Wow, what a week! Below highlights pearls I found hiding below the headlines full of pandemic levels of intimidating stats, cancellations, and predictions.
Below The Headlines
For an easy start, I’ll first look at a few items I found interesting in the information I read this week.
Coronavirus (CoV) refers a family of virus named for the crown-like spikes on their surface.
SARS-CoV2 is the virus causing our current pandemic. SARS is the abbreviation for severe acute respiratory syndrome. So, we are dealing with the 2nd coronavirus contributing to SARS.
COVID-19 is the disease SARS-CoV2 causes, short for “coronavirus disease 2019”.
High Percentage of Negative SARS-Cov2 Tests
As reported cases grow, it seems like everyone with upper respiratory or fever symptoms might have COVID-19. However, at Friday’s White House press conference, task force member Dr. Deborah Birx pointed out early results in the US from LabCorp/Quest are only 1-2% positive 1. In Washington, as of 3/14/20 769 positive and 9,451 negative2. MOST ARE NOT COVID-19, and its not even close. We are in the middle of cold/flu season, so please keep that in mind – if for no other reason to keep panic at bay.
Plus, we seem to be holding the death rate near the bottom of the top 20 infected countries:
I took the worldmeter.info columns and calculated deaths per 1 million. Further, outside the nursing home near Seattle (27 deaths), we drop the rate to 0.18 deaths per 1 million. This isn’t put to minimize any deaths, rather provide additional context to the intimidating news cycles – even as we will see cases grow.
First, this is the official CDC COVID-19 How to protect yourself page.
Hang with me here, I’m not going for captain obvious.
While people have been hoarding alcohol based hand sanitizers, we need to give soap its due (as the CDC says). A large thread on twitter from a chemistry professor helps explain why3.
Soap helps dissolve this lipid bilayer rendering SARS-CoV-2 inactive (note proper terminology!). According to the professor, alcohol and disinfectants can act here as well, but soap is superior.
Why So Critical
This virus hangs on quite a while on various surfaces – unfortunately. A recent paper reported survival on these different surfaces4:
-72hr on plastic
-48hr on cardboard
-24hr on steel
-8-24hr on copper
DON’T FORGET ABOUT YOUR PHONE!
Doesn’t do much good to wash your hand for 20 seconds after going to the grocery store, and then answer a call and put it up to your face (which you shouldn’t do because of the radiation anyhow). Apple says you can use warm soapy water, 70% alcohol, and even disinfecting wipes5. I’m not an Android user, but here is a general article on disinfecting phones.
This weeks shocking cancellations (NBA, NHL, PGA, NCAA, everything) are because of many reasons.
First, action is important because this virus has significant properties of high transmission and lethality – dangerous combination. We also don’t have immunity as a community – COVID-19 is new.
Second, a new study found that over 10% of patients with COVID-19 become infected by somebody who has the SARS-CoV-2 virus but does not yet have symptoms6. With this feature, it is hard to just tell sick people to hunker down.
Likely the biggest reason is that social distancing policies will reign is they appear to work.
That image from an article viewed 27 million times as of 3/13/20 explains “Countries that act fast reduce the number of deaths at least by 10x.”7. No leader will want to risk delaying action.
Seeking Medical Care
Medical facilities are where sick people go. With what we have seen above (bad cold flu season, rising cases, and virus survivability on surfaces), seek guidance from your provider before visiting these facilities in person. Call. Have them provide guidance on when/if it is necessary to come in physically. As new drive thru testing facilities come online, you may be directed away from the clinic any how. Obviously, if you are having breathing difficulties or any other acute issue, do not delay. For anyone else, a phone call seems safest for all involved – including the medical staff.
Focus On Avoiding Those At High Risk
As the nursing home in WA taught us, introducing the virus in a close environment with at-risk individuals can be catastrophic – 27 of the 40 WA deaths are from Life Care Center residents8. It is responsible for the most significant contribution to death numbers, and 95 of its employees are now exhibiting symptoms (around half confirmed positive, more pending).
While this is certainly hard, phone/video conversations should be the rule for those who are high-risk until we get a better handle on COVID-19’s spread.
SARS-CoV2 & Blood Pressure Medications
To tie these together, we need to look at how the virus enters the cell.
From a discussion with Dr. Hotez on The Drive Podcast, we learn SARS-CoV virus use Angiotensin‐converting enzyme 2 (ACE2) as a functional receptor with high affinity.
We find ACE2 throughout the body, but most interestingly in the lungs, GI tract, and heart for this topic. The more ACE2, the more binding targets for the virus.
ACE (and ACE2) is part of the Renin-Angiotensin-Aldosterone system regulating sodium retention, blood pressure, among other markers in the body. ACE facilitates conversion from Angiotensin I to Angiotensin II.
ACE and angiotensin are targets for popular prescription drugs – ACE inhibitors (e.g. lisinopril full list here) and angiotensin receptor blockers (ARB’s, e.g. losartan, full list here). Lisinopril is the number #1 drug dispensed in the US, with losartan at #910. Throw in other drugs in the class, and we have millions of Americans using RAA targets to lower blood pressure and/or protect kidneys from diabetic complications.
Why is this important?
Blocking ACE with lisinopril or Angiotensin receptors with losartan INCREASES ACE2 expression.
More ACE2 receptors (measured by presence of its mRNA), more SARS-CoV2 entry points.
Increasing receptors during an interruption of the process (ACE inhibition) is normal in biology. We see this with cholesterol. Block cholesterol synthesis with statins via the enzyme HMG-CoA, we increase LDL receptors pulling more LDL out of circulation. Read more on cholesterol in my free 100 page paper, Deprescribing Statins, here.
To me this is concerning. We have heard that COVID-19 strikes those elderly with chronic health conditions. Well, cardiac and diabetic standard of care usually involves lisinopril or losartan – as evidenced by their usage, and the image below.
I happened to come across this by googling lisinopril and ACE2. Turns out, I am not the only one – another individual wrote the BMJ urging this issue to be investigated13. Further, after the initial writing of this article, The Drive Podcast had an expert discussing ACE inhibitors/ARBs as well – confirming increased ACE2 activity with these drugs (at around minute 21).
A recent article describing interviews with Wuhan (city in China where COVID-19 exploded) doctors drives this point home. While they can’t point to the exact mechanism, Chinese doctors observed a significant percentage of severe patients have high blood pressure – up to around 50%. Might it be that hypertension patients receive prescriptions for ACE inhibitors or ARB’s most times?
NEW UPDATE 3/16/20: An additional article in Lancet detailing these risks adds ibuprofen to the list of ACE2 increasing medications. See below for additional ibuprofen concerns. The authors also claim thiazolidinedione such as Actos do the same. As you will see below the World Health Organization (WHO) used this Lancet article to justify recommending avoidance of ibuprofen in COVID-19.
Do NOT just stop your ACE inhibitor or ARB without your prescribers permission.
Do consider asking if there is an alternative, or an option, to avoid these medications during this pandemic.
Salt – The Natural RAA Inhibitor
I’v written before about one of the biggest con jobs ever – Fake Health News: Low Salt is best! You can learn more from James DiNicolantonio, who is a pharmacist I have referenced here before. Mainly from his book The Salt Fix: Why Experts Got It All Wrong – and How Eating More Might Save Your Life.
Go back up to the RAA diagram, and notice the first step in triggering RAA along with ACE2 and the rest.
Na+ deficiency is SALT deficiency.
Pardon the rant, but…
So, they tell us to restrict salt. Then RAA fires up, increasing blood pressure and causing the kidneys undergo effort to salvage salt before it escapes in the urine. Solution? Drugs that slow down the RAA system – the same one we just forced into action from terrible dietary advice.
There you have it. Salt is the natural way to blunt the RAA response. We have evidence to support this in animals14. Further, if you notice the receptor graph above, when you block both ACE and ARB (lisinopril and losartan), ACE2 expression is lower as opposed to either alone. This is analogous to the RAA system being quieted, as we would see in sufficient salt status.
Let’s quiet our RAA system by bringing back salt to the table and making food great again (pardon the political humor). Make it good salt though (with additional electrolytes/minerals) like Redmond Real Salt, not junk table salt (sodium chloride only plus chemicals to prevent clumps).
One caveat. Make sure you are hydrated before ramping up salt intake. A lower hydration status, plus increased salt load, will spell trouble. Increasing salt WITH fluids is the way to go.
Fever: To suppress or not
We’re in cold and flu season. Add in COVID-19, and we are bound to see a few fevers.
Pop some ibuprofen? Not so fast…
Fevers do a fantastic job at killing invaders. Why would we want to suppress it?
Turns out, treating fevers with antipyretics (ibuprofen, acetaminophen), INCREASE MORTALITY from influenza in animal models15. This makes sense if we actively tamp down our first and best defense.
Run any decisions on fever treatment by your doctor first, but ask how high is ok to NOT treat. Uncomfortable yes, but a great weapon.
Fresh Air & Sunlight
With society shutting down, Netflix and chill maybe where many turn. Let’s encourage outdoor time. Not for any feel good reason, but because fresh air and sunlight can hinder viruses.
A 1971 study demonstrated the Viricidal activity of open air16. I’m typing this next to an open window now, then heading out for 9 holes of golf. Hopefully, improving antiviral activity along the way.
A 2003 study showed SARS-CoV1 UV light efficiently eliminates the viral infectivity.
I’ve written a detailed paper on the benefits of sun exposure here, many people are missing out.
Yes, these outbreaks are in areas where we have colder weather now. That’s actually an excuse to seek the outdoors even more. Those who are cold exposed and/or adapted have increased immune activity17.
There you have it, a prescription to go outside, and maybe even shiver a bit for extra benefit. You may not even have to ask your doc for permission!
Obviously we are zooming through a highly fluid situation. The daily news cycles have enough content for at least a week or more. Same with our understanding of COVID-19. Color me optimistic, but I think we may turn this around sooner than the doomsday predictions generating all the clicks and views. Warm weather, more daylight, and social distancing appear to be lining up in our favor.
The BP meds being potentially problematic angle is untested at this point. However, I believe – strongly – it is worth discussing with your doctor if ACE/ARB drugs are part of you or a loved ones regimen. At least consider bringing back the salt shaker.
Overly suppressing a fever is not untested. The dance of how long/high to let it go needs to be under supervision. But, if I get a fever, I intend to let it run the show.
Also, check out my previous article Coronavirus and Influenza Nutritional Support. A new post in the series titled COVID-19 Defense: More Prevention and Treatment Considerations now available as well.
Until then, get outside for the most enjoyable antivirals we have – UV light and fresh air!
- https://www.whitehouse.gov/briefings-statements/remarks-president-trump-vice-president-pence-members-coronavirus-task-force-press-conference-3/ Video at 49:30 ↩
- https://www.king5.com/article/news/health/coronavirus/real-time-coronavirus-updates/281-b258146d-219a-40a0-8874-cb0fb4f81ec2 ↩
- https://twitter.com/PalliThordarson/status/1236549305189597189 ↩
- https://peterattiamd.com/peterhotez/ ↩
- https://support.apple.com/en-us/HT207123 ↩
- https://www.eurekalert.org/pub_releases/2020-03/uota-csq031320.php ↩
- https://medium.com/@tomaspueyo/coronavirus-act-today-or-people-will-die-f4d3d9cd99ca ↩
- https://www.kiro7.com/news/local/life-care-employees-tested-coronavirus-facility-be-cleaned/EYNT43G5ZBH5BKZ3MATJOVVV5A/ ↩
- Du and Jiang, 2009 ↩
- https://clincalc.com/DrugStats/Top200Drugs.aspx ↩
- https://www.ahajournals.org/doi/full/10.1161/CIRCULATIONAHA.104.510461?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed ↩
- https://www.wsj.com/articles/whos-most-at-risk-from-the-coronavirus-11584048476 ↩
- https://www.bmj.com/content/368/bmj.m810/rr-2 ↩
- https://www.ahajournals.org/doi/pdf/10.1161/01.HYP.4.5.590 ↩
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2951171/ ↩
- https://www.ncbi.nlm.nih.gov/pubmed/8925815 ↩