The rationale for naturopathic supportive treatment of patients with COVID-19 symptoms
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We are concerned at the number of clinics completely shutting down in Missoula, leaving many patients without primary care and few options other than to risk exposure at an Urgent Care clinic. At Montana Whole Health our goal is to reduce the burden on the healthcare system of Missoula during this time of COVID crisis.
We aim to do this by the following:
- Seeing non-COVID patients with acute, urgent needs via Telemedicine to reduce the burden on the few operating urgent care clinics in town.
- Continuing in-office well child care and vaccinations for young healthy children (see our rationale for continuing Well Child Care at the end of this article).
- Seeing patients via Telemedicine for mental health visits, including anxiety, insomnia, depression, “burnout” and more.
- Seeing suspected COVID patients via Telemedicine (see our rationale below).
The goal of naturopathic supportive treatment of COVID-19
The goal of naturopathic supportive treatment is to assess, inform, prevent spread and provide symptomatic treatment to keep patients OUT of the hospital system. Naturopathic outpatient care, when done safely, should reduce the burden on the local hospital system and free up resources for the most critical patients.
We encourage all patients to seek naturopathic supportive care early, preferably at first onset of symptoms, when outpatient care will be most effective. At Montana Whole Health we use the following principles to guide treatment:
Do not suppress a fever and do not interfere with immune system function
Naturopathic doctors recommend to not use fever-suppressing medications unless absolutely necessary, and certainly in the early course of the disease. This includes ibuprofen and acetaminophen (Tylenol).
Research shows that CD8+ lymphocytes work better at a slightly elevated body temperature. CD8+ lymphocytes are capable of eliminating virus-infected cells.
Some studies (here and here) show that fever in patients, especially early and robust fever is associated with better prognosis. (Limitations: these studies are in patients with sepsis, which is typically bacterial in nature.) The use of fever-reducing medications does not appear to reduce mortality in severely ill patients.
And here is a randomized controlled trial (ibuprofen vs. no ibuprofen) in septic patients, which showed a 2.6% mortality in the patients with no ibuprofen treatment vs. 15.9% in patients with aggressive fever reduction with ibuprofen. (The study was ended prematurely by the Ethics Committee.)
In the case of COVID-19 it appears that using ibuprofen and NSAIDs in general may be particularly problematic. This appears to be because NSAIDs upregulate an enzyme called angiotensin-converting enzyme 2 (ACE2). ACE2 happens to be the exact location that COVID-19 binds to target cells. The theory appears to be that an increase in binding sites can lead to a worsening of COVID disease. We should note that this has not been scientifically proven, though the mechanism of action does make sense. (NSAIDs include aspirin, ibuprofen, celebrex, ketoralac, aleve and more. To find a full list of NSAIDs click here)
Based on this data it is prudent to advise patients to avoid fever-reducing medications, especially ibuprofen. Suppression of fever is probably more harmful early in the course of the disease, as it reduces the body’s ability to mount an immune response early, allowing the virus to replicate earlier and faster.
Many physicians recommend using acetaminophen (Tylenol) as a replacement for ibuprofen for fever reduction at this time due to the NSAID concern. However, Tylenol carries a number of other risks, including a potential for liver toxicity from accidental overdose. We find no compelling reason to give acetaminophen early in the course of illness, as a fever at this stage is typically beneficial. (Suppression of a fever in later stages of the disease would be by the clinical judgment of the attending hospitalist. Evidence suggests that fevers in late-stage disease increase cardiopulmonary demand. However, no definitive research supports suppressing fevers as a method of improving outcomes.)
Treat patients with underlying medical conditions before they become sick.
The data clearly shows an increase in mortality for patients with heart disease, diabetes, asthma, obesity, chronic kidney disease, and immunodeficiencies.
Naturopathic doctors work alongside conventional medical providers to optimize their patient’s health. Naturopathic doctors use customized dietary plans, exercise prescriptions, mind-body-medicine, herb and nutrient supplementation, and more. Many naturopathic patients experience less stress, better sleep, increased energy, increased exercise tolerance, faster weight loss, better mood and more.
Provide naturopathic supportive care early when patients do become sick.
Currently conventional medicine has no medications that are proven to prevent or treat COVID-19. A number of drugs are currently being used, either by compassionate use, or by clinical trial (e.g., remdesivir)
Here is a short list of drug treatments that are currently under investigation for COVID-19 treatment or prevention:
- Chloroquine or hydroxychloroquine
- Azithromycin (typically an antibiotic, but has been shown to have antiviral activity in-vitro.)
Immunomodulating or inflammation-blocking medications:
- Tocilizumab, an IL-6 blocking medication.
- (Other interleukin-blocking medications considered including Sarilumab, Siltuximab and Anakinra)
Convalescent plasma from recovered patients is also under investigation.
We should note that despite the now-widespread use of hydroxychloroquine + azithromycin combination, the evidence is very limited that these two medications provide any benefit.
From a naturopathic perspective, it is this author’s humble opinion that in the vast majority of cases these medications, even if they were effective, are being prescribed much too late to expect nearly any efficacy.
The goal of antiviral treatment should be to prevent viral replication before it overwhelms the body’s immune response. As in the case of influenza and oseltamivir (Tamiflu) – if an antiviral is given after 24-48 hours of the illness it has no effect whatsoever. The best analogy is that giving an antiviral after a patient has become symptomatic to the point of hospitalization is a bit like social distancing 6 weeks too late – it won’t do anything, it has already run its course.
Where conventional medicine is looking for a “magic bullet” or medication that completely inhibits viral replication, the naturopathic approach is somewhat different. Naturopathic doctors have training in several hundred herbs, nutrients and supplements. The goal of naturopathic care in a COVID patient is to: 1) attempt to prevent viral replication early, 2) enhance the body’s own immune response, 3) prevent excess inflammation and a cytokine storm, 4) keep the patient as comfortable as possible and alleviate fear, panic and anxiety.
A naturopathic treatment plan at Montana Whole Health typically includes a custom herbal tincture, supportive nutrients, a dietary plan, and comfort strategies such as breathing exercises for anxiety relief. A typical herbal tincture includes herbs which are anti-inflammatory, immune modulating, spasmolytic, and, importantly, anxiolytic. Supportive nutrients may include supplements to prevent vitamin deficiency (e.g., vitamin D, A), slow viral replication, decrease excess inflammation, and thin mucus, if necessary.
A discussion of respiratory herbs and substances
First, again, we should note that NO substances whether medication, herb or nutrient have been definitively proven to treat or prevent COVID. Naturopathic doctors can choose from our formulary of several dozens of herbs that have historical use in supporting respiratory conditions. Most have excellent safety profiles, and nearly all have additional actions which may be helpful (e.g., anti-spasmolytic, anti-inflammatory, diaphoretic, and more). We believe the risk:benefit ratio is strongly in the favor of giving herbs. We particularly prefer to add herbs which have both respiratory support and anxiolytic properties (e.g., Lamiaceae family herbs), as fear and anxiety worsen cough and shortness of breath.
It should also be noted that in China COVID patients almost always received a Traditional Chinese Medicine herbs, which changed according the patient’s symptoms and disease course. At Montana Whole Health we also advocate changing the patient’s herbal prescription according to their specific symptoms if and when they change.
A note regarding Elderberry
There has been some discussion on social media about the possibility of Elderberry inducing a cytokine storm. Pro-inflammatory cytokines are involved in the pathogenesis of Acute Respiratory Distress Syndrome (ARDS). It is currently believed that an excess of cytokines, particularly IL-6, is either directly responsible for respiratory failure, or at least is a marker of poor outcomes. The discussion regarding Elderberry comes from two small in vitro studies which show that Elderberry extract increases levels of cytokines in cultures made from human monocytes.
It should be noted that in vitro studies do not prove that a cytokine storm would occur in an actual human body. In fact, a 2019 meta-analysis of Sambucus supplementation (in actual, whole humans) showed no adverse events. It is this author’s opinion that a cytokine storm from Elderberry supplementation is extremely unlikely.
A discussion of ionophores
As I mentioned earlier, the combination of hydroxychloroquine and azithromycin has only weak evidence of benefit. One major drawback to using both medications is the potential for QT prolongation which can lead to potentially fatal cardiac arrhythmias.
One possible mechanism of action for hydroxychloroquine as an antiviral is that it is a zinc ionophore. Zinc is a well-known antiviral that inhibits viral replication. Zinc typically doesn’t have much effect once a virus has invaded a cell, though, because zinc does not cross a cell membrane easily. Hydroxychloroquine does appear to both change the pH of the surface of the cell and shuttle zinc across the cell membrane.
Interestingly, there are other natural products that are also zinc ionophores. The most well recognized is the flavonoid epigallocatechin-3-gallate (ECGC) from green tea extract. Note this author does not recommend taking green tea extract away from a physician’s advice, as there are now several case reports of liver toxicity. However this does not seem to happen with normal intake of the plant in tea form. Again, the risk:benefit ratio lies heavily in favor of drinking green tea as long as the dose is moderate.
A short summary
Naturopathic doctors have many options available to support the care of their COVID patients, including much more research into natural products and herbs than can be summarized in one article.
Our rationale for continuing Well Child Care during the COVID crisis.
Prevention is one of the 6 principles of naturopathic medicine. Dr. Featherman and myself are huge proponents of well child care, as we have seen firsthand the difference in health between children treated in our office at birth compared with children starting well child care years or sometimes just months later.
Screening children for appropriate growth, development, and for risk factors for disease development (e.g., asthma, anemia, autism, even childhood cancers) is extremely important.
Well children should continue to be seen for vaccination visits. An outbreak of measles, Hib or Pneumococcal meningitis would be devastating to our already overloaded healthcare system.
We ARE open for in-office well-child checks, including new patients. However, we are severely limiting the number of patients being seen physically in-office. This typically means no more than 2 patients/families in the office per provider per day, with time in-between visits for thorough sanitization. No children or family members with sneezing, cough or fever are allowed in the office. Well child checks can include 1 or both parents/caregivers, but should not include siblings in the office to avoid over-exposure.
We recommend healthy children under the age of 4 to be seen on-time for their well child checks and vaccinations whenever possible. Children older than 4 can defer their wellness exams for several months until the Coronavirus outbreak is under control.
Finally, a thank you to all nurses, doctors, sanitation staff and critical infrastructure workers
You are the heroes of this medical war. Thank you.
Heidi SchnarrApril 7, 2020 at 10:53 am
Thank you for this great article. As an English major I just want to point out one sentence you may consider revising: “In the case of COVID-19 it appears that avoiding ibuprofen and NSAIDs in general may be particularly problematic. ” I think you are trying to say that *using* ibuprofen and NSAIDs may be problematic–avoiding them is a good thing. 🙂
Dr. Erika KrumbeckApril 7, 2020 at 11:36 am
Got it, thanks for correcting! 🙂
Dr. Jennifer SandersApril 7, 2020 at 12:02 pm
Thank you for the well researched and thought out article!
Jane SheafferApril 14, 2020 at 1:43 pm
Thank you. Very informative.