President Trump’s transfer to Walter Reed reflects a cautious approach to treating his covid-19 symptoms



“The reason someone would go to the hospital would include closer observation, oxygen therapy and perhaps consideration of other therapies,” said Helen Boucher, chief of infectious diseases at Tufts Medical Center in Boston.

White House physician Sean P. Conley late Friday released a statement saying doctors had begun giving Trump the antiviral medication remdesivir, which has shown modest benefits for some patients.

Other treatments could include the steroid dexamethasone, which has helped covid-19 patients with serious breathing problems, and blood thinners to prevent clotting.

Earlier Friday, White House Chief of Staff Mark Meadows described Trump’s symptoms as mild. By late Friday afternoon, two people familiar with the president’s condition said he had “a low-grade fever, a cough and nasal congestion, among other symptoms.”

Trump’s physicians have surely been monitoring his heart rate, the level of oxygen in his blood, his respiratory rate and his blood pressure since he was diagnosed, said Priya Sampathkumar, an ­infectious-disease physician and head of infection prevention and control at the Mayo Clinic in Rochester, Minn. The trends in those results are critical, she said.

With Trump at Walter Reed, doctors would be able to step in quickly if, for example, his blood oxygen falls to a dangerous level, usually below 92 percent, she said.

“After taking care of patients for a while, you can sense when a patient is not doing well,” Sampathkumar said of the decision to move Trump from the White House.

In some covid-19 patients, symptoms can turn severe in a matter of hours, especially as they near the second week of the illness. That phenomenon took doctors by surprise in the early months of the pandemic.

On Friday afternoon, Conley said in a memo that Trump had received an eight-gram infusion of a monoclonal antibody made by the company Regeneron. He described the medication as “a precautionary measure.”

The drug, a combination of two monoclonal antibodies, is designed to generate the body’s own disease-fighting force. The experimental shot of lab-produced antibodies imitates the body’s defenses, which is quicker than waiting for human biology to muster its own response.

Regeneron said the drug was provided to Trump in response to a “compassionate use” request from the president’s physicians. Such programs allow patients to receive experimental therapies that have not yet been approved.

The drug, called REGN-COV2, is being evaluated in a late-stage clinical trial for both the treatment and prevention of covid-19.

Leonard Schleifer, chief executive of Regeneron, said in an interview on CNN that Trump “is in a race, with his immune system racing against the virus, and if the virus wins, you can have dire consequences.” The antibody treatment, he said, is designed to “make it a fairer fight,” to “give his immune system enough of a boost to make a full recovery.”

“We are just trying to mimic the natural immune system, which isn’t ready to go” when the virus first infects the body, Schleifer said. He said the treatment is given as a single dose. He declined to say whether Melania Trump also got the antibody treatment.

Conley said the president also is taking zinc, vitamin D, famotidine, melatonin and a daily aspirin. Famotidine, which is used to reduce the production of stomach acid, is being studied as a possible therapy for covid-19. Melatonin can be employed as a sleep aid.

Conley said the president “remains fatigued but in good spirits” and was being evaluated by “a team of experts.”

As of now, Trump’s advanced age, 74, and his immune system’s response may exert some of the strongest influences on the course of his illness. Covid-19’s impact ranges unpredictably from no symptoms at all to rapid death.

The president’s path over the next 10 days — or possibly longer, if he develops an extended version of the disease — also may be dictated by whether he inhaled a large amount of virus deep into his lungs.

Trump, famously opposed to the medical guidance that Americans wear masks in most circumstances, may have left himself vulnerable with that behavior to receiving a heavy dose of the coronavirus. Covid-19 has killed at least 208,000 people and infected more than 7.2 million in the United States, according to a Washington Post analysis.

People with underlying health problems also tend to have poorer outcomes. Trump weighs 244 pounds, which makes him slightly obese at 6 feet 3 inches tall, according to information released by the White House after his physical exam in June. He takes a statin for high cholesterol, and his blood pressure is somewhat elevated.

“This is a reminder that covid-19 is an ongoing threat to our country and can happen to anyone,” said Tom Frieden, who was director of the Centers for Disease Control and Prevention in the Obama administration. “Learning more about when President Trump and others with whom he had contact last tested negative and first tested positive will help understand this outbreak and limit the risk of further spread.”

Human immune systems, which battle the virus, become less effective as we grow older. Even as the overall covid-19 death rate in the United States has declined during the eight months of the pandemic, nearly 80 percent of fatalities have occurred among people 65 and older. Older men die more often than older women.

Someone in Trump’s age group faces five times the risk of hospitalization as does an 18-to-29-year-old and an even greater risk of death, said Graham Snyder, medical director of infection prevention and hospital epidemiology at the University of Pittsburgh Medical Center. The likelihood of Trump developing symptoms, and the severity of those symptoms, also increases with age.

“Age is very clearly the strongest predictor of not doing well with the virus,” Snyder said. “The likelihood of him developing symptoms, including death, is most strongly predicated on his age.”

It is not clear whether Trump has other underlying health problems.

In November, he made an unplanned visit to Walter Reed. The White House described it as part of the president’s annual physical, but in a book about Trump, New York Times reporter Michael S. Schmidt asserted that Vice President Pence was put on standby to take over Trump’s powers if the president needed a procedure that required him to be anesthetized. Pence has said he does not recall being told to be on standby.

Now that the virus has taken hold, doctors will closely monitor the response of Trump’s immune system. Many people who suffer the worst outcomes experience a “cytokine storm,” an overreaction of the immune system that can ravage delicate blood vessels and lead to fluid buildup and pneumonia. Many of those patients require ventilators, typically in a medically induced coma, that essentially breathe for them.

The first five to seven days after Trump was infected — a date that may be difficult to determine — are critical. That is when he could develop the pneumonias, blood clots and bacterial infections that have made covid-19 so deadly, though some complications also can come later.

“Usually, over the first week you get a sense of how severe this will be,” Snyder said. But another part of the disease’s unpredictability is the harm it causes a small number of people in the second week of infection and beyond.

As the pandemic has made clear, the coronavirus can kill or have almost no impact. As many as 40 percent of people may never develop symptoms. Some recover in a matter of days, while “long-haulers” suffer an array of symptoms — including shortness of breath, coughing, fatigue, pain and neurological problems — for months.

Anthony S. Fauci, director of the National Institute of Allergy and Infectious Diseases, said he has never seen a virus with such a wide range of outcomes. For most people, symptoms are mild to moderate.

The severity of Trump’s illness also may depend, in part, on how he contracted the virus. Many researchers believe the virus is airborne — that it can float distances on tiny exhaled particles smaller than respiratory droplets, which are heavy enough to fall out of the air.

That could lead to infection deep in the lungs and a more severe outcome, said Columbia University epidemiologist Jeffrey Shaman. Wearing a mask can help prevent that, research has shown.

The amount of virus transmitted to a patient — the viral load — is another important factor in disease progression, said Albert Ko, an infectious-disease epidemiologist at the Yale School of Public Health. “For many infectious diseases, the higher your infecting inoculum dose is, the more risk you have of getting infected, the more risk you have of getting a disease and severe complications and dying,” Ko said.

“That’s something that’s hard to predict. It’s not like we’re measuring the number of viruses that someone was exposed to at the time they were infected.”

Supportive care to relieve discomfort is also a part of the typical medical regimen, said Amesh Adalja, an infectious-disease expert at the Johns Hopkins University Center for Health Security. Those measures include hydration and acetaminophen for fever, aches and pains.



First Published at www.washingtonpost.com on 2020-10-03 10:30:00

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