How Doctors Would Treat a 74-Year-Old Man Who Has Covid-19
How Doctors Would Treat a 74-Year-Old Man Who Has Covid-19
(Bloomberg) -- The decision on whether to start giving medicine to a 74-year-old man with Covid-19 begins with a small mechanical device placed on his finger.
It’s called a pulse oximeter. Using beams of light, it measures how much oxygen is in the blood, as well as heart rate. If it produces a reading of less than 95%, it can be the first determiner for doctors on whether to start aggressive treatment with antiviral and anti-inflammatory medication, according to Hugh Cassiere, medical director for respiratory therapy services at North Shore University Hospital on Long Island.
Cassiere was speaking hypothetically about a patient with the same physical profile as President Donald Trump, who said last night that he had tested positive. Trump is experiencing mild symptoms, according to a person familiar with the situation. The president is working from his residence and was in touch with White House Chief of Staff Mark Meadows by phone on Friday, the person said.
If a patient is asymptomatic, “I would tell him to isolate himself, monitor himself and be aware of any symptoms that crop up,” Cassiere said in response to questions about how he would treat a man of Trump’s age and weight in his practice. “If he gets them, he should call me. Does he feel run down, exhausted?”
William Schaffner, an infectious-disease specialist at Vanderbilt University in Nashville, said there are no specific treatments for the mild Covid-19 symptoms the president is said to have. Fever and cough can typically be managed at home, even in an older patient, Schaffner said. It is also important to stay hydrated, he said.
“We are concerned for the president because he is older, hefty and he is male, and those three things combined put him at greater risk for severe disease,” Schaffner said.
“The next several days are important” to see whether the symptoms worsen, Schaffner said.
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Trump will likely have to be watched carefully for more than a week because Covid-19 is essentially a two-phase disease, said Helen Boucher, chief of the division of geographic medicine and infectious diseases at Tufts Medical Center in Boston. Most people get either no symptoms or mild ones.
“But in a very small proportion around day 8, in the second week after contracting the virus, they will get sicker,” Boucher said. Their cough or fever will worsen and their blood oxygen levels may decline. It’s these people who end up in the hospital. And of this subset, an even smaller percentage get sick enough to end up in the ICU, she said.
“We know that in many patients who do get very sick, it happens around day 8 to 10,” Boucher said.
If a patient without initial symptoms starts “feeling a little worse, then the next trigger for me is going to be what his oxygen levels and a chest X-ray shows,” said Cassiere of North Shore University Hospitals. “That drives every other treatment that’s out there.”
Rapid Progression
It’s important, he added, to closely monitor the patient at this point, “because the disease can progress pretty rapidly, hence the reason for hospitalizing these patients.”
If hospitalization is suggested, treatments should immediately kick in, according to Cassiere. As of right now, he said, that means the use of the antiviral remdesivir and anti-inflammatory dexamethasone.
“The reason for that, remdesivir, is because we want to stop viral replication,” he said. “Although there’s no data that it slows progression to severity, we all believe that it does.”
Remdesivir, made by Gilead Sciences Inc., received emergency use authorization from federal regulators in May after a big study showed it helped hospitalized patients recover faster.
Giving dexamethasone, Cassiere said, decreases mortality and disease progression.
In a large clinical trial, dexamethasone was only helpful in hospitalized patients who were receiving respiratory support, such as people on ventilators; it didn’t help people who weren’t getting some form of respiratory therapy.
Convalescent Plasma
Another treatment that has gotten an emergency-use authorization based on preliminary data is convalescent plasma, which contains a mix of antibodies from patients who have recovered from Covid-19. While the authorization is for hospitalized patients, the plasma therapy is likely to be safe and, at least in theory, could also help outpatients, said Schaffner. But he said the data behind it was relatively weak.
“Theoretically it could work on a non-hospitalized patient,” Schaffner said. While there is no hard evidence it would work at an early stage of infection, it could relatively easily be administered on an outpatient basis, he said.
Additionally, blood thinners have been widely discussed as a treatment option for Covid-19. Some studies say that routine anticoagulation doesn’t seem to be beneficial, Cassiere said. But there’s also data suggesting if you come into the hospital with Covid-19, you should be put on a blood thinner to prevent harmful clotting that can lead to organ damage.
Cassiere said that given Trump’s office, there also could be a tendency to give him too much treatment.
“That means he’s probably going to get what we call VIP care, more treatment than is recommended,” he said. “There’s a tendency to do more than recommended for obvious reasons, and that’s not always good.”
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