Dear Friends and Patients, 

It’s been a long two weeks since my first email sent morning 15th of March 2020. I have been requested to write an update. These are my thoughts and experiences, the answers to frequently asked questions from my patients as of morning 2^nd April 2020. 

My answer when asked about my experiences so far with COVID–19: 
 

• Most importantly, the vast majority of cases really are quite mild. Perhaps not pleasant, but bearable.  
   
• People are confused about isolation. Basically, we are now all isolating in our homes. If we develop COVID-19 symptoms, or if somebody in our household does, we should then avoid the grocery/pharmacist (if possible) /our daily outside x 1 exercise.  
   
• For people who have been in touch with someone with COVID-19/suspected COVID-19, they must self-isolate for fourteen days from the last time that they saw that person.  
   
• If symptoms come on during the course of these fourteen days, then one resets the counter and needs to isolate for seven days from the onset of symptoms i.e. if I see somebody with COVID-19 on the 1st of April I should isolate entirely for fourteen days; if however I develop symptoms on the 6th of April then I need to press reset and quarantine for seven days from the 6th so until the 13th April. So in actual fact the isolation from onset of symptoms is shorter than the duration of isolation if one is exposed as one might be shedding before symptoms appear. 
   
• Some people are complaining of only headaches and/or loss of taste or smell. Great thirst is not uncommon. 
   
• I am starting to see more patients who have already been isolating for over a week with symptoms creeping on. They can start quite mildly and then become more severe at day five/six. Also, I have seen where they can be quite severe and then start to get better, and then flare again with more significant symptoms. 
   
• From the day one develops symptoms, one is contagious for seven days. One needs to self-quarantine for seven days and then no longer needs to isolate from day eight, provided one is feeling better. 
   
• Presenting with fever, dry cough, body aches and pains is most frequent. 
   
• I am surprised to have seen several patients presenting with symptoms of diarrhoea/abdominal ache.  
   
• Some patients are presenting with fatigue, dizziness and feeling faint (a few have actually fainted). 
   
• Some people are complaining of only headaches and/or loss of taste or smell. 
   
• Some of the people I have seen most unwell have surprisingly not had a fever, although fever and dry cough remain the most common symptoms. 
   
• The chest pain/discomfort/heaviness/tightness and acute shortness of breath can come on suddenly. Just because one was fine yesterday or earlier in the day does not mean that one should ignore acute breathlessness or assume it will pass. One should speak to the doctor. 
   
• Although less common, we are hearing of more young people being admitted to Intensive Care Units, and also those without underlying pathology. It is important that people in their teens/twenties/thirties do not feel invulnerable to COVID-19. 
   
• I have had fifteen patients in the age group 21-30 with significant symptoms in the past week. 
   
• Symptoms can last up to 25 days (usually not this long).  
   
• It is not infrequent to experience a post-infective cough which persists, secondary to residual airways inflammation.  This type of cough is not unique to COVID-19. I cannot comment yet if this seems more frequent with COVID-19. 
   
   

What is the status of the private sector? 
 

• The private hospitals have now been requisitioned by the NHS. My understanding is initially they will treat acute surgical and medical emergencies, then recovering COVID-19 patients, and then eventually, if required, acute COVID-19 patients. 
   
• Routine medical care has been suspended as the advice of Public Health England. 
   
• There is no private facility for treating COVID-19 in hospital. 
   
   

Obs and Gynae: 
 

• Contraception: take the pill on time, and do not run out of the pill if you do not want a surprise. 
   
• Pregnant ladies: liaise with your antenatal team to see if your outpatient clinics will be going ahead or if remote consultations are an option. For patients who have private obstetric care, you should liaise directly with your Consultant Obstetrician who will guide you. 
   
   

What about the Nurofen/Ibuprofen/Brufen/Aspirin/Non-steroidal anti-inflammatory drugs (NSAIDs) debate?  

• After my email sent on the 15th of March 2020, the French Health Minister tweeted to be careful with Ibuprofen. I was contacted by numerous concerned patients.  
   
• Three separate points have arisen: 
   
  1. Concern that Ibuprofen increases susceptibility of the lungs to COVID-19: there is no significant evidence that taking NSAIDs (non-steroidal anti-inflammatory drugs) increases the risk of lung complications in people who are fit and well and “normally tolerate these medicines”. People with established asthma and emphysema sometimes do not tolerate them and they will be aware of this through the previous management of their respiratory disease with their doctor. Many of them have no problem with NSAIDs but we always say to be careful (as per my email 15th March 2020).  
      
  2. Following the tweet and concern that circulated, in many countries advice changed: to mainly take paracetamol and the was caution about NSAIDs. This is to avoid the side effects of NSAIDs, which will increase if they are not taken with care and as increased numbers of people take them, not because COVID 19 increases the risk of respiratory complications. This has not been made clear and as a result many people who would benefit from taking NSAIDs to help alleviate symptoms are now afraid to do so which is a shame. NSAIDs are often more effective at lowering a fever and reducing muscle aches and pains. I know of Intensitivists in Italy telling their family to take an NSAID at the first onset of symptoms to help protect the lungs, and they have the most experience with severely ill patients with COVID 19 at present. My point is advice varies, experience is evolving and so one needs to tailor this bespoke for oneself and one’s family, which is what I aim to do for my patients. 
      
     My advice, as a doctor written to my patients in email 15th March 2020, was purposely more informative to avoid the pitfalls associated with non-steroidal anti-inflammatories (which include Ibuprofen and Aspirin). The side-effects of NSAIDs have been known for a long time. The fact they may affect the immune system has also been known for a long time. There were/and there remain conditions to taking these medicines:  
      
     • “Speak to a doctor after taking them for 2-3 days”   
       (nothing is missed, you are not self-medicating ad infinitum; there is a reason in the UK Nurofen is sold in boxes of (usually) a half dose and there are only between 10-16 tablets in a box, which gives 2.5-4 days of the medicine if taken regularly: it is to prevent people from taking too many)  
        
     • “Do not take them if you have asthma or kidney disease or are known not to tolerate them”  
       (if you know a medicine makes you feel unwell you should not take it; if you know you have a stomach ulcer you will have been told you cannot take this group of medicines; if you know you are taking other medication which interacts, e.g. blood thinners, you know you cannot take NSAIDs; if you are pregnant you do not take Ibuprofen and other NSAIDs (it’s one of the first things I tell a lady when she wants to become pregnant (and then there are even some cases when aspirin, another NSAID is actually prescribed in pregnancy: there are always exceptions!)); if you are known to be allergic then do not take them (obviously); if you have asthma or lung disease, in some people it can exacerbate the symptoms, but in many it does not so they know they can take them) 
        
     • “Take them after food” 
       (prevents irritation to the tummy, gastritis and stomach ulcers) 
        
  3. There are multiple emails and WhatsApps circulating allegedly originating in Cork and Vienna that people who died of COVID-19 were found to have Ibuprofen in their system.  These have been proven to be false information fabricated on the web (The Irish Health Minister made a statement about this as the data was supposed to come from Cork) however I would like to make a point:  
      
     I would expect a person who had become so severely ill from COVID-19 that he/she tragically passed away to have so many medicines in his/her body: Paracetamol, Ibuprofen/Aspirin, Hydroxychloroquine/Chloroquine, antibiotics (probably several of them), antivirals (several), Morphine, paralytics and numerous of the medications mentioned in the list below. I do not think it would be the Ibuprofen or other NSAID which would have caused this. A normally fit person would not have passed away from a few doses of an NSAID (unless they were for example allergic and did not know this, which is a risk of any medication). 
      
• I feel the NSAIDs issue has been blown entirely out of proportion and this was triggered by a tweet. If there are any concerns whether or not you can take this, (or any medication), it should be discussed with your doctor, which was also written in email 15 March 2020. Importantly, if there is a medication you feel uncomfortable taking, then of course you must not take it. There is nothing new which in a way is reassuring. 
   
   

The experience of my COVID–19 patients: 
 

• When a patient develops symptoms they are concerned about, I speak with them either by telephone or by FaceTime/video consultation to assess how they are doing. We discuss their symptoms and get certain measurements. We make an action plan based on their health and past medical history. 
   
• Medication is either delivered to them or faxed/telephoned/emailed through to their nearest pharmacy which is likely to have the medicines in stock. The post is currently delayed so less favourable if the medication is urgently required.   
   
• Patients are WhatsApping me (on a number they get given if they are unwell) from once daily to once every few hours, depending on their symptoms and what I ask them to do. If they are deteriorating, they reach out sooner. Please do not use this number for any admin whatsoever. It is for clinical issues. If I do not get back to them within five minutes, they know to contact the practice directly to liaise with my secretary Jade or access the on-call doctor. 
   
• In the updates they send me their temperature, pulse, oxygen saturation, and symptoms. We adapt the management/treatment as much as we are able to in the community by supportive measures. 
   
• Many patients are asking how they can be tested for COVID-19. There are a few facilities which are providing this by post. This is completely separate from myself at present. We are unable to offer this testing yet. A significant limiting factor is the delays in the post. I have some patients where their tests have arrived, they have been able to post the test results back, and the results are through. Most are still waiting for either the swabs or the test results to arrive. 
   
• If there is a special way to take some of the medication I prescribe (for example, inhalers) then a video demonstration is sent. 
   
• If a person is deteriorating or we are concerned and further investigation such as chest- X-ray, CT scan and/or arterial blood sample is indicated, then a person is sent to hospital. 
   
• Currently when one is seen in hospital – in A&E – a COVID-19 test is not available. It is only available if a person is admitted to hospital, and even then it depends on the hospital whether or not the tests are available.  
   
  The patient may be diagnosed with COVID-19 based on chest X-ray results and the change in inflammatory markers and effects on white cells seen on the blood tests. 
   
  I do not think these clinically confirmed cases are included in the UK numbers as positive cases as they have not actually tested positive, as there is no test available. The doctors too are frustrated these tests are not available for their patients, and themselves/their families. 
   
• Once patients have left hospital, we continue to support them and to monitor their symptoms closely. 
   
   

Testing: 

• There are two types of testing currently: 
   
  • One is the nasal/throat swab which quite a number of patients have ordered themselves. This tells us if you have evidence of COVID-19 RNA in these passageways. It gives us an idea of what is going on here and now. 
     
  • There are now antibody finger prick tests. You place a drop of blood on to what looks much like a pregnancy test. These tests have false positives of up to 9% and false negatives about 2%. There are a few different ones and they should be readily available in the next week or two online. They are not entirely clear cut to interpret – so if you are early in the infection, and not yet producing antibodies, this might not be picked up. If people are unclear about the results, it should be discussed with one’s doctor/the company who produces the test. Many of these tests have information on how to interpret your results on their websites.   
     
• I know labs abroad are extremely close to developing an actual blood tests which measure the antibody levels in the serum (so a normal blood test from your arm). It is the same type of test as when we check if somebody is immune to chicken pox or rubella for example. This test is the deal breaker: it will tell us when it is safe for somebody to return to work and help to get the economy going again. In Germany they are discussing giving “Immunity Passports/Certificates”. Super idea. It is prudent in my opinion to get these tests and many of them as soon as available. 
   
    

Negative effects of isolation: 
 

• I am worried for all of the other medical issues that are being left untreated/missed/under prioritised: heart attacks, strokes, serious infection, cancers, long-term aliments that cannot currently be monitored, screening (albeit a “luxury” to be able to do) not being done etc. Once isolation/quarantine is over, we must play “catch up” where we can in earnest and really try to undo some of the other damage which is being done. 
   
• I am concerned anxiety and/or depression will be exacerbated in those who already suffer from this. If you are having a hard time reach out. I am contacting my patients with anxiety and/or depression to ensure they are coping. 
   
• I think the incidence of new cases of anxiety and depression will increase as isolation is prolonged, as stress increases and once social distancing is over, as people try to rebuild their businesses and lives. 
   
   

Medications for treating COVID-19 (simplified): 
  

The following medications are being used in various capacities: 
 

• Azithromycin/Zithromax, (also referred to as Z-pack (some hospitals are also giving Clarithromycin/Klaricid which is in the same group of medicines as Azithromycin)): this is an antibiotic which has anti-inflammatory properties on the lungs and also has some crossover antiviral activity. 
   
• Hydroxychloroquine/Chloroquine phosphate (sometimes being used in combination with Azithromycin):  old anti-malarials, makes it more acidic around the cells so the virus has a tougher time attaching. There has been an interesting study done in France on a very small group of patients which showed quite promising results. There was however no control in this group. Donald Trump picked up on this trial and announced to the world that all people in America would have access to Hydroxychloroquine/Chloroquine phosphate. Unfortunately it is not a clear-cut miracle treatment. Larger trials are being done. 
   
• Remdesivir/Favipiravir (and less so Oseltamivir which is Tamiflu used for treatment of Swine Flu): antivirals which have been/are being used and have shown some promise. Used to treat flu. In Italy, family doctors (GPs) will soon be prescribing Remdesivir to COVID-19 patients in the community. In Japan they are very excited about Favipiravir (Avigan). 
   
• Ritonavir/Lopinavir: medicines used to treat HIV which are being used on some COVID-19 patients. 
   
• Tocilizumab: a drug to the Interleukin-6 receptor. Also has immunosuppressant properties. Used normally for adolescents and adults to manage their Arthritis (which is an auto-immune condition). 
   
• Corticosteroids: have anti-inflammatory properties although can impact immunity so it is a balance. The doctors know this. 
   
• Baricitinib: a tumour necrosis agonist again used for treatment of arthritis. 
   
• Camostat mesylate: this medicine blocks certain protease enzymes. It is used for example to treat some cancers, it can be used as an antiviral (here obviously) and in some conditions where organs in the body, such as the pancreas, are chronically inflamed. I understand to be less promising. 
   
• Antibody-rich plasma for people who have recovered from COVID-19: this is being experimented on in patients who have active COVID-19 to help their body fight the disease. 
   
• Various types of ventilation. 
   
   

Over-the-counter support to help support one’s resistance at this time: 
 

• Vitamin C 1000mg daily 
   
  • Ideally after food (to protect your tummy). 
     
  • If symptoms of COVID-19 develop: an adult can increase this to 1000mg after breakfast, lunch, and dinner. 
     
  • Vitamin C can make diarrhoea worse so be careful. 
     
  • Vitamin C can be hard on the kidneys, so one does not want to be taking higher doses for more than a week without speaking with a doctor. 
     
  • Do not take high doses of Vitamin C if you have kidney disease. 
     
• Vitamin D3 
   
  • My patients know that I have been banging on about vitamin D for years. It is thought to be good for immunity and have anti-inflammatory properties. 
     
  • There was a report out in Italy this past week explaining a very high proportion of people going into intensive care due to SARS secondary to COVID-19 had low levels of vitamin D. 
     
  • I recommend Vitamin D3 3000-4000 iu daily currently. If you spend time in the sun, reduce this dose. 
     
  • Patients who have sarcoidosis or other forms of sarcoid should not be taking vitamin D supplementation without discussing with their doctor as it can trigger a flare of sarcoidosis. 
     
• Magnesium 
   
  • Can be helpful for achy muscles. 
     
  • It is however also a natural laxative, so if you take too much be close to the loo. 
     
  • Any good quality over-the-counter brand such as Magnesium citrate 400 mg once daily. 
     
•  Zinc 
   
  • Thought to be good for immunity. Do not take more than the dose recommended on the bottle, obviously.  
     
  • Sometimes being used in a hospital setting with Hydroxychloroquine and Azithromycin as is thought to interfere with the RNA replication, but there are no studies on this yet. 
     
• Turmeric 
   
  • There are no trials on this, however it is a naturally occurring anti-inflammatory. Extra can easily be added to your food. 
     
• Omega-3 
   
  • Omega 3 has anti-inflammatory properties (Omega 6 is pro-inflammatory, it is the ratio between the two which is important, but that for another time); 
     
  • I usually recommend that my patients take a good-quality preparation of omega-3, 2000mg daily. Even in people who eat plenty of fish. 

Taking the above supplements will not treat COVID-19 and will not stop somebody from getting it. The idea is to support the body as much as is possible in a safe way through supplementation which some people find particularly beneficial. 
 
A final thought for the university students/secondary school students whose exams have been cancelled and do not have closure to their years of study working towards their degree: do something useful with this time. It will help you to process the unexpected changes. It does not need to be grand or important, but fulfilling to you in some way. I am certain in future you will be asked what you did with this time. I expect we will all be. 

With very best wishes. 

Yours sincerely,  

Kristina 

Dr Kristina Brovig 
MBChB DRCOG DFFP