Q&A: Trump's COVID-19 treatments suggest severe illness, expert says

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Before his discharge from Walter Reed National Military Medical Center yesterday evening, President Donald Trump tweeted, "Feeling really good! Don't be afraid of COVID. Don't let it dominate your life."

However, according to John Swartzberg, clinical professor emeritus of infectious diseases and vaccinology at UC Berkeley, the use of three separate drug treatments during the president's hospitalization for COVID-19 suggests that he was experiencing serious signs and symptoms of the disease. The drugs included the antiviral remdesivir, the corticosteroid dexamethason, and Regeneron's experimental monoclonal antibody therapy, the last of which is still in clinical trials and not approved for use by the U.S. Food and Drug Administration.

Berkeley News spoke with Swartzberg about the pharmaceutical cocktail doctors have used to treat the president and what its use implies about his current health.

Berkeley News: The president has reportedly been treated with the antiviral drug remdesivir, the corticosteroid dexamethasone and Regeneron's new monoclonal antibody therapy. What are these drugs, and how do they work?

Right now, we have two drugs that have demonstrated some degree of efficacy for treating seriously ill people with COVID-19. The first one that got approved was remdesivir, and it's an antiviral ; that is, it stops the replication of the virus. It has been shown to reduce the duration of hospital stays for people who are hospitalized with COVID-19, and there are ongoing studies now looking at the possibility that, if given earlier, or to people who are less sick, it might improve their outcomes and could even decrease mortality.

Dexamethasone is the other drug that's been approved. Dexamethasone is a drug that's been around for years; it's a corticosteroid, just like prednisone. It's been shown to reduce mortality in people who are very sick with COVID-19 and who have difficulty with their oxygen exchange.

The other drug that Trump received was by Regeneron, which is one of two companies that have produced monoclonal antibodies. Eli Lilly is the other. The Regeneron product has two monoclonal antibodies that block the spike protein on the coronavirus from attaching to the ACE2 receptor sites on human cells. The hope with these antibody therapies is that, if you could somehow give the antibodies to a patient really early, maybe it could help prevent the secondary inflammation and cytokine storm that causes people to become seriously ill. But, again, they are not approved for use yet.

Theoretically, Regeneron's monoclonal antibodies should be safe, but we don't know that yet, because they haven't been studied except in the 275 people who've received them as part of a non-controlled clinical trial.

If the Regeneron monoclonal therapy has not yet been approved for use by the FDA, how was the president able to receive treatment with it?

Trump got Regeneron on what's called a compassionate use, which is for people who have a desperate disease and typically are dying, and they need be given something that's not yet approved because there is no further treatment. The doctors' decision to give the president Regeneron on compassionate use was odd, in the sense that it's not an approved drug; we don't yet know about its safety or efficacy.

I think he received it either because he demanded it or because he was a lot sicker than we thought, and the doctors were really worried and wanted to throw the kitchen sink at him.

What about his treatment with remdesivir and dexamethasone? Was the use of these drugs consistent with the messaging that the president was never that ill?

After the Regeneron therapy, the next step they took was to put him on remdesivir. Since he was hospitalized, he would be a candidate for remdesivir. So, that seems appropriate. Except the messaging was that he didn't really need hospitalization, but because he's the president, we wanted to just take every precaution. Those two don't fit.

Dexamethasone is probably the most problematic of the three treatments. People take steroids for lots of things: For example, if you have a terrible case of poison oak, you would take a short course of steroids at the dosages that Trump's taking. But you would have to be otherwise healthy to take that, because we know that corticosteroids blunt the immune system. They have other side effects, as well, including stress ulcers, and they can have a lot of psychological side effects, like euphoria and depression.

But the side effect that we really worry about is the immune suppression, which makes somebody a compromised host. You don't give that to somebody lightly. As I said, it's approved for people who require supplemental oxygen—that is, people who have so much inflammation in the lungs that they have significant gas exchange problems.

So, all of the treatments, the remdesivir, the Regeneron and the dexamethasone, argue that he was a lot sicker than the doctors divulged, and that he claimed he was.

Of course, I'm speculating. I didn't take a history and do a physical exam on him. So, I don't know with certainty. But, we can't get the truth out of him, and we can't get the truth out of his doctors. We're forced to speculate.

On Monday, before his discharge from the hospital, Trump tweeted, "I feel better than I did 20 years ago!" Do you think he is out of the woods now?

His statement about feeling better than he did 20 years ago suggests to me that he's getting euphoria from the steroids. He does often speak in hyperbole anyway, but it suggests he probably does feel better because of the euphoria. Steroids will also mask a fever, because they're treating the inflammation. The fact that, according to his doctor, he has not had a fever in a few days, means nothing.

He's also not out of the woods by any stretch of the imagination. We've seen a lot of people go into the hospital and be stable for several days and then crash. We see people at home saying they're doing okay, and then they crash. And we've seen a lot of people with the interesting observation that they don't appreciate their shortness of breath with this disease until they crash from low oxygen saturation. They often don't feel the air hunger. This has been a really interesting observation with COVID-19. The fact that he denied shortness of breath (means) he's either lying, which he does on a daily basis, or he doesn't feel shortness of breath. But we know he's got a problem with gas exchange.

In his Monday tweet, Trump also said, "Don't be afraid of COVID. Don't let it dominate your life." Is this accurate advice to give Americans at this point in the pandemic?

I have three thoughts on his tweet. The first is that it was ignorant, because when we experience something and learn from it, that's called acquiring knowledge. When we experience something and don't learn from it, that's called ignorance. He is experiencing a very serious illness, and to make a comment like that means he hasn't learned anything from it.

The second thing is, the tweet is very dangerous, because it tells people what everybody wants to hear: COVID-19 is not a big deal, and don't worry about it. To suggest that to the approximately 210,000 Americans who are dead, and the nearly 7.5 million who have gotten sick from COVID-19, including people who are having long-term complications—many of which we haven't identified yet, and we don't know how long (they) will last or whether they will permanent—is dumbfounding. It's dangerous to suggest that COVID-19 is a benign disease, because it's not.

And then, finally, it's narcissistic, because all he's doing is thinking about his election and what's best for him, while ignoring the implications for the health and welfare of the people he is supposed to be serving. That's what I think about his comments: ignorant, dangerous and narcissistic.


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