Monoclonal antibodies: Method in madness. - Dr. Ravi Godse

The world was awaiting monoclonal antibodies. Well, they are here now. Federal Drug Administration in the United States has given emergency authorization to both Eli Lilly and Regeneron for their antibody treatments. It is curious that no one seems to want them. They are in such short supply that we cannot give it to everyone, so rather than selecting a few preferentially, we are not giving it to anyone. At least, now. It is not fair. It is foolish.

Let us briefly review what this is. When a patient successfully fights off SARS –CoV-2  he/she does do that by likely developing immunity to the disease. Part of this immune response is antibodies and hence taking plasma from a recovered patient was thought to be a breakthrough. Frankly, it has not lived up to the promise. Monoclonal antibody is a smarter, sexier short cut. It figures out a specific antibody that will block a vital part of the virus, and then reproduces it artificially. The more closely it resembles human antibodies, the less likely it will be to have an adverse reaction.

Regeneron has a cocktail of antibodies. The most famous patient was President Donald Trump. His age and weight was a set up for a potential problem but he was fighting fit very soon. There was speculation as to what made him better. We needn’t speculate. It was the antibody treatment. Period. Eli Lilly has a similar product. Both were tried in several scenarios but where they seem to work best is early.  So much so that if given late, they might make things worse, by lending a hand to the friendly fire damage done by the immune storm.

The antibodies work well within 10 days of symptom onset, but really speaking, earlier the better and within 72 hours would be ideal. We cannot give it on suspicion and we need a confirmed RT PCR test. The tests are backlogged and that could be a problem.

The antibodies are given as an infusion. It takes about an hour to infuse and an hour to watch afterwards. In case there is a reaction, it is better that the patient is in a larger set up. So the ideal place is a hospital Emergency Room/Casualty. But the hospitals are so busy with the second wave that they don’t have the staff. And also they anticipate a problem.

The cornerstone of the management so far, was, for people with mild to moderate symptoms to stay away from the hospital and isolate/recuperate at home and head to the hospital, only if they are hypoxic (low on oxygen) and getting worse. If there is a hope of getting a potentially curative antibody treatment, it may drive a horde of mildly symptomatic people to the hospital ER/Casualty, overburdening them. And when we give antibody treatment, if it is too late, too bad, if it is given to someone who would have gotten better anyway, too bad. Well, there is a simple solution.

We create an app that will work with apple and android. It will ask the patients 9 simple Yes/No question.

First question: Are you requiring oxygen or more oxygen than you usually do?

 If you answer, yes, the survey ends there.

Second question: Are you sick for more than 7 days?

 If yes, it ends the survey. If it is NO to first 2, then you take a quick risk score. A Yes earns you one point.

1)   Do you have hypertension?

2)   Do you have diabetes?

3)   Are you more than or equal to 65 years old?

4)   Are you a health care worker?

5)   Do you have other chronic diseases like heart failure, kidney disease, and cancer?

6)   Please input your height in meters and weight in kilograms here to see your Body Mass Index, and is it more than or equal to 26?

7)   Do you belong to minority community or have an economic hardship that will make it harder for you to get good care should you get sick?

If you are allowed to take the survey and you score more than 4 or more, you get a code, that will let you lead to the local hospital ER/Casualty, where you can get rapid tested, and if confirmed positive, you leave with an antibody treatment. If the antibody doses at the local hospital become low, they can make the initial score requirement 5 or higher, at their discretion.

It seems that the immunity conferred by natural SARS –CoV-2 could be lasting longer than 3 months. The vaccines are just around the corner. If we somehow take the most vulnerable amongst the people struck with SARS -CoV-2 and give them the best chance to recover without getting hospitalized or dying, that’s how we end the pandemic. And we keep wearing the masks for a while.