What experts say about Lianhua, ivermectin, remdesivir as COVID treatments

The Philippine Society for Microbiology and Infectious Diseases (PSMID) the country’s leading professional association of specialists in infectious diseases and microbiology, last week came out with the “Philippine COVID-19 Living Recommendations.”

The study, which recommends guidelines on the effective management and control of the spread of COVID, was funded by the DOH and research was in collaboration with the Institute of Clinical Epidemiology, National Institutes of Health and UP Manila.

On screening of symptoms, PSMID says to look for influenza-like illness symptoms within the past 14 days in healthy adults.

On testing for the disease they recommend swab (throat and nasal) and saliva tests, but not antigen test alone in diagnosing COVID-19 in asymptomatic patients suspected of COVID-19 infection. They only recommend the latter in patients that are symptomatic and in early phase (around seven days) of onset of symptoms and “specific brands that have demonstrated sensitivity of ≥80% and have very high specificity ≥97-100%.”

Ivermectin, remdesivir, Lianhua, VCO, ibuprofen

Since COVID-19 became a global pandemic, many treatments have floated on the internet with very little scientific backing but with very powerful men backing some of them.

Former US President Donald Trump for many months pushed the use of malaria drug hydroxychloroquine for treatment of COVID patients. While he claimed in May 2020 that he took it for two weeks as a precaution against COVID, his doctors did not include it in his treatment after he tested positive for COVID in October 2020.

PSMID does not recommend the use of hydroxychloroquine/chloroquine, azithromycin, convalescent plasma, ibuprofen and Lianhua for COVID treatment.

Lianhua Qingwen was the subject of a Philippine FDA public health warning on May 5, 2020. It warned Filipinos against the purchase of the then unregistered China-made drug, which in China is part of standard therapy for mild COVID patients.

Later that month, Customs seized illegal imports of the drug. On Aug. 7, 2020 the FDA approved the traditional Chinese medicine that comes in capsule form.

The Chinese Embassy in the Philippines said on Aug. 12, this markd “an important progress in the entry of TCM (Traditional Chinese Medicine) products into the Philippine market, which we welcome. Lianhua Qingwen Capsule is an approved COVID-19 treatment for mild and moderate cases in China.”

CNN Philippines reported on the same day that while Lianhua Qingwen had ben approved, it was not as COVID-19 treatment. “FDA Director General Eric Domingo told CNN Philippines on Wednesday that the drug should only be used as indicated in the Certificate of Product Registration, a copy of which was released by the Chinese Embassy in Manila.

“It states that the Lianhua Qingwen capsule got the government’s greenlight on August 7 as a ‘traditionally used herbal product [that] helps remove heat-toxin invasion of the lungs, including symptoms such as fever, aversion to cold, muscle soreness, stuffy and runny nose.’”

There are several treatments that PSMID makes conditional recommendations on based on the low quality of evidence.

On ivermectin, it says there is “insufficient evidence to recommend” its use. Ivermectine is used to treat or prevent parasites in animals; in humans it is used “at very specific doses for some parasitic worms.”

The US FDA came out on March 5, 2021 with a categorical statement against using ivermectin to treat or prevent COVID, “Taking large doses of this drug is dangerous and can cause serious harm,” the US FDA said.  

In a statement yesterday, April 4, ivermetctin maker Mecrk said there is "no scientific basis for a potential therapeutic effect against COVID-19 from pre-clinical studies; no meaningful evidence for clinical activity or clinical efficacy in patients with COVID-19 disease; and a concerning lack of safety data in the majority of studies.

"We do not believe that the data available support the safety and efficacy of ivermectin beyond the doses and populations indicated in the regulatory agency-approved prescribing information," it added.

On remdesivir, PSMID says, “There is insufficient evidence for or against the use of remdesivir in patients with COVID-19 infection who are already on high flow oxygen, non invasive or invasive mechanical ventilation. We suggest against the use of remdesivir in patients with COVID-19 infection who have O2 saturation ≥94% and do not require oxygen supplementation (low quality of evidence; conditional recommendation) We suggest the addition of remdesivir to dexamethasone in patients with COVID-19 infection who have O2 saturation < 94% and/or requiring oxygen supplementation. (low quality of evidence; conditional recommendation).”

However, in its clinical summary, it says that while remdesivir was introduced early in the treatment of COVID and prefered because of its “inhibitory action on the RNA-dependent polymerase resulting in halting of viral replication…its cost should be considered. Hence, routine use of the drug is not recommended.”

One wonders what the recommendation on remdesivir would be if they took out the cost factor, if the Universal Health Care Bill that President Rodrigo Duterte signed in February 2019 was—for lack of a better word—for real.

Healthcare in the Philippines is mostly shouldered by patients who are treated in private hospitals, whose bills can reach upwards of P1 million for COVID patients. One patient reported that for her 15-day hospitalization, she had to pay P1.3 million—half a million went to medication, intubation, laboratory tests, ventilator and respirator; P300,000 to doctors or specialists, among other bills.

PSMID recommends the addition of tocilizumab to systemic steroids in patients showing rapid respiratory deterioration and/or requiring high doses of oxygen and against its use in patients with COVID-19 infection who do not require oxygen supplementation. 

As for virgin coconut oil (VCO), PSMID says there is no evidence to recommend its use as treatment.

Don’t believe all the ‘interventions’ online

PSMID strongly recommends against the following in the prevention of COVID infection: melatonin, vitamin D and zinc supplementation, hydroxucholorquine/chloroquine, lopinavir/ritonavir and steam inhalation.

On the other hand, PSMID says there is insufficient evidence to recommend the use of saline nasal irrigation and antiseptic gargles.

On vaccines, it recommends BNT162b2, mRNA-1273, ChAdOx1 and Gam-COVID-Vac, the scientific names of vaccines produced by Moderna, AztraZeneca and other pharmaceuticals.

On adjunct treatments, or other treatments used together with the primary treatment for COVID patients, PSMID says there is no sufficient evidence to recommend the use of intravenous vitamin C, vitamin D, melatonin or VCO.

It strongly recommends against the use of intravenous N-acetylcysteine as adjunct treatment. But recommends the continuing maintenance of RAAS blockers for hypertension among patients with COVID-19 infection.