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Covid-19 Prophylaxis

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I spoke with Dr David Boulware about this, he is the infectious disease doc running the PEP/post exposure prophylaxis study. They did not include azithromycin in PEP d/t QTc prolongation. Both are known to cause QTc lengthening, he explained out of an abundance of caution he decided to not include it for PEP. HCQ is known to cause QTc prolongation leading to torsades de pointes and sudden cardiac death. Azithromycin has been shown to prolong QTc as well but does not lead to torsades de pointes. Given these are outpatients without cardiac monitoring and the interaction between the two is unknown, he decided not to include it for PEP. But in truth we only see QTc prolongation rarely with chronic HCQ use so this concern is definitely way overblown for the vast majority and may not even be a real concern for anyone. Personally if I had confirmed infection I would include but currently not being used for PReP/pre exposure prophylaxis or PEP.

Rex.
What would he say about giving a patient like me the two drugs together at the same time? I have arrhythmia problems and take Mexiletine for that. I tend to go into V tach and have a lot of PVCs. I do have an internal defibrillator.
 
Above study is enrolling 1500 people for PEP.

Doses used for PEP, as in HIV, are higher than doses for PReP. They decided on doses that were actually slightly higher than the current treatment doses being used.

Boulware PEP protocol:

HCQ 800 mg orally once, followed in 6 to 8 hours by 600 mg, then 600mg once a day for 4 consecutive days.

It may be best to do a loading dose for PReP as loading doses are done both for tx and PEP. Maybe 800-1400mg po divided on week 1, then 400mg qwk on same day thereafter. If using for malaria prophylaxis you would be instructed to start 2 weeks before travel which is essentially your loading dose. But if already in an environ with the pathogen may be better to do a loading dose. Half-life of a single 200 mg po dose is 22.4 days so it will hang around awhile.

Only sides Maldorf are retinal deposits related to chronic use, d/t the very long half-life, and the previously mentioned QTc prolongation which is also with chronic use and much more rare. People with RA and lupud have used this drug at 400mgh qd for 20-30 years with no sides. They just have to have their retinas checked once per year.

Swifto, we have seen people turn around within 24 hours of admin of loading dose. These are people in ICU also who should have been dosed much sooner. Not proof obviously though and you're right there were problems with the French study. Though some have calculated a 1/10000 chance of achieving the reductions seen in viral load in the study being due to placebo effect. Also, apparently the Chinese came across this by observing in clinic that none of the lupus patients became sick with Covid-19. They were on Plaquenil for lupus.

Rex.
 
What would he say about giving a patient like me the two drugs together at the same time? I have arrhythmia problems and take Mexiletine for that. I tend to go into V tach and have a lot of PVCs. I do have an internal defibrillator.

This is so experimental there is just no way to answer something like that. If you were dying in ICU with continuous cardiac monitoring not responding to monotherapy/HCQ then maybe. But if you can implement HCQ soon enough with symptom onset then hopefully you won't find yourself in that situation. But that would be a call your doctors would have to make at the time obviously.

Rex.
 
so people being treated with hydroxychloroquine are feeling better (95% of cases) after 6 days if they are treated within 24-48 hours of contracting virus, is that correct? How does that differ from just riding the virus out? Aren't people normally feeling better after a week without medication?

If a situation occurs such that a younger not at risk person catches the virus, then passes it on to a higher risk person (old) - would you recommend this older person get a prescription for hydroxychloroquine right away then?

I'm personally not nervous at all about the virus. It sounds like it sucks, but its not a big deal for a strong person with good lungs. I am very nervous about the older people in my life though :(

There appears to be some efficacy past 48 hrs but the sooner a person starts, the better, simply due to viral load. The incubation period can be up to 14 days, though most seem to be symptomatic within 5-6 days. Are people normally feeling better after a week without medication? Well, that depends on the person. The first confirmed case of community transmission in California for instance. She went to the hospital on Feb 15. Presumably she had symptoms for at least 2-3 days before going to the hospital on Feb 15. She soon deteriorated, was intubated, and transferred to another hospital for intensive care on Feb 19. She was diagnosed on the vent in ICU on Feb 26 11 days after her initial hospitalization and probably at least 2 weeks after onset of symptoms. 77% of people who contract influenza will not have symptoms and there seems to be a fairly high percent of people with Covid-19 who do not have symptoms. So how it differs from riding the virus out could be anywhere from no symptoms at all to life and death.

If a younger person passed it to an older person at risk I would absolutely consider PEP for the at risk person. The PEP study was initially up to 3d post-exposure to initiate meds and has since been amended to 4 days. So for PEP I would start within 3-4 days.

Rex.
 
Serious question here, I do PT in many facilities and most if not all of my patients are in the high risk category. How do I go about getting the facilities or the patient doctors to initiate this prophylaxis? I mean obviously I can tell them about it, but most doctors don't actually listen to what some PT says and actually get offended that you would try to tell or discuss with them something that they might not be aware of. What would be the best approach in a situation like this? My mom also lives in a facility back in MD and would like to see her have access to this as well.

I definitely understand your predicament and I wish I had an answer. There is really nothing you can show them about PReP. As I mentioned I had a pharmacist tell me that a physician called to order 1000+ tabs HCQ, probably 3 days before I posted this, for every resident in his facility and was requiring 12 tabs per patient. As you say all you can do is mention that people are doing this but most won't be receptive. If you know someone who was exposed then you could present Boulware's protocol for PEP or tell them to enroll in the trial if spaces remain. There probably isn't stock at this point unfortunately to initiate PReP for many skilled nursing, assisted living facilities even if the doc were forward thinking enough to initiate.

Rex.
 
Why is Zithromax helping with a viral infection? Is the issue that the virus brings on secondary bacterial infections?
 
Why is Zithromax helping with a viral infection? Is the issue that the virus brings on secondary bacterial infections?

 
Rex
How different are HCQ and Chloroquine Phosphate? I see in the initial dosing protocol it used as a possible substitute in place of HCQ.
 
Thanks Rex, Stay safe, brother:cool:
 
Rex
How different are HCQ and Chloroquine Phosphate? I see in the initial dosing protocol it used as a possible substitute in place of HCQ.

I have zero experience with chloroquine, it is an antiquated drug. I'm impressed that you actually read the paper I posted, many will not. If you do, you'll know as much as almost anyone in the world.

Off the top of my head, it is approximately 1/3 as effective as HCQ. This is the old anti-malarial that causes the old time sides associated with malaria treatment, the bad nightmares etc. The study I posted uses 250mg qd for pre exposure prophylaxis. I believe they were using 1gm qd in China and the tx recs I posted were loading followed by 600mg qd. I read of really bad sides at the 1gm dose the Chinese were using. The therapeutic, toxic and lethal dose is fairly close, very few drugs are like this. So maybe the 600mg is as effective with less sides vs 1gm but I don't know. I do know that you would never choose chloroquine over HCQ unless absolutely necessary and then I would follow the recs on the treatment doc I posted. Personally I wouldn't use it for pre exposure prophylaxis but I have no experience with this drug and have access to HCQ.

Rex.
 
Rex, what's your impression on the overall availability of the two drugs? Particularly the HCQ. With the whole world potentially wanting those drugs, will pharma be able to produce enough at a rate that is adequate? I fear that the supply will run out and people continue to die. I wonder if pharm companies that dont make it now could start production fast enough to be of use when we need it and not after the virus has already swept through.

Seems many doctors have had great results and that Trump is willing to fast track it.
 
I have zero experience with chloroquine, it is an antiquated drug. I'm impressed that you actually read the paper I posted, many will not. If you do, you'll know as much as almost anyone in the world.

Off the top of my head, it is approximately 1/3 as effective as HCQ. This is the old anti-malarial that causes the old time sides associated with malaria treatment, the bad nightmares etc. The study I posted uses 250mg qd for pre exposure prophylaxis. I believe they were using 1gm qd in China and the tx recs I posted were loading followed by 600mg qd. I read of really bad sides at the 1gm dose the Chinese were using. The therapeutic, toxic and lethal dose is fairly close, very few drugs are like this. So maybe the 600mg is as effective with less sides vs 1gm but I don't know. I do know that you would never choose chloroquine over HCQ unless absolutely necessary and then I would follow the recs on the treatment doc I posted. Personally I wouldn't use it for pre exposure prophylaxis but I have no experience with this drug and have access to HCQ.

Rex.
I may not have a choice. I have CP & Az on hand. I'll go grab some ZS. It may be 5 days of hell at triple the dose of HQ but if it stops replication in it's tracks then it's worth the nightmares. I would most likely only use this cocktail if I or one of my friends/family members developed a fever after direct contact with someone who tested positive for Covid-19. Wondering if Mag would be a good thing to have on hand and a cardiac monitor.lol
 
Rex, what's your impression on the overall availability of the two drugs? Particularly the HCQ. With the whole world potentially wanting those drugs, will pharma be able to produce enough at a rate that is adequate? I fear that the supply will run out and people continue to die. I wonder if pharm companies that dont make it now could start production fast enough to be of use when we need it and not after the virus has already swept through.

Seems many doctors have had great results and that Trump is willing to fast track it.
I think at this time it IS available but off course in limited supplies.
It is not a complex chemical to produce and the pharma companies will ramp up production if there is a demand for it.Some have already started making it.
 
I think at this time it IS available but off course in limited supplies.
It is not a complex chemical to produce and the pharma companies will ramp up production if there is a demand for it.Some have already started making it.
I'm worried switching up a production line takes months to do, guess not?
 
I'm worried switching up a production line takes months to do, guess not?
not when its there thing to leave everything else and 'DO IT'! :)
 
not when its there thing to leave everything else and 'DO IT'! :)
Surely motivation there too as the demand will be insane. Much profit. I believe the private sector does this sort of thing much more efficiently than government.
 
I have always been interested in AAS influence on immune function and found this article a while ago.


I did not know until recently the Nandrolone suppresses IL-6, which rises to dangerous levels during pneumonia.
Not saying AT ALL than Deca is a cure for Covid-19, but interesting nonetheless.
 
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