due to poor absorption from the gut
  • Hormonal imbalance: hypothyroidism or its overtreatment, hyperthyroidism, hyperparathyroidism, insufficient or excess insulin/diabetes, low growth hormone/IGF-1
  • Chronic inflammation and oxidative stress: infection or leaky gut-based
  • Heavy metal toxicity: cadmium, lead, mercury, aluminum, iron

The approach to treatment is as follows:

  • Healthy diet and weight-bearing exercise
  • Nutrient supplementation with magnesium, calcium, Vitamin K2, Vitamin D3, strontium, and trace minerals
  • Address issues identified through history and diagnostic testing: nutrient deficiencies, hormonal gut health, inflammation/oxidative stress, heavy metal toxicity

Helpful resources are:

 

IV Nutrient Infusions

Nutrients given by intravenous infusion have been used by many alternative and integrative medicine practitioners for decades.  The rationale for their use is that the blood levels of such nutrients when given orally is limited by the ability of the gut to absorb them, whereas with IV nutrients blood levels can be substantially increased.  This has been confirmed by clinical studies.

In considering use of IV nutrients, two questions must be asked:  are they effective in achieving their intended therapeutic purpose, and are they safe.  Ideally, the answers to these questions would be based on clinical research, but unfortunately the amount of such research is limited.

Four types of IV nutrients are in common use:  Vitamin C infusions, glutathione infusions, multinutrient (Meyers’) infusions, and phosphatidylcholine infusions.

Vitamin C infusions are the best studied.  Vitamin C has many effects:  it is an antioxidant that protects against damage caused by free radicals, boosts the immune system’s effect on wound healing and infections, and is toxic to some types of cancer cells.  There is some evidence that such infusions are beneficial in cancer patients in improving quality of life, and possibly that there are effects on tumors that reduce size and increase time to relapse.  It may also have benefit in patients with infection, shingles, and with chronic fatigue.  Used in patients without contraindicated medical conditions, IV Vitamin C is safe.

Like Vitamin C, glutathione is an antioxidant.  Most literature on its use is not based on clinical research, but instead based on case reports.  It may be effective in increasing the effectiveness of manual therapies in patients with musculoskeletal conditions, in reducing symptoms of parkinsonism, and in improving symptoms associated with autoimmune or other inflammatory response.  It appears to be safe.

Multinutrient infusions were popularized decades ago under the name Myers infusions, based on the work of a Baltimore physician named John Myers, and a modified version of this infusion has been used with thousands of patients across the country.  The infusion includes Vitamins C, B complex, B12, B5, B6, calcium, and magnesium.  It has been shown to have some benefit for patients with fibromyalgia, and based on case reports may result in improvement in fatigue, pain, and depression in patients with such issues.  Multinutrient infusions are safe.

Phospholipids are a key component of the membranes that surround all of our cells.  When such membranes are disrupted by toxicity or injury, particularly in nerve cells, illness results.  IV phospholipids are widely used in Europe, and based on experience, may be of benefit to patients with brain injury and inflammatory/degenerative conditions.  They are safe.