Pathophysiological Basis and Rationale for Early Outpatient Treatment of SARS-CoV-2 (COVID-19) Infection - 17/12/20

Doi : 10.1016/j.amjmed.2020.07.003

Peter A. McCullough, MD, MPH ^a,^b,^c,^⁎ , Ronan J. Kelly, MD ^a, Gaetano Ruocco, MD ^d, Edgar Lerma, MD ^e, James Tumlin, MD ^f, Kevin R. Wheelan, MD ^a,^b,^c, Nevin Katz, MD ^g, Norman E. Lepor, MD ^h, Kris Vijay, MD ⁱ, Harvey Carter, MD ^j, Bhupinder Singh, MD ^k, Sean P. McCullough, BS ^l, Brijesh K. Bhambi, MD ^m, Alberto Palazzuoli, MD, PhD ⁿ, Gaetano M. De Ferrari, MD, PhD ^o, Gregory P. Milligan, MD, MPH ^a, Taimur Safder, MD, MPH ^a, Kristen M. Tecson, PhD ^b, Dee Dee Wang, MD ^p, John E. McKinnon, MD ^p, William W. O'Neill, MD ^p, Marcus Zervos, MD ^p, Harvey A. Risch, MD, PhD ^q
^a Baylor University Medical Center, Dallas, Tex
^b Baylor Heart and Vascular Institute, Dallas, Tex
^c Baylor Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, Tex
^d Cardiology Division, Regina Montis Regalis Hospital, Mondovì, Cuneo, Italy
^e Christ Advocate Medical Center, Chicago, Ill
^f Emory University School of Medicine, Atlanta, Ga
^g Johns Hopkins School of Medicine, Baltimore, Md
^h Cedars Sinai Medical Center, Los Angeles, Calif
ⁱ Abrazo Arizona Heart Hospital, Abrazo Health System, Phoenix, Ariz
^j Carter Eye Center, Dallas, Tex
^k Cardiorenal Society of America, Phoenix, Ariz
^l University of Texas McGovern Medical School, Houston, Tex
^m Bakersfield Heart Hospital, Bakersfield, Calif
ⁿ University of Siena, Le Scotte Hospital Viale Bracci, Siena, Italy
^o University of Torino, Torino, Italy
^p Henry Ford Hospital, Detroit, Mich
^q Yale University School of Public Health, New Haven, Conn

^⁎Requests for reprints should be addressed to Peter A. McCullough, MD, MPH, Baylor Heart and Vascular Institute, 621 N. Hall St, H030, Dallas, TX, 75226.Baylor Heart and Vascular Institute621 N. Hall St, H030DallasTX,75226.

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Abstract

Approximately 9 months of the severe acute respiratory syndrome coronavius-2 (SARS-CoV-2 [COVID-19]) spreading across the globe has led to widespread COVID-19 acute hospitalizations and death. The rapidity and highly communicable nature of the SARS-CoV-2 outbreak has hampered the design and execution of definitive randomized, controlled trials of therapy outside of the clinic or hospital. In the absence of clinical trial results, physicians must use what has been learned about the pathophysiology of SARS-CoV-2 infection in determining early outpatient treatment of the illness with the aim of preventing hospitalization or death. This article outlines key pathophysiological principles that relate to the patient with early infection treated at home. Therapeutic approaches based on these principles include 1) reduction of reinoculation, 2) combination antiviral therapy, 3) immunomodulation, 4) antiplatelet/antithrombotic therapy, and 5) administration of oxygen, monitoring, and telemedicine. Future randomized trials testing the principles and agents discussed will undoubtedly refine and clarify their individual roles; however, we emphasize the immediate need for management guidance in the setting of widespread hospital resource consumption, morbidity, and mortality.

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Keywords : Ambulatory treatment, Anticoagulant, Anti-inflammatory, Antiviral, COVID-19, Critical care, Epidemiology, Hospitalization, Mortality, SARS-CoV-2