In the year since COVID-19 sickened thousands of New Yorkers, doctors have learned important lessons about treating people with the baffling disease that comes from the SARS-CoV-2 virus.
The quick development of effective vaccines has been hailed by medical experts, even as the coronavirus challenges science with the emergence of variants. But there is still much researchers don’t know about helping the human body battle COVID-19, and there is no cure for the disease that has killed more than 500,000 people in the United States.
"At the beginning, there were a lot of unknowns. It was very scary," said Dr. James A. Vosswinkel, chief of trauma, emergency surgery and surgical critical care at Stony Brook Medicine. "People came in and we did a lot of treatments. Some panned out to be beneficial. Some not so much."
Treatments have improved since the pandemic's early days when hospitals were overwhelmed with sick patients, many of whom struggled to breathe. At the peak in April, there were 4,108 people hospitalized with COVID-19 on Long Island. More than 1,100 were in intensive care units.
The numbers are down today, as people are getting shots and doctors have found drugs and therapies that ease symptoms while researchers look for advances. Just about 900 patients with the virus remained in Long Island hospitals by the end of February this year, fewer than 190 in intensive care.
Steroids and blood thinners have been used to manage the inflammation and blood clots that certain COVID-19 patients develop. The noninvasive therapy of proning — turning a patient on their belly — increases blood flow to their faltering lungs, possibly sparing many from ventilators.
Despite earlier hype, the antimalarial drug hydroxychloroquine is no longer recommended for COVID-19 patients. The antiviral remdesivir has shown benefits for people hospitalized with the virus.
"Therapeutics for COVID-19 have definitely lagged behind that of vaccine development," said Dr. Debra Chew, assistant professor at the Rutgers New Jersey Medical School in Newark. "Unfortunately, we do not have a magic drug against COVID-19 … We are still studying what therapeutics work best, but we do know that most treatments work best in the early stages of the illness."
Doctors and researchers have found reason to be optimistic about monoclonal antibody treatments. Dr. Kevin J. Tracey, president and CEO of the Manhasset-based Feinstein Institutes for Medical Research at Northwell Health, also believes the future of treating COVID-19 patients could be found in generic, tested pharmaceuticals used on other ailments.
These drugs should be put through controlled, clinical trials to measure their success — or failure — with COVID-19 patients, he said.
Feinstein, for example, is working with Cold Spring Harbor Laboratory on a clinical trial of famotidine, also known as Pepcid.
"Every story is about the vaccine, but if your grandma, your child, husband, wife gets sick, you want to know what the best treatment is, and the answer is we are not sure," Tracey said.
He said not everyone sick with COVID-19 has access to monoclonal antibody treatments.
"We can’t stop, we have to keep exploring," Tracey said, "especially when there are relatively cheap and safe drugs like famotidine, like ivermectin, like colchicine that we still don’t have all the answers. … We have to be focusing on getting the answers."
In the early days of the pandemic, no drug got more attention than hydroxychloroquine, which has been used to treat malaria, lupus and rheumatoid arthritis.
One of hydroxychloroquine's champions was former President Donald Trump. Some researchers said the studies that cited the drug's benefits were small and did not use control groups. In March 2020, the Food and Drug Administration issued an emergency use authorization that allowed doctors to use hydroxychloroquine on hospitalized COVID-19 patients.
By June, the FDA had revoked that authorization, saying the drug had little benefit and could cause "serious cardiac adverse events and other serious side effects" in COVID-19 patients.
In October, remdesivir became the first drug approved by the FDA to treat certain COVID-19 patients.
Pharmaceutical firm Gilead Sciences said the research to develop the antiviral drug dates to 2009, when it was looking at drugs for hepatitis C. It was tested for use in 2014 against the Ebola virus.
Studies in cells and animals showed it was effective against other coronaviruses such as the Middle East respiratory syndrome (MERS) and severe acute respiratory syndrome (SARS), according to the National Institutes of Health — information that led researchers to think it might help with COVID-19.
Clinical trials showed some hospitalized patients recovered quicker, leading to its approval. According to the NIH, the drug works by interfering with a key enzyme the virus uses to replicate the RNA in its genetic material — preventing it from multiplying.
Steroids and blood thinners
Hospitals across the country have turned to the common steroid dexamethasone to calm the inflammation caused by the body’s response to COVID-19. That response can lead to lung injury and multisystem organ dysfunction, according to the National Institutes of Health.
"Early on, we looked at this as an inflammatory disease," said Vosswinkel, who survived his own battle with COVID-19 last March. "The use of steroids, once you get some pulmonary compromise, has been shown to improve survival."
They started giving steroids to patients in need of supplemental oxygen. Staff also knew inflammation could lead to blood clots.
"We started people on different levels of blood thinner," Vosswinkel said. "The data panned out that it was a good thing to do. We now know using different levels of blood thinner, depending on the degree of inflammation, can be beneficial."
Ventilators and proning
Last spring, as COVID-19 patients with breathing problems flooded emergency rooms, doctors often turned to mechanical ventilators in an effort to keep them alive.
In most cases, the machines move air in and out of a person's lungs via a breathing tube. But there are serious side effects, including lung damage and pneumonia, according to the NIH.
Doctors are looking at other noninvasive methods, including using masks and equipment for sleep apnea or applying a method called "proning."
"By having someone lay on their abdomen, you change the way blood flow preferentially is in their lungs," Vosswinkel said. "When you are standing upright, more blood flows to the base of your lungs. When you are laying on your back, more blood flows to the back part of your lungs. When you are on your stomach, more blood flows to the anterior or chest part of your lungs."
Public officials have said the weapon that will win the war is getting people vaccinated before they are exposed to COVID-19.
More than 2.2 million New Yorkers have received at least one dose of either the Pfizer-BioNTech or Moderna vaccines, which both require two shots taken weeks apart.
The Johnson & Johnson vaccine, which only requires one shot, could be key to getting more people vaccinated. On Saturday, the FDA cleared it for use after deciding it offers strong protection against serious illness, hospitalization and deaths.
Monoclonal antibody treatments
In recent months, the FDA issued two emergency use authorizations for monoclonal antibody treatments, described by the agency as "laboratory-made proteins that mimic the immune system’s ability to fight off harmful pathogens such as viruses."
A single infusion of bamlanivimab was approved for adults and certain pediatric patients with mild to moderate COVID-19.
A joint dose of bamlanivimab and etesevimab can be used for adults and children, 12 years and older, who test positive and are at high risk of progressing to severe illness.
The intravenous "monoclonal antibodies appear to be effective in patients before they get very sick," Tracey said.
Exploring generic drugs
Tracey said more time, effort and money needs to go into launching and sustaining clinical trials to determine whether common drugs might help COVID-19 patients. He said the federal government should set a coordinated strategy to study potential drugs, whether they are generic or for-profit, organize the data and share it.
He pointed to famotidine, the antiparasitic ivermectin and the gout drug colchicine as potentially showing some promise in COVID-19 treatment. But there should be larger, controlled studies to measure whether any benefit exceeds risks, Tracey said.
"It’s not about effectiveness, it’s about risk-benefit," he said. "Some of the available treatments have benefit but also have significant risk or significant expense."
Masks and social distancing
Short of getting vaccinated, the most effective way to ward off the coronavirus is to follow the advice of health experts: Wash your hands, wear face coverings and observe social distancing protocols.
Masks and face coverings have become mandatory, even though federal health officials initially did not encourage people to wear them when the first cases of COVID-19 surfaced on Long Island. Part of that advisory was based on the concern there would not be enough protective equipment for health care workers and first responders.