A few weeks ago, former Health Secretary Enrique Ona and I were tossing ideas to each other by Viber on how we could possibly reduce deaths due to COVID-19.

High-flow oxygen therapy and steroids are definitely game changers, but we still need more regimens up our sleeves when we encounter COVID patients with severe pneumonia.

Usually these patients present with already low oxygen levels in the blood, called hypoxemia.

One tricky thing about the hypoxemia in COVID-19 is that the patient’s symptoms may not be commensurate to the severity of the hypoxemia.

The oxygen level may be low, but some patients still say they’re not really feeling short of breath. Hence, clinicians and scientists now label it as the “happy hypoxemia,” and we need to rely more on the oxygen saturation reading, which one can quickly determine using a pulse oximeter—a must-have in every household.

Obviously, the hypoxemia points to the lungs as the source of the problem, but it’s not due to the typical infection one gets with any bacterial or viral pneumonia.

Foreign intruder

In fact, in many cases, the level or load of the virus is low already in the body when this happens, i.e., the viral replication phase of COVID-19 is over.

It’s like the foreign intruders have already left yet the defenders are still firing artillery continuously, uselessly decimating the area it’s supposed to be defending.

The hypoxemia is more due to an extensive inflammation of the lungs triggered by the virus before it left.

This causes adult respiratory distress syndrome, which is still the main cause of death in COVID-19.The Sars-CoV-2 virus is really a cunning, deceptive virus. It tricks the immune system into hyperreacting, causing the body’s immune system to release a lot of natural substances known as cytokines which eliminate a “foreign intruder.”

However, in excessive amounts, the amount of inflammation (swelling) the cytokines cause in every cell of the body can be potentially fatal if not properly treated.

This is called as the cytokine release syndrome (CRS). Some call it the cytokine storm because it virtually causes a stormy downpour of various immune system cells including neutrophils, macrophages and T-cells into the tissue sites of infection.All these cells are part of the immune response artillery, which the immune system has been tricked into activating and releasing to the various cells of the body, especially the lungs and the extensive network of arteries and blood vessels.

This is why COVID-19 may also present as heart attack and stroke, even in the young, because of the involvement of the arteries.

The steroids are doing great in minimizing CRS and the severe inflammation it causes, but in more advanced cases, it needs help.

Good resolution

Ona broached the idea of the use of umbilical cord mesenchymal stem cells (MSCs) in the treatment of severe COVID-19 pneumonia.

A local group of experts collaborated with the National Hellenic Research Foundation in Greece and conducted a study on patients admitted at The Medical City.

The study was published in the Jan. 21 issue of the Journal of Embryology and Stem Cell Research.

The authors presented 11 cases of severe COVID-19 pneumonia treated with umbilical-cord-derived MSCs administered as four separate intravenous doses.

The clinical symptoms, measurements of inflammatory cytokines, and chest X-ray or computed tomography (CT) scan results were recorded for each patient. They particularly noted any side effects attributable to the infusion, and none were recorded.

So, the stem cell infusion seems to be safe based on this preliminary data.

The baseline cytokine levels were elevated in all 11 patients, but the degree of elevation varied depending on the severity of the COVID-19.

In all patients, all cytokine levels decreased after the four infusions of the MSCs, but in different magnitudes also.

Seven patients remarkably improved, with good resolution of pneumonia on chest X-ray or CT scan, and were discharged. Three patients died, one of whom expired before completing the therapy.

Based on this preliminary report, there is an indication that stem cell infusion may help regulate the cytokine storm.

It has to be shown in a bigger, well-designed clinical trial that this can really translate to better clinical outcomes, including survival of patients with severe COVID-19.

We really want to ascertain that the patients improved or survived because of the stem cell infusion, and not because of the steroids or other treatments they were given. I understand the group is now preparing for this kind of trial.

Cutting-edge science

If stem cell therapy is just as readily accessible and cheap as ivermectin or melatonin, I think it’s something we can already try in appropriate patients in our practice.

I have no idea how much it would cost, and we can imagine that the technical preparation is something that would only be available in few properly equipped hospitals. So, it’s not something that we can look forward to trying in our practice in the near future.

It would be nice, though, if they could share their complete protocol with the rest of the medical community here. This is really cutting-edge science, and it makes us proud to know we have local capabilities to do it. We just want to ascertain that it is really a cost-effective treatment.

We commend our colleagues at The Medical City for pioneering it here and their collaborating researcher from Greece, Vasiliki Kalodimou. We support their goal to pursue this potential treatment for severe COVID-19 with a bigger trial, so as to come up with more definitive conclusions.

Speaking of definitive conclusions, Dr. Pierre Kory and fellow experts of the Front Line COVID-19 Critical Care Alliance reviewed all available data on the use of ivermectin in the treatment and prevention of COVID-19 and concluded with a strong recommendation in their stringently peer-reviewed systematic review and meta-analysis that “ivermectin should be globally and systematically deployed in the prevention and treatment of COVID-19.”

Indian variant

We hope that our government and others can seriously consider this recommendation in view of the looming threat of the variants (such as the Indian variant), which are feared to be probably resistant to currently available vaccines.

Since we have a fairly narrow window to act on the threat, we can augment our vaccination rollout with the much easier deployment of ivermectin and other readily available immune system boosters.

This can be implemented through the various local governments nationwide in less than three weeks, provided we have available stocks.

We’re not saying that ivermectin is the miracle drug or iron shield that can protect us 100 percent from COVID-19. We’re not saying it’s definitely free of side effects.

We’re saying it’s listed as an essential drug by the World Health Organization and our own national drug formulary, which is an affirmation of its safety even in wide population distribution, and the reasonable evidence borne out of more than two dozens international trials in various clinical settings suggesting its highly probable benefit in COVID-19.

“Highly probable benefit” still sounds a lot better than “apocalyptic,” “no hope anymore” or “total health-care collapse,” as what the Indian situation is now described. God forbid it happens here. INQ