COVID-19 Nancy O’Hara, MD and Dennis Bouboulis, MD

Dr. O’Hara and her colleagues at New England Center for Health continue to host a series of zoom calls on COVID-19. The schedule will be updated weekly. Recently she sat down with Dennis Bouboulis, MD of Advanced Allergy, Immunology & Asthma, P.C. to discuss COVID-19. For more Q&As and articles on COVID, please see ASPIRES’s COVID-19 section

Dr. O’Hara: Dr. Denis Bouboulis is here to talk about IVIG and what is happening in his office during social distancing and COVID-19.

Dr. Bouboulis: We are following federal guidelines. We are limiting patients to less than ten within the infusion center. There is only one patient per infusion room with a nurse that is gowned, masked, and gloved. Then we are wiping the infusion center down every two hours. So we are comfortable that everyone is safe including everyone who is being treated for their immune deficiency or their autoimmune disorder.

As far as this virus is concerned, I think the verdict is still out about when we will be on the other side of this. It will probably take several more weeks, and in the meantime, many more cases will surface as we test more people. So once the numbers spike, it will plateau then will see a decrease in cases, but that probably won’t happen until the end of the month until we even start to plateau.

As far as the medicines we hear about, specifically the Hydroxychloroquine and the Azithromycin, we don’t have any concrete data yet. France’s data that showed about 78 patients had improvement has not been corroborated as of yet in the US. But US studies should be coming soon in approximately 3,000 patients.

My personal opinion is that if these medications are to be helpful is that they will probably be beneficial in advanced patients but not for the patients with the mild cases as neither have historically have had any antiviral properties. If they do work, it is probably working on an immune-modulating basis to prevent the ARDS we see in the lungs. But we will know shortly.

Dr. O’Hara: To add to that information, the original study had about 60 people at the start. Twenty were lost to follow up. One died in the ICU. There are several specifics on the others. Only six people that they continued to follow actually got both medications. So that study was minimal, but there was a follow-up study. Many pharmacists are withholding those medications, and it really should be reserved for just hospitalized patients at this point.

Dr. Bouboulis: Yes, that is right. Unfortunately, some health care professionals are taking them now to prevent them from getting COVID-19, but there is no evidence that it works that way. All which limits the supply of medication available to those who need it in the community for bona fide conditions.

Dr. O’Hara: Especially many of our Lyme patients.

Dr. Bouboulis: Exactly.

Dr. O’Hara: Are there any other medications that you recommend or do not recommend for people to take either preventively, or immunologically, or if they have COVID-19?

Dr. Bouboulis: So there is the recommendation not to take non-steroidal medicine for those with active COVID-19 because of the immune suppression, as the immune system is necessary to fight the virus. This really is contradictory to using Hydroxychloroquine, so this is something I do not understand. But in the meantime, if you have tested positive, then it is not recommended to take non-steroidal anti-inflammatories such as ibuprofen and naproxen sodium.

Dr. O’Hara: To expand on that, for many of our patients who are using ibuprofen in their PANS/PANDAS kids for behavioral reasons, we recommend they continue to do so unless they have symptoms of COVID-19.

Dr. O’Hara: The WHO has come out and said that taking ibuprofen is probably very safe to take, though. We just don’t want to suppress the fever. If your child gets a fever, then tepid baths, fluids, and calling your primary care is what we suggest.

Dr. Bouboulis: That is correct. I agree 100%. I don’t think we should be afraid to use these medications that have proven to work in the past for our patients. Just take them with caution if you are positive for COVID-19.

Dr. O’Hara: Some of the supplements that are very safe to use if you get COVID-19 are Zinc and Vitamin C. The recommendation for Zinc Picolinate, in a child younger than 12 is 15-30 mg, and for older children and adults is 30-60mgs. The dosage for Vitamin C is to bowel tolerance. It is a water-soluble vitamin, so you will pee or poop out that which you don’t need. So once you reach that level, back off the dose a little bit, and you should have your correct dose. Most kids can easily tolerate 2,000mg up to 5,000mg without trouble. A study showed that the dosage of Vitamin C in the IV form would be 1500 mg given three times a day in hospitalized patients. Typically in our practice, when starting new supplements, we recommend spacing them out over a few days. If your child is not currently on Zinc and Vitamin C, you could add them at the same time; you are not going to get diarrhea from zinc.

Vitamin A & Vitamin D3 are great antioxidants, but they do increase ACE Receptors on your cells. Although we feel they are very safe, from a professional standpoint, we do recommend that if you get symptoms to stop taking them because this virus is binding to the ACE receptors. So with the utmost caution, we do not want to increase ACE receptors if you already have COVID.

Elderberry, we feel is very safe. However, it does increase cytokines, so, in the utmost of caution, we recommend to stop taking it if you have symptoms of COVID-19.

Dr. Bouboulis: What do you think about CoQ10 in this situation?

Dr. O’Hara: It is a great anti-inflammatory and very good for mito support, so we definitely recommend it.

Two other supplements that are studied more in regards to COVID-19 are quercetin and melatonin. Melatonin binds to an area of the inflammasome of the cells that may actively help prevent COVID-19. So especially in these days of stress, when many of us may not be sleeping well, melatonin may be helpful for that too. The dosage of melatonin is usually based on age. If you have a small child who is not on it, we typically start with 1mg going up to 3mg, for a kid who is about 6-12, then 3mg-6mg and older adolescents could take 6mg-9mg. If your doctor has you on a different dose, then stick with that. There should not be any negative interactions with melatonin or Hydroxyzine. However, Hydroxyzine and melatonin both cause significant sleepiness, so I would give them separately the first time. It is perfectly safe to give melatonin in the short term.

Quercetin is anti-inflammatory in the anti-histamine panel. Regarding dosage amounts for quercetin, follow what is on the bottle; usually, that is one to two pills per day. Please see Dr. Wells’s QA on quercetin and melatonin. There are significant interactions with quercetin and antibiotics, especially in the quinolone group as well as with some cyclosporins, and any medications that work through the cytochrome P450 interactions. If your child is on azithromycin, I recommend adding quercetin on an individualized basis.

This is a question from a parent: if a child has mycoplasma pneumonia, are they at higher risk for getting COVID-19 or increased complications?

Dr. Bouboulis: A lot of the time, when we check bloodwork for mycoplasma, we find that IgG level is elevated but usually not exceptionally high, and the IgM is normal. These are the cases in which someone was exposed to or had mycoplasma in the past, and the IgG being elevated modestly is not an indication of an active infection. It is the case of immunologic memory in which the immune system is making antibodies to protect us from future infections. So, you have an army of antibodies ready to fight mycoplasma when re-exposed. Those are not generally viewed as exacerbating conditions for PANS or PANDAS.

But an active mycoplasma infection certainly makes one more vulnerable or likely to have a worse case of COVID. This is because the virus attacks the lungs, and the immune system would already be battling a small gram-negative bacterial infection in the lungs. The coronavirus would just serve to overwhelm that organ.

Perhaps those patients who end up in the ICU with pneumonia perhaps are patients with mycoplasma pneumoniae that previously had been asymptomatic for pneumonia.

Dr. O’Hara: Taking another parent question. Are there any special concerns for those on blood pressure medications? Some children are on blood pressure medications but not for blood pressure issues. For example, Clonidine, an alpha-receptor blocker, is used for anxiety and Propanolol is used for anxiety or POTS. I am not concerned about those kids because they are not on those medications for blood pressure issues.

Dr. Bouboulis: I would agree with that.

Dr. O’Hara: Do seasonal allergies make one more susceptible to complications from COVID-19?

Dr. Bouboulis: No, generally not, unless, the seasonal allergies were complicated by moderate or severe asthma.

Dr. O’Hara: We do tell patients to really keep their allergies under control, especially since some of the symptoms can overlap.

Dr. Bouboulis: Of course, and to further that point, as we go into the spring, a lot of the allergy symptoms can mimic some of the COVID symptoms, cough, malaise, even shortness of breath, particularly if they have seasonal or allergic asthma. We don’t want to over-diagnose allergy symptoms as COVID. And one way to differentiate between the two is to treat the allergies well. So the allergy symptoms are at a minimum and not confused with COVID.

Dr. O’Hara: Another question we got was on the use of cholestyramine, which is a binder we use with patients dealing with mold, mycotoxins, and Chronic Inflammatory Response Syndrome (CIRS). Taking cholestyramine does not increase your risk of COVID; it is okay to keep taking. We encourage those to keep taking it as there can be an overlap between COVID and mold disease symptoms.

I just want to mention social isolation recommendations that I went over in my last zoom call. Some of our kids are immune-compromised and we may have some older people in the house. Wipe things down, items from the grocery store, mail, packages. They should be left outside or opened outside, then wiped down or put in different containers.

Another question from our parents is for the child with PANS and Lyme who receives IVIG monthly, will the immunoglobulin be screened for COVID?

Dr. Bouboulis: The immunoglobulin being used to treat COVID is something called hyperimmune globulin and its antibodies are harvested from plasmapheresis in patients who have recovered from COVID. These antibodies are reserved exclusively for patients who have severe symptoms in the ICU. But IVIG has antibodies, many of which can be protective for COVID and other viruses. But they are not specific for COVID. But it does turbocharge the immune system to help fight many infections.

Dr. O’Hara: If we get a resurgence of coronavirus in the Fall, do you anticipate the same outcome as the situation we are in right now?

Dr. Bouboulis: I think we will all be better prepared as a nation and as a medical community. It is a novel virus that spread very quickly throughout the country. There is intense research going on, and in the Fall, we will be in a much better place. We will be armed with medications and be closer to a vaccine.

Thank you for having me join in this conversation. I do believe in my heart we will get through this, and I am confident the world around us will get better.

Please Note: Coronavirus disease (COVID-19) is a new strain that was discovered in 2019 and has not been previously identified in humans. The WHO is closely monitoring and updating the information regularly. Recommendations regarding prevention and treatment will change and evolve as more data is processed. It is essential to communicate with your Primary Care Provider (PCP) directly regarding you and your family’s unique healthcare needs.



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