Updated October 7, 2020 - 9:25 am
After spending three nights at Walter Reed National Military Medical Center, President Donald Trump returned to the White House on Monday evening to continue receiving treatment for COVID-19.
That treatment, for earlier symptoms such as a mild cough, congestion and fatigue, had included an experimental monoclonal antibody cocktail, the antiviral drug remdesivir, the steroid dexamethasone and supplemental oxygen, according to the president’s doctors.
The Review-Journal asked Dr. Robert Smith, associate chief medical officer at Sunrise Hospital and Medical Center in Las Vegas, about these treatments and what they suggest about the president’s condition and recovery.
RJ: What is a monoclonal antibody cocktail and what does it do?
Smith: If you give somebody an antibody, you’re giving them somebody else’s — or something else’s — immune response to something that shouldn’t be in their body. You’ve basically borrowed that immune response, those proteins that fight the infection or fight the toxin. …
That’s different from a regular immunization you get like a flu shot or a measles shot … where you’re actually giving somebody a weaker version of the offending agent and your body is making the antibodies to that thing. With a monoclonal antibody, you’re skipping a step. You’re just giving them the protein that marks the foreign invader as being foreign so your immune system can then take care of it. …
If you come into Sunrise and you were stung by a scorpion and you’re having really bad symptoms, and we give you the anti-venom to that, most of the anti-venoms are antibodies. Most of them are taken from animals that have been stung by scorpions or bitten by rattlesnakes or something like that.
My understanding is this cocktail is an antibody from a recovered human and one from a genetically engineered mouse.
Yeah … you give the animal something so that it is stimulated to make the antibody.
What does the antiviral drug remdesivir do?
It basically helps to reduce the ability for the virus to replicate its cells. It interrupts the reproductive cycle of the virus. We use similar antivirals for HIV. … If somebody has herpes or shingles, we can use antiviral drugs. So there’s a lot of specific antiviral drugs. There’s several for the flu. …
What has been your observation of the effectiveness of this drug (remdesivir) or its side effects?
The early indications are that if you give it to a specific set of people with kind of rapidly deteriorating clinical status, or if they’re getting sick really quickly, and you give it early, remdesivir seems to make an impact in reducing their complications.
This is clearly not something that you give to somebody who was exposed to COVID or has early COVID, and then they’re just completely good to go. … This isn’t like giving penicillin for strep throat. It is not that effective. …The unpleasant side effects of antiviral drugs tend to limit how much you can give to somebody and not hurt their body.
Would that suggest that the president was in a rapidly deteriorating clinical status?
No, my assumption would be that they just gave him the full-court press because he’s the president. … He did require oxygen, and that’s one of our triggers for starting remdesivir.
What do you make of the fact that he did have oxygen on a couple of occasions?
It sounds like his oxygen saturation was probably low enough that he needed oxygen. That’s not uncommon for our patients who come in with COVID.
I was trying to put that in perspective, if it necessarily meant that he had moderate or severe disease.
My guess would be that they were just monitoring him so closely they picked up something that you might not pick up in a regular person being treated for COVID.
He was also given dexamethasone, which is used in COVID patients to deter immune-system overreaction. When does this get used on a patient typically?
It’s the same sort of scenario of a patient who is clinically deteriorating, needing hospitalization, and needing some oxygen support. We would go ahead and give them dexamethasone early. It’s another one of those drugs that we’ve realized the earlier you give it, the better off the patients are. If you give it late, it tends not to be helpful.
You say “clinically deteriorating” … that means the patient is getting worse instead of better?
That just means that either they’re having a harder time breathing, or they’re breathing more times for a minute, or their respiratory rate’s gone up. … Clinical deterioration can mean a whole host of things. It’s basically your mom’s spidey sense of, you’re getting worse, something’s not going right.
We have lots of different metrics for measuring that, whether it’s blood pressure, or oxygen saturation or respiratory rate. It’s hard to say which ones of those things, other than the oxygen saturation, were causing him problems, because the indication for getting oxygen is your oxygen saturation is going lower. So we don’t know whether he was breathing faster or coughing more or his fever was up very high. We don’t know any of that.
The one thing they have said about oxygen level — the doctor said it was below 94 (percent). Does that indicate severe illness, or what does that indicate? Is that unusually low?
No, there’s a lot of people who run around with oxygen levels that are that low and they don’t have any untoward effects. So it kind of is a drop from your baseline. So if your baseline is 99 to 100, then the oxygen level of 93 or 92 is a big change.
Are you drawing any conclusion about the president’s condition from what is said — or maybe what isn’t said?
I guess he’s gone home today (Monday), and so he seems to be improving. And that’s all good news. We all want the politics decided by the voter and not decided by the virus.
It has seemed a little like they’re throwing everything at him but the kitchen sink. Can there be a drawback to that?
Every single medicine that we give to somebody has risks. These monoclonal antibodies, they’re great drugs when they work. But there’s a reason why we watch people after we give them that shot for scorpion envenomation and other things. We need to make sure that people don’t have an extreme allergic reaction or anaphylaxis to the shot. Everything they gave him really except the dexamethasone had a risk of causing anaphylaxis.
Remdesivir does have some toxicities to the kidneys, I’m sure they were watching that very closely. …
I’m sure somebody will make a study of this 10 years from now. And the question will be, should they have treated the president with all these things? My guess is, it’ll be an interesting discussion, and there may not be consensus on that.
Is it telling at all that they’re not saying anything about any scans or chest X-rays?
Not really. With the severity of illness that he had, I don’t know that he would have wanted to have a bunch of scans other than the chest X-ray. …
His doctors haven’t said anything about a chest X-ray, and reporters keep asking.
I’m sure that there’s a lot of national security that goes into this, too. I don’t make anything of that at all, really.
I think what’s most telling is that he’s clinically improved and gone back to the White House, and he’s not still at Walter Reed. And he’s not getting intubated. Those things would be concerning. The fact that clinically he’s turned the corner is what’s telling. The reality is scans and blood tests, they don’t really tell you the whole story. Somebody’s CT scan or chest X-ray can look worse days after they’re getting significantly better from pneumonia. …
Do you think the president is out of the woods?
There are a few patients who do OK for … four days or so, and then turn the corner and get worse. … But they’re very few and far between.
This interview was edited for length and clarity.