The discouraging ubiquity of improper Covid treatment

Here we are, after three years of Covid, and infected patients are still and widely being given improper medical treatment by their primary care providers. How is that possible?

This state of affairs is discouraging not just because a lot of patients aren't getting the care they need, but also for what it says about the medical profession writ large. Physicians and other practitioners, who as a matter of professional competence should know better, have shown themselves as susceptible to anecdote and herd mentality as anybody else, with all the failure of reasoning that implies. Worse, they seemingly have no idea where to go to find correct treatment protocols, so many rely instead on word-of-mouth misinformation that, as far as I can tell, is mindlessly, or at least carelessly, passed along from provider to provider.

There's seemingly no comprehension about when certain drugs should and shouldn't be used, and no understanding of why. The level of comprehension that's required—about the presentation and progression of the disease, and the action of certain drugs—strikes me as rather elementary for any medical professional. And yet, a lot of providers seem oblivious.

It's especially perplexing when it happens in a once-in-a-century (we hope) pandemic that has killed millions. You'd think at least in this instance physicians would make some minimal effort to treat their patients appropriately, where "effort" involves some modicum of finding out.

I'm referring here to the routine and incorrect practice of prescribing Prednisone plus a Z-pak (Azithromycin) for non-hospitalized run-of-the-mill Covid patients. As far as I can tell, the practice is very common.

To understand what I assume is the rationale for this wrongheaded protocol, it's useful to consider how our experience with the disease, and our understanding of it, has progressed since those first brutal months when New York was a horrific ground zero for the exploding pandemic in the U.S.

You remember. In mid-March of 2020 the virus was devastating Italy (which led the U.S. by a few weeks in cases and deaths), and here at home there was a call to "flatten the curve" in order to keep the health care system from collapsing under the expected onslaught. Hospital rooms were being retrofitted with negative pressure systems. New York's governor Andrew Cuomo made desperate pleas for ventilators. Toward the end of March, President Trump invoked the Defense Production Act to compel General Motors to build ventilators. The Navy hospital ship U.S.S. Comfort docked in New York Harbor to provide overflow capacity. Refrigerated semi-trailers were parked at New York hospitals to handle the glut of bodies that overwhelmed local mortuaries.

The reason for all those ventilators was that victims were dying in large numbers in hospital ICUs from Covid pneumonia, in which the patient's lungs were ravished, and blood oxygen levels plummeted to dangerously low levels. Remember how back then people everywhere were buying pulse oximeters to monitor their own levels?

In those early days a pattern began to emerge in which some patients would ease uneventfully into the disease for a week or so, and then suddenly crash with a precipitous drop in blood oxygen. Physicians and researchers began to describe what they called "cytokine storms" that were occurring in such patients. Cytokines are a class of signaling chemicals involved in modulating the body's immune response. Researchers believed they were seeing an abnormal "storm" of such chemicals circulating in some patients, which hyper-excited their bodies' immune response, causing dangerously high levels of inflammation that savagely attacked the lungs. Thus Covid pneumonia came to be understood not so much as a direct assault from the virus, but rather as a destructive overreaction of the body's own immune system.

By early April some physicians believed they were seeing benefit from the administration of steroids to such desperately ill patients. Steroids, particularly dexamethasone (which in hospitalized patients is administered intravenously), soon became standard treatment for Covid pneumonia. Death rates declined substantially, and countless lives were saved. This, more than anything, is what is meant when it's said we now know a lot more about how to treat seriously ill Covid patients compared to the early days of the disease.

The reason steroids work in this instance is that they actually tamp down the body's immune response. I learned this decades ago when every fall I'd get 60 mg of Kenalog painfully injected into my butt. The drug could have a rapid and sometimes miraculous seeming effect on the seasonal allergies from which I suffered. As you know, allergies are caused by an inappropriate immune reaction to a harmless allergen, a reaction which Kenalog, a steroid, calmed down. But of course, we still need our immune systems to operate appropriately against real threats, and steroids can interfere with that too. Over the years I noticed that I frequently suffered from early winter sinus infections, presumably because my immune response had been diminished by the steroid I'd had that fall. When I stopped getting the Kenalog shots, my sinus infections stopped too.

And therein lies a lesson. Steroids diminish the immune response—something that every physician should understand implicitly, as a matter of basic medical training. In the case of Covid pneumonia, steroids can be literally lifesaving by calming an out-of-control immune system that's attacking the lungs. But not every person infected with Covid has Covid pneumonia—not even close. Administering a steroid to Covid patients whose immune systems are not overreacting—which is the vast majority—is a fundamental mistake, because those persons need their immune systems to fight the virus, and the steroid can interfere with that.

With Covid, when and when not to administer a steroid isn't really a hard call, which is why it's so maddening that so many physicians botch it. Steroids should only be given to persons with Covid pneumonia, or who are developing it. Such persons are so sick that they'll almost certainly be hospitalized. At a minimum, they'll need supplemental oxygen. Some will be candidates for ventilation. So a useful rule of thumb is that when it comes to Covid, anybody who's not in the hospital shouldn't be given a steroid.

As you probably know, Prednisone is a steroid. My guess is that physicians have misapplied the lesson of steroid efficacy against Covid pneumonia to the general population of Covid patients. Thus the routine practice of prescribing Prednisone to non-hospitalized Covid patients can have the perverse effect of delaying their recovery from the infection, by in effect forcing the body's immune system to fight the virus with one hand tied behind its back. We should properly expect every primary care provider to understand that, but many seem to not.

As for the Z-pak, Azithromycin is an antibiotic, which is useless against viruses, and which can have its own adverse effects. Antibiotics are only appropriate when a secondary bacterial infection is suspected. Their administration should not be routine.

Thus the rote administration of Prednisone plus Z-pak for non-hospitalized Covid patients is poor medical practice, and is contraindicated according to official treatment protocols. A competent physician ought to grasp that on first principles. If first principles weren't enough, you'd think providers could be bothered to consult authoritative sources rather than going with what they hear through the provider grapevine. You'd also think that large medical clinics, at least, would have channels for disseminating crucial information to the organization's providers. Even before Covid, I'd long suspected that is generally not the case.

But even if the efficient organizational dissemination of information hasn't been the norm, wouldn't you think a bit of extra effort, whether at the organizational or individual level, would be made in a pandemic? After all, official guidance from the nation's public health authorities has long been readily available, to anybody who bothered to consult it. Me, for example. Thus, in the most recent update (April 25, 2022) on CDC's Health Alert Network we find this:

"Systemic corticosteroids are not recommended to treat patients with mild to moderate COVID-19 who do not require supplemental oxygen; patients who are receiving dexamethasone or another corticosteroid for other indications should continue therapy for their underlying conditions as directed by their healthcare providers. Antibacterial therapy is not recommended for the treatment of COVID-19 in the absence of another indication." [my italics -mb]

In its Therapeutic Management of Nonhospitalized Adults With COVID-19, The National Institutes of Health says it

"recommends against the use of dexamethasone or other systemic corticosteroids in the absence of another indication." [boldface in the original -mb]

These NIH and CDC protocols and recommendations are dated December and April of 2022, but previous advisories saying the same thing go back much further. Similar guidance had been disseminated in 2020, which is why I was disturbed to learn late that year of an acquaintance who'd been prescribed two courses of Prednisone plus Z-pak. That might well explain why it took him so long to recover from his infection. Because he wasn't improving after his first improper course of the drugs, his doctor decided to double down for another round.

Now it's early 2023, and within the past month or so an elderly couple I know was prescribed the same treatment. A year or more ago I spoke with a provider who implied it's just common knowledge (but from where he didn't know) that the normal Covid treatment is Prednisone plus Z-pak.

While I'm dismayed that so many people are being treated improperly, I'm just as disappointed at a medical establishment that just can't seem to get this right. And it's not just the steroids and antibiotics. Over the course of the pandemic, too many physicians have prescribed disproven treatments such as hydroxychloroquine and, later, ivermectin. In the early days this could be forgiven: Everybody was desperate, and the necessary studies hadn't been done. So you try things. But it was soon definitively established by multiple high-quality studies that these treatments don't work. Yet some physicians persisted anyway, on the basis of mere anecdote, seemingly unable to understand how and why determinations of efficacy are properly made. Later still, a certain proportion of the medical community (a distinct minority, I hope) fell into the anti-vax camp, as always in service to anecdote, apparently unable to make simple risk-benefit judgements based on readily available data, and despite very clear guidance from public health authorities.

To me, all this represents a basic failure to think, in persons for whom thinking is a professional obligation. What a shame.

Copyright (C) 2023 James Michael Brennan, All Rights Reserved

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