Two points I want to make about treatment of COVID-19 in the ICU:
1. Plaquenil should not be administered without zinc for patients on saline/glucose IV drips.
Many practitioners, perhaps due to the recent FDA approval, are administering Plaquenil (hydroxychloroquine sulfate, allegedly a safer form of quinine), as a prophylactic to their ICU patients not having contraindications. But, the results are poor at best. As nawlinsag wrote on this forum recently in one of his excellent posts, "Plaquenil which has weak ACE2 blockade doesn't appear to be a savior of any kind in our patient population."
I think all practitioners should set aside a few minutes to understand a few things about COVID-19 and, more particularly, the proffered theoretical mechanism of action of hydroxychloroquine. It is not against SAR-CoV-2. Rather, it is as a zinc ionophore. The word "ionophore" means "ion carrier." These compounds catalyze ion transport across hydrophobic membranes, such as lipid bilayers comprising some human cell walls. The effect against SARS-CoV was shown in a 2010 paper. Zinc is actually the likely antiviral agent. See https://journals.plos.org/plospathogens/article?id=10.1371/journal.ppat.1001176 . Commenters to the end of Dr. Roger Seheult's Youtube video at pointed out that chloroquine is one of many known zinc ionophores. See the first 10 minutes and 25 seconds of for a great summary of all of this.
From a theoretical perspective, since zinc is not in standard saline or glucose IV drips, intracellular zinc concentrations of patients in an ICU on such IV solutions will be rate-limited not by any zinc ionophore serum concentrations but, rather, the extracellular zinc concentrations. Moreover, hydroxychloroquine has several negative side effects. For this reason, I would not recommend administration of hydroxychloroquine to an ICU patient without also including zinc.
An obvious question is how much zinc to prescribe. The level of zinc prescribed by Dr. Vladimir Zelenko was 220mg zinc sulfate po qd for 5 days. (See https://docs.google.com/document/d/1SesxgaPnpT6OfCYuaFSwXzDK4cDKMbivoALprcVFj48 .) It is worth noting that the RDA of zinc is only about 8mg. So, this is ~28x more than dietary intake. Zinc probably binds to copper, so such extreme dosages might cause copper deficiencies. As such, I would recommend including other trace minerals, especially copper, to anyone prescribed 220mg zinc qd. The RDA of copper is only 1-2 mg/day, so perhaps 10mg po qd might mitigate any negative secondary influences of such high zinc dosages.
2. Intubations probably do not help COVID-19 patients.
Generally speaking, it is worth noting that intubating a COVID-19 patient is not really treating the real problem. Rather, it is treating a symptom of COVID-19. Therefore, since February 2020 I've questioned the high rate of critical COVID-19 patient intubations. nawlinsag wrote, "[W]orldwide 86% of covid 19 patients that go on a vent die." Despite the widespread reports in the media implying that alleviating ventilator shortages would help reduce COVID-19 morbidities, I disagree. The new raw data merely bolsters my prior perspective. The data just does not support intubating COVID-19 patients in the first place.
In a traditional ICU scenario, a hypoxic patient who was, for example, in a recent auto accident, would indeed probably benefit from intubation because it allows the body to heal from the acute trauma. With COVID-19, however, the cause of the hypoxia, probably the "cytokine storm" and viral load, isn't going to be easily self-cured just by buying a little time.
Moreover, while intubation will help SaO2 levels in the first few days, it will probably do so at the cost of reducing the strength of the lung muscles after this, in the long term.
It is important to realize that the human DNA molecule is not that large because human organs and muscles are, instead, adaptive and unspecified in exactness; instead of specifying how strong a muscle needs to be, a generic albeit delicate feedback mechanism allows growth only when and where really needed. If a human is placed in zero gravity, for example, the heart size and strength will decrease. Intubation will reduce needed stress to the lung tissue, causing it to be too weak upon potential extubation.
Also, intubation interferes with normal coughing. This reflex is probably especially important to expel fluids from lung tissue to allow them to operate with reasonable efficiency.
Additionally, intubation interferes with other beneficial activities, such as eating nutrient-dense foods and the cardiac exercise due to walking. This may be important for a COVID-19 patient because after 10 days, some exercise during the day might decrease the probability that morbid hypoxia occurs during sleep, when the usual conscious oversight of lung operation does not exist.
Compounding this is the likely potential for SARS-CoV-2 to infect brain stem and sympathetic nerve cells causing respiration.
For the above reasons, I think ICU practitioners should reconsider intubating COVID-19 patients unless they would not otherwise survive the Zelenko 5-day treatment, which for reference was 5 days of 200mg Plaquenil po bid, 500mg Azithromycin po qd, and 220mg zinc sulfate po qd. I think his results, if true, are indeed statistically significant. (For a little math, see https://www.quora.com/Are-you-worried-at-all-about-contracting-the-coronavirus/answer/Jason-Taylor-16 .)
--Jason Arthur Taylor, PhD
Disclaimer: I'm not an MD, and certainly not an ICU MD.
1. Plaquenil should not be administered without zinc for patients on saline/glucose IV drips.
Many practitioners, perhaps due to the recent FDA approval, are administering Plaquenil (hydroxychloroquine sulfate, allegedly a safer form of quinine), as a prophylactic to their ICU patients not having contraindications. But, the results are poor at best. As nawlinsag wrote on this forum recently in one of his excellent posts, "Plaquenil which has weak ACE2 blockade doesn't appear to be a savior of any kind in our patient population."
I think all practitioners should set aside a few minutes to understand a few things about COVID-19 and, more particularly, the proffered theoretical mechanism of action of hydroxychloroquine. It is not against SAR-CoV-2. Rather, it is as a zinc ionophore. The word "ionophore" means "ion carrier." These compounds catalyze ion transport across hydrophobic membranes, such as lipid bilayers comprising some human cell walls. The effect against SARS-CoV was shown in a 2010 paper. Zinc is actually the likely antiviral agent. See https://journals.plos.org/plospathogens/article?id=10.1371/journal.ppat.1001176 . Commenters to the end of Dr. Roger Seheult's Youtube video at pointed out that chloroquine is one of many known zinc ionophores. See the first 10 minutes and 25 seconds of for a great summary of all of this.
From a theoretical perspective, since zinc is not in standard saline or glucose IV drips, intracellular zinc concentrations of patients in an ICU on such IV solutions will be rate-limited not by any zinc ionophore serum concentrations but, rather, the extracellular zinc concentrations. Moreover, hydroxychloroquine has several negative side effects. For this reason, I would not recommend administration of hydroxychloroquine to an ICU patient without also including zinc.
An obvious question is how much zinc to prescribe. The level of zinc prescribed by Dr. Vladimir Zelenko was 220mg zinc sulfate po qd for 5 days. (See https://docs.google.com/document/d/1SesxgaPnpT6OfCYuaFSwXzDK4cDKMbivoALprcVFj48 .) It is worth noting that the RDA of zinc is only about 8mg. So, this is ~28x more than dietary intake. Zinc probably binds to copper, so such extreme dosages might cause copper deficiencies. As such, I would recommend including other trace minerals, especially copper, to anyone prescribed 220mg zinc qd. The RDA of copper is only 1-2 mg/day, so perhaps 10mg po qd might mitigate any negative secondary influences of such high zinc dosages.
2. Intubations probably do not help COVID-19 patients.
Generally speaking, it is worth noting that intubating a COVID-19 patient is not really treating the real problem. Rather, it is treating a symptom of COVID-19. Therefore, since February 2020 I've questioned the high rate of critical COVID-19 patient intubations. nawlinsag wrote, "[W]orldwide 86% of covid 19 patients that go on a vent die." Despite the widespread reports in the media implying that alleviating ventilator shortages would help reduce COVID-19 morbidities, I disagree. The new raw data merely bolsters my prior perspective. The data just does not support intubating COVID-19 patients in the first place.
In a traditional ICU scenario, a hypoxic patient who was, for example, in a recent auto accident, would indeed probably benefit from intubation because it allows the body to heal from the acute trauma. With COVID-19, however, the cause of the hypoxia, probably the "cytokine storm" and viral load, isn't going to be easily self-cured just by buying a little time.
Moreover, while intubation will help SaO2 levels in the first few days, it will probably do so at the cost of reducing the strength of the lung muscles after this, in the long term.
It is important to realize that the human DNA molecule is not that large because human organs and muscles are, instead, adaptive and unspecified in exactness; instead of specifying how strong a muscle needs to be, a generic albeit delicate feedback mechanism allows growth only when and where really needed. If a human is placed in zero gravity, for example, the heart size and strength will decrease. Intubation will reduce needed stress to the lung tissue, causing it to be too weak upon potential extubation.
Also, intubation interferes with normal coughing. This reflex is probably especially important to expel fluids from lung tissue to allow them to operate with reasonable efficiency.
Additionally, intubation interferes with other beneficial activities, such as eating nutrient-dense foods and the cardiac exercise due to walking. This may be important for a COVID-19 patient because after 10 days, some exercise during the day might decrease the probability that morbid hypoxia occurs during sleep, when the usual conscious oversight of lung operation does not exist.
Compounding this is the likely potential for SARS-CoV-2 to infect brain stem and sympathetic nerve cells causing respiration.
For the above reasons, I think ICU practitioners should reconsider intubating COVID-19 patients unless they would not otherwise survive the Zelenko 5-day treatment, which for reference was 5 days of 200mg Plaquenil po bid, 500mg Azithromycin po qd, and 220mg zinc sulfate po qd. I think his results, if true, are indeed statistically significant. (For a little math, see https://www.quora.com/Are-you-worried-at-all-about-contracting-the-coronavirus/answer/Jason-Taylor-16 .)
--Jason Arthur Taylor, PhD
Disclaimer: I'm not an MD, and certainly not an ICU MD.
