The treatments for COVID-19 are varied and some are in short supply.
OPB
A group of infectious disease physicians and pharmacists at Oregon Health & Science University have been meeting weekly since the early days of the pandemic to discuss the various treatments available to fight the coronavirus. At first, the group was mainly focused on reacting to severe disease with tools already on hand, like ventilators, and then later preventing it with vaccines. Then they moved on to assessing various treatments that became available as well as alternatives to vaccines for people who are immunocompromised. The treatments are varied and some are in short supply. We talk with a member of the OHSU group, Dr. Lorne Walker, about what kinds of treatments are available to Oregonians and how these therapeutics fit into the next phase of the pandemic.
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Note: The following transcript was computer generated and edited by a volunteer.
Dave Miller: From the Gert Boyle Studio at OPB, this is Think Out Loud, I’m Dave Miller. A group of pharmacists and infectious disease physicians that have been meeting weekly since the early days of the pandemic. They’ve been getting together to talk about the various treatments available to fight the Coronavirus. Those treatments have evolved a lot in the last two years. So we thought we would check in with one member of this group to look back over what’s changed and to get a sense for where we are now in terms of treatments as we enter what the federal government is calling the test to treat phase of this pandemic. Lorne Walker is a pediatrician who focuses on infectious diseases. Welcome to Think Out Loud.
Lorne Walker: Thanks very much for having me, Dave.
Miller: Can you remind us what treatment for COVID-19 looked like at the very beginning of this pandemic, in March or in April of 2020?
Walker: That’s a great question. As you pointed out, this is something that’s changed quite a bit over the course of the pandemic. And early on we really didn’t have a lot, we certainly had the supportive treatments, mechanical ventilation, and ICU care that we could give to people who became very ill, but we didn’t have medications that we could use to prevent severe illness in people who had contracted Covid 19. The first medication that we had early in 2020 was an IV medication called Remdesivir which had been studied previously for things like Hepatitis C and Ebola. But early in the pandemic, that was really used for people who are already sick enough to be in the hospital to require additional oxygen for their breathing. So we had some things we could do for you once you were quite ill, but we didn’t have a lot of tools to keep people safe or keep people healthy
Miller: And in terms of things like proning or other more truly mechanical efforts, was it even obvious at the very beginning that those were important and helpful?
Walker: I think, themes throughout the pandemic is that a lot of the things that we understand about how to treat COVID-19 now we learned as we treated. So, very early on, things like proning, things like how to decide when to use more aggressive ventilation techniques like positive pressure ventilation, we didn’t know early on, and I think as we gained more experience with COVID-19, as studies started to come out, those were the things that we were able to to learn and improve our survival rates and our ability to treat this disease.
Miller: How much at the beginning were you able to rely on studies as opposed to anecdotes and word of mouth from other countries or other doctors you knew in Oregon or around the country?
Walker: That’s been a real challenge. One of the things that we’re fortunate to have now, as we are a couple of years into the pandemic, as we have more evidence, we have evidence for what medications we can use and what scenarios we have some evidence about what we can do to help prevent people from becoming ill, needing those aggressive things like intubation and mechanical ventilation. But you’re absolutely right. Early in our response to this pandemic, we didn’t have the benefit of that data. So one of the purposes of the group that you described – of pharmacists and physicians that meet weekly to discuss this – is to try to be really on the front edge of updating what we do at OHSU to respond to all that new data as it comes in so that we’re doing the best for the patients that we serve.
Miller: So what are those meetings like?
Walker: It’s really been a great group to work with. We have pharmacists who really are up to date on the latest data about what medications are available and what’s coming available through the FDA. We have both adult and pediatric physicians and infectious diseases experts who are also looking at that data, on a week to week basis. We’re looking at what are the latest studies, what’s the information that’s coming from pharmaceutical companies about the medications that they’re producing, and how does that match up with what we’re offering here at OHSU? And through doing that we’ve been able to continuously update guidelines for our physicians here at OHSU, so that we’re doing our very best to be using the most up to date approaches to COVID-19.
Miller: So let’s turn to those up to date approaches. What happens now, when somebody who is at high risk for serious illness or death because of COVID-19? What happens when a person in that circumstance tests positive?
Walker: That’s the thing that’s changed the most in the last three or four months. As we had talked about previously, we had tools to use when people were in the hospital and they were quite sick. Now we have some tools that we can use before we get to that point. So for somebody who is at high risk for severe disease or death we have two oral antiviral medications that people can take by mouth at home that have been shown to reduce your risk of coming to the hospital or having severe COVID-19. One of those is called Nirmatrelvir and Ritonavir in a combination which goes by the brand name Paxlovid and the other one is called Molnupiravir. We also have monoclonal antibodies that can be given as an IV injection, and those, in a similar vein are intended to reduce the risk of somebody who has COVID-19, who has some symptoms who’s at risk but is not yet here in the hospital, to keep them out of the hospital, keep them home and keep them safe. Then you know, most recently we have some some data that shows that that Remdesivir medication that we’ve had, earlier in the pandemic and we typically have used in people in the hospital, if we are able to give that to people before they’re severely ill, it seems to reduce the risk of severe illness as well. So now we have several different medications, some you can take by mouth. Some are administered in a healthcare setting that help prevent the severe disease that’s been such an impactful and terrible part of this COVID pandemic.
Miller: So you’ve just outlined a number of different treatments or therapeutics which I imagine have different supply chains or amounts that are available. But broadly, are there enough of these different medicines for all the people who need them now or might need them in the future?
Walker: Again, that’s something that has changed over the course of the pandemic. We’ve had to adapt to as we’ve gone. Here in March of 2022, we’re in a much better position, in part because we’re coming off of the large peak of the Omicron variant of SARS-COv-2, that has gone through our community. So here in Oregon, the case rate of COVID-19 is relatively low, which means we’ve been able to build up some supply of all of these medications. So, you know, right now, here in Oregon, if somebody who was at risk who talks to their physician, who’s a good candidate for one of these medications, we have these in good supply. Another thing that I think has been a real value of this working group at OHSU, is to have an eye on the future. To be aware that, we haven’t been able to predict, always, when a new wave or a new variant is going to come through and to make sure that we have these medicines on hand as much as possible for whatever comes in the future.
Miller: Who do you think should actually be getting these medicines? Let’s say that the availability is not super short. Who should get, after they test positive, access to Paxlovid or monoclonal antibodies or other treatments? I’m not talking here about the ones that are being given when people are very sick in the hospital, but you know, they have tested positive, they have some symptoms, who should get these medicines?
Walker: Right. The main message there is anybody who is at high risk for severe COVID-19 and our experience with this infection has shown us that some of the groups that would fit that description are older folks. So in general, folks over 65 years of age would be a group that I would have a strong consideration for using these medications. Folks who have weakened immune systems, whether that’s because of a treatment for something like cancer or immune-suppression medicines for an organ transplant, and folks who have comorbidities. So, folks who have other illnesses that put them at higher risk for severe COVID-19, like any medication that we use, we always want to consider the risks and the benefits of using that medication. I think a good starting point is always going to be a conversation between a patient and their health care provider about what we know about their personal risk for having a severe case of COVID-19 and how that would inform their decision to take one of these medicines.
Miller: Do you see something on the horizon that would be more of a standard if you test positive you get X medicine. Is that in the future?
Walker: I think that’s something that we would all like to see. I think with the medicines that we have right now, as we’ve talked about, we have two that we can take by mouth. Both of those have the obvious benefit of reducing your risk of severe COVID. But they have some precautions to be thinking about along the way. So, for instance, Paxlovid interacts with other medicines that person might be on. So you want to have a careful look at that. I know of medications that are in the pipeline now, that would really be a one size fits all medication that anybody that tests positive for COVID, they really ought to go get this medication right away. I think with the ups and downs of these medical options we’re still in the realm where I think it’s a careful conversation between patient and healthcare provider that helps make that decision and that’s where I would see us being in the foreseeable future.
Miller: If you’re just tuning in. I’m talking right now with Lorne Walker, a Pediatrician and a Professor at OHSU who focuses on infectious diseases. We’re getting an update on what treatment for COVID-19 looks like right now. So Dr. Walker, we’ve been focusing on different kinds of treatments for people who are not necessarily super, super sick in the hospital, but has treatment for people who are hospitalized, has that changed significantly within the last year?
Walker: We’ve learned some lessons about treating folks who are sicker and who are in the hospital as well. So Remdesivir has been a part of our toolkit for severe COVID for quite a while now. Also, early in the pandemic, there was a recognition that inflammation in the lungs was a really important part of why people would get so sick with COVID-19. Part of the puzzle is to stop the virus. So the anti-viral medications that we have to do that. But inflammation is important too. So early in the pandemic, there was some recognition that things like steroids, medicines like Dexamethasone, could help reduce the inflammation in the lungs, and help folks who are more sick and were in the hospital. More recently. In addition to that, we have some additional advanced medications, things XXXX which are again, medications that are really targeted at reducing inflammation. So people who are having a lot of lung disease because of that inflammation, we have some tools that can help with that. Then also a recognition that that blood clots were an important thing that could happen in the setting of severe COVID-19. So using anti-coagulation medicines to reduce the risk of those.
Miller: How challenging has it been to be working in this work group, at a time when some number of the therapeutics that you’re talking about and trying to find data about, and trying to advise doctors about, when so many of these have also been talked about, often with tons of misinformation in the general public?
Walker: That’s been a real challenge. Many of the medicines that they were using for COVID-19 are re-purposed from other uses. So we talked about Remdesivir already, as being a medicine that had been used for other infections in the past and the Ritonavir part of Paxlovid has been used in the past as an HIV medication. And so as we were looking at at this data as it came out, other medicines that were looked at for repurposing things like as Erythromycin and Hydroxychloroquine and Ivermectin, you know, I think deserved a very serious consideration because that’s where a lot of our medicines came from. Unfortunately for those medications, the data just hasn’t borne them out as helpful for folks with COVID-19. I think as a working group at a place like OHSU with folks that can help out looking at all the latest data, keeping up to date on the latest papers, I think we’ve been fortunate to be able to to look at some of those options and say, you know, looking at all this information, I just wouldn’t recommend these for patients. But it’s been a dizzying amount of data that’s come out, and so I certainly have a lot of sympathy and a lot of understanding of folks that maybe are hearing data from other sources or who are only looking at pieces of the data. It’s been a pandemic where we haven’t always been able to help all the people that we want to help. And so looking at those options and really wanting them to be good options, I certainly understand that. One of the things that we’ve really been able to accomplish through this group is to be at the front edge of the data and to be able to look at those things and give our patients informed advice and say, I know you might have heard about this, I know you might have somebody who’s giving you some information, but we’ve really been able to keep up on all the data and are able to tell you that’s probably not what’s going to help you. Here’s something else that we might recommend.
Miller: What options are there right now for people who have compromised immune systems and either can’t take any of the COVID-19 vaccines or the vaccine is not particularly helpful for them?
Walker: We have a good option for folks that meet that description and we certainly do take care of patients, who again, have weakened immune systems who might have even received one of the COVID-19 vaccinations. But we worry or we expect that because of their weakened immune system, they’re not going to produce a strong immune response. So there’s another combination of monoclonal antibodies called Tixagevimab, which goes by the brand name Evusheld. That’s a preventative medication that we can provide for people who don’t have their own immunity to rely on, or a good vaccine response to rely on. And the data for that medication has shown us that if that’s given by a muscular injection and it provides, we think about six months of antibody protection that reduces the risk of a symptomatic COVID infection in people who might not be able to respond to vaccines on their own.
Miller: But I have read that nationwide, it’s been hard for many people to access this drug. The New York Times had a recent article about a Portland based doctor who had to travel five hours away to get this drug for herself. She herself is immuno-compromised. What does the supply look like in Oregon right now?
Walker: I think again with the decline of the Omicron wave, we’re in a better position than we were before. I think that we’ve gotten more supply of Evusheld from the government and with fewer circulating cases in the community, I think the eagerness for it is a little bit lower. So our stockpile, our ability to give that medicine is a little bit better now than it has been in the past. But you’re certainly right. There are a lot of people in our community who meet that description who have immune systems that might not respond well enough to the vaccine to really give them good protection. So at OHSU, it’s different than the medications we give when somebody is sick because we have to reach people when they don’t have an infection, you know, the people who are the best candidates for Evusheld, people who are at home, and people who are well, who don’t currently have an infection. So at OHSU we’ve been able to put together an approach to identify the patients in our population we care for, who meet that description, who would be good candidates for Evusheld, and have started reaching out to those patients proactively, but also, with a real focus on equity. We know that not all populations here in Oregon have the same access to health care. So for Evusheld, we’re being proactive in reaching out to people, but reaching out with a real emphasis on some of our underserved communities and communities of color to make sure that they have access to this medication as well.
Miller: I noted that you’re a pediatrician, how many of the various treatments we’ve been talking about can be taken by kids?
Walker: That’s a great question and something that we’ve worked a lot on here at OHSU, so most of the medications that I’ve described can be given to people who are at least 12 years of age. So for older children, we have some tools, but I think there’s a real key demographic of younger children who currently aren’t eligible for vaccination. Kids under five are not currently being vaccinated. A lot of these medications just haven’t been studied in that age group. We’ve been a little bit lucky as pediatricians that even the more vulnerable kids in that group don’t seem to get as sick from COVID as older adults, students. So we certainly feel fortunate for that. But of the treatments that we’ve talked about, Remdesivir, which is that medicine that’s been with us for a while and we give as an IV Injection is available to young kids. So if we identify somebody who maybe is at really, really peak risk for severe COVID and they develop a COVID infection, then we do have some tools to provide them, but it’s much more limited than in adults.
Miller: Finally, the news from the CDC yesterday is not exactly a surprise, but the Omicron variant known as BA-2 is now the dominant variant in this country. What do you think that’s going to mean for Oregon?
Walker: I think that that’s going to come at the same time as a lot of other things are happening in our state. For instance, mask mandates have really reduced recently. Kids are now going to school and not necessarily wearing masks. So the combination of a new variant and those reductions in some of the measures we use to reduce transmission, we’re gonna have to keep a close eye. I think that that creates a possibility that we’ll see some increase in cases. The data that we have so far indicates that this BA-2 variant seems to be like the Omicron we’ve been seeing so less hospitalizations, less ICU cases, which is certainly good news.
Miller: Less than Delta…
Walker: … less than Delta, right, and some of the other previous variants. Again, with this group that is looking at all the data, one of the things that we’ve learned recently is for this newest variant, this BA-2 variant, the monoclonal antibody that we have been using, which is called Sotrovimab doesn’t seem to work well for that variant. So there’s a new one that is being distributed now, that we’ll be able to respond with. So another example of how COVID-19 has been a real shifting landscape for us in healthcare. Things are changing on a week to week to week basis. And so being able to make sure that we have the most up to date options for our patients has really been our focus.
Miller: Lorne Walker, thanks very much.
Walker: Thank you so much for having me.
Miller: Lorne Walker is an Assistant Professor of Pediatrics in the Division of Infectious Diseases at the OHSU School of Medicine.