Ernie Dainow's Blog

Almost two years ago I started to have a lot of stomach upset, a condition that is called Irritable Bowel Syndrome – IBS. Dealing with it has been a long learning path. Even if you don’t have any gastrointestinal issues, you may find it interesting to read this account. It demonstrates how
– Modern medicine still relies a lot on trial and error
– Why doing your own research is important
– How to collaborate with your doctor to find solutions to health problems

I never had a history of gastrointestinal (GI) problems. But with age and perhaps reactions to medicines, things change. I developed a typical gamut of gut (stomach) problems – cramps, gas, bloating, diarrhea. The pain and discomfort were not that severe but their erratic and sudden occurence created havoc with my daily life. I had accidents on occasions when I was out somewhere and was not able to get to a bathroom in time. I restricted some activities and most travel was out of the question.

I tended to have more stomach upset in the morning so I grew suspicious of some of my breakfast foods. I eliminated eggs and coffee from my diet. Eggs are very rich and coffee is well known to be a possible irritant of the GI tract. It wasn’t that hard for me to give up coffee. I had never gotten into the gourmet coffee grind and I never went to Starbucks. I also never liked coffee all that much, but it made milk and sugar taste good and went well with dessert. It was hard to tell if these changes in diet helped very much because my symptoms persisted and continued to be very erratic and unpredictable. 

Yhe next thing I tried was yogurt. I had long been a big believer and promoter of yogurt, ever since my student days when I had founded the Underground Yogurt Co-op (but that is another story). I was no longer eating yogurt regularly so I added it to my breakfast. Disappointingly this did not have the magic outcome that I had professed in my younger days. 

Next I upped my game to a probiotic. My wife had seen a gastroenterologist a number of years earlier about IBS symptoms and he had recommended Align, which had worked well for her.

Probiotics are live bacteria and yeasts that supplement the bacteria that inhabit your GI tract and play an important part in digestion. A number of foods such as yogurt contain probiotics but there are probiotic supplements that have more bacteria than you get from food. I took Align for several months but it did not seem to help me very much.

There are up to 1000 different types of bacteria in the GI tract. Which ones are the ones that are important for helping with IBS? I found this really comprehensive article about The Best Probiotics for IBS that had a guideline. Based on your symptoms, it recommended a particular type of probiotic.

Going through its checklist, I selected and found a probiotic containing Lactobacillus acidophilus. After what I thought had been such good research, I had high hopes for this probiotic. But it turned out to be an example of the gap between theory and practice. In practice this supplement exacerbated my cramps and diarrhea and I had to stop using it.

The next thing I tried was Metamucil. I had seen it recommended in a number of articles about IBS. Metamucil is a fiber supplement that is typically used daily to prevent constipation. It seems contradictory to take it when your digestive problems are the opposite, namely diarrhea. However it does seem that making sure you have enough fiber in your diet is good for general digestive and bowel health. I diligently took Metamucil for six weeks. While there might have been some slight improvement, it really was not effective enough. 

It occurred to me that perhaps a different sort of fiber might work better for me. Metamucil is psyllium husk but there are other fiber supplements. As I was browsing in the drugstore I found another fiber supplement that was made from guar gum and was advertised to be

Low FODMAP and CERTIFIED for IBS

I grabbed it off the shelf with great hope that this really sounded perfect for me. However it turned out to be a disaster. After 4 days my diarrhea had become worse than ever and I had to discontinue that supplement.

With this lack of success from common sense and my own devices, I turned to modern medicine. The first advice I got from my doctor was to try a stricter diet. He suggested lactose-free, gluten-free, and FODMAP. I tried them all. None led to any big improvement and I could not see any pattern between any particular food and the IBS symptoms.

My next step was a referral to a gastroenterologist. The first thing he wanted to do was a colonoscopy. I wasn’t quite due for another one according to the standard 5 year schedule but I succumbed to the annoying procedure in the hopes of reaching a diagnosis. Fortunately I had a very clean colon, but unfortunately there was no diagnosis. Some gastrointestinal conditions have physical symptoms which can be seen such as diseases like colorectal cancer, colitis, celiac disease or diverticulitis. If a gastroenterologist can’t see anything physical, your condition will generally just be lumped into the category IBS, a catch all to cover everything that modern medicine doesn’t understand yet. The GI guy didn’t suggest any medication or treatment.

So it was back to the drawing board. The Internet has a lot of information but sometimes it’s not easy to find the right information that’s going to help you. Eventually I came across IBS Tales, a website with a wealth of information. It was created by a woman who had IBS for over 20 years and had explored and documented many of its different aspects. One section of the website contained stories from people who have IBS. A lot of these were interesting but it wasn’t easy to draw conclusions from individual cases that would apply to me. The website had recommendations for a number of books. I bought this one, but in the end it did not help me very much.
The First Year: IBS: An Essential Guide for the Newly Diagnosed

The most interesting part of the website for me was the section on Treatment Reviews. In particular there was a subsection for IBS Medications. It had a long list of antispasmodic drugs. It is thought that one cause of IBS is abnormal “motility” in the digestive system. Normally the intestines rhythmically contract and then relax to move food through the intestines. Contractions that are stronger and last longer than usual can cause gas, bloating and diarrhea. Contractions that are weak can slow the passage of food and lead to constipation. Antispasmodic drugs slow the motility of the GI tract by relaxing the muscles in the stomach and intestines.

On a hunch, I decided to try and see if the FDA had approved any drugs for IBS. I soon hit paydirt. I was astounded to discover that there were not one, not two, not three, but four FDA approved drugs for IBS; two for IBS-C (constipation) and two for IBS-D (diarrhea). In my consultations with several doctors, this option had never been mentioned.

After some more digging I hit a gold mine. I found an article in the American Journal of Gastroenterology titled Clinical Guideline: Management of Irritable Bowel Syndrome. It was a review of studies of IBS treatments and provided a list of not only what was recommended but what not was not recommended.

Armed with my new medical knowledge, I made an appointment with the gastroenterologist for a follow up of my case.

In the meeting, I summarized the various things I had tried since my colonoscopy, all without real improvement. Then I asked him about using an antispasmodic drug. He said No he didn’t prescribe them, they were addictive. I had not come across this in anything I had read so I asked “There are quite a lot of antispasmodic drugs, are they all addictive?” 

He didn’t answer. Instead he said “Are you going to read things on the Internet and do your own research or did you come here for my medical advice?” 

I backed off and said No I would like to know what he recommended. He said I should use Metamucil. I replied that I had tried Metamucil and it really didn’t work for me. Then he asked if I used the flavored Metamucil. I said “Yes, I used the orange flavored one.” He said, “That’s your problem. The added sugar prevents Metamucil from working properly. I have a lot of patients using plain Metamucil and they’re all doing well.” 

So I said (dubiously) “Thank you. I will try that.”

At home I checked my Metamucil jar that was still on the shelf. Even though it was orange flavored, it was sugarless. So I don’t know what that sugar theory was. But if this doctor had so many IBS patients doing well with Metamucil, I decided I should give it another try. However to no avail. After six weeks I still saw no improvement.

He did give me one piece of useful advice. He suggested that before going on an outing, if my stomach was unsettled I could use Imodium as a preventative. I had relied on Imodium many times when diarrhea had become severe and it worked very well, but it was not recommended for use on a regular basis. However, using a lower dose of Imodium occasionally as a preventative measure slows the motility of the intestinal tract and it did prove to be helpful, but overuse could lead to constipation.

Then a curious thing happened. I got a cold that lodged in my chest. After seven weeks I got an antibiotic. Five days of levofloxacin cleared up my respiratory infection and it also cleared up my IBS cramps and diarrhea. It must be that the antibiotic had killed certain intestinal bacteria that had been interfering with my digestive system. 

This was a wonderful turn of events and I enjoyed it for about four months. But then my IBS symptoms gradually came back. 

I had pretty well tried all the non pharmacological treatments in the Journal of Gastroenterology IBS guidelines. I felt that the best way forward was to try one of the prescription drugs that was recommended for IBS. Going back to the gastroenterologist surely was a dead end, so I booked an appointment with my family doctor. I extracted the following summary of the pharmacological treatments from the Journal paper to bring in to review with him. He actually hadn’t seen the paper which had been published in 2021 or a very similar paper that had been published in 2019 by the Canadian Association of Gastroenterology.

___________________________________

1. We recommend against the use of antispasmodics currently available in the United States to treat IBS symptoms.
Conditional recommendation; low quality of evidence.

2. We recommend that TCAs (tricyclic antidepressants – amitriptyline, nortriptyline, imipramine, desipramine) be used to treat symptoms of IBS.
Strong recommendation; moderate quality of evidence.
57% improvement vs 36% placebo.

3. We recommend the use of rifaximin (FDA approved) to treat IBS-D symptoms. 
Strong recommendation; moderate level of evidence. 
Most favorable safety profile. 
41% improvement vs 32% placebo but relapses; 64% respond to retreatment.

4. We suggest that mixed opioid agonists/antagonists (eluxadoline FDA approved) be used to treat IBS-D symptoms.
Conditional recommendation; moderate quality of evidence.27% improvement vs 17% placebo.

___________________________________

He thought that treatment 2 would be the best. It had the highest response rate in trials; 57 % of patients had improved and he was familiar with the antidepressants drugs which he prescribed for a lot of patients with depression. 

I said I thought recommendation 3 might be a better option for me. It had a lower success rate in trials, only 41%, but I said that I was pretty sure that it would work for me, because this drug was actually an antibiotic and I had just had success with an antibiotic. In addition the treatment was only two weeks. I would not have to take it every day and it had the lowest risk of side effects of all the recommendations.

So that’s what we did. He wrote out a prescription for rifaximin. After the 14 day course of this antibiotic, my IBS symptoms improved immensely. After almost two years, I could lead a more normal life.

This is not a story that ends by saying “And he lived happily ever after.” People on rifaximin tend to relapse. At that point I will have to decide whether to use it again or try one of the other treatments. At this time IBS cannot be considered an illness that can be cured by a treatment. But there are a lot of options that can make it more manageable.

What is there to learn from this convoluted path of discovery?

First of all, no one treatment works for everybody. Even the FDA approved drugs didn’t work for most people; they worked for less than 50%. In the case of rifaximin, the clinical trial did not show a huge improvement over the placebo group, only 41% versus 32%. However this was enough to be statistically significant and receive FDA approval. 

What this means is that most things that you try will probably not work. You have to keep trying more options until hopefully you find a treatment that works for you. In spite of the many advances in modern medicine, a lot of medicine is really just trial and error, and it can be quite a lot of error.

The second thing to learn is how important it can be to do your own research. It was only after I found the Journal of Gastroenterology IBS guidelines which provided me with the direction to push for a treatment that ended up working for me.

And finally, it’s important to find a doctor that you can collaborate with so that you collectively arrive at good medical decisions.

In August, the respected and influential British Medical Journal (BMJ) published a series of articles investigating the Covid-19 response in Canada. Contrary to the impression of many Canadians that Canada handled the Covid pandemic well, especially as compared to the United States and the UK, the BMJ had a long list of skathing criticisms, and stated in several places that a national enquiry is needed to make sure that important lessons are learned for the future. 

“The picture that emerges is an ill prepared country with outdated data systems, poor coordination and cohesion and blindness about its citizens’ diverse needs. What saved Canada was a largely willing and conforming populace that withstood stringent public health measures and achieved among the world’s highest levels of vaccination coverage. In other words, Canadians delivered on the pandemic response while its governments faltered.”
… The Guardian

“The willingness of Canadians to comply with vaccination requirements and harsh public health restrictions did more to bring Covid-19 under control than the fragmented, deficient and unsavvy response of governments … Canada leads wealthy nations for Covid related fatalities in care homes, despite more than 100 reports and inquiries over 50 years that foreshadowed a nursing home crisis … More long-term care home outbreaks occurred in 2022 than 2020 and 2021 combined.”
… National Post

During the pandemic, many articles in this blog were pretty critical of the decisions and actions taken, and the actions not taken, from public health officials to politicians. The vaccine rollout was particularly chaotic. People scrambled to find out where they could get a vaccination and in the beginning a lot depended on word of mouth. It took Ontario three months to provide a vaccine reservation system, but for weeks it was overloaded and crashed, making it difficult for people to book a shot. In the meantime Doug Ford blamed Justin Trudeau for not delivering enough vaccines. The botched vaccine rollout was a classic case of a series of bad management decisions. The effect was that vaccine distribution was inequitable for many and stressful for everybody. 

Bad Management 1. No planning for a vaccine rollout

By May 2020 it was clear that the results of the phase 3 clinical trials for the Moderna and Pfizer vaccines would be submitted to the FDA by December 2020 and that with fast track approval, vaccines would be ready to ship in January 2021.

Neither the federal nor provincial governments began any serious planning until vaccine deliveries were confirmed in December.

Here is a revealing interview that makes this clear. One week before the first batch of vaccines were due to be delivered, the CEO of UHN, which was the first vaccine distribution center for Toronto, had only a few vague answers but no answers for a lot of key questions that should have been planned many months before.
“How will we make this logistically work?”
“Healthcare workers have been really busy, do we have the right people?”
“We have not been told anything about the next batches of vaccines.”

Bad Management 2. Poor selection of leaders

The Trump administration appointed F. Perna, a four-star general and a logistics expert, as the chief operating officer of “Operation Warp Speed”. The thinking was that the major challenge of the vaccine rollout was the logistics to move vaccines from suppliers to vaccine centers and that military people had the experience with these kinds of logistics. Canada followed suit as did Ontario. 

At the end of November, about one week before vaccines were due to arrive in Canada, Trudeau appointed Major-General Dany Fortin, a former NATO commander in Iraq, to head up the Federal vaccinations task force. A short time later, Doug Ford appointed former head of the Canadian Armed Forces, General Rick Hillier, to lead a new task force to oversee the rollout of the Covid-19 vaccines in Ontario. 

What shallow thinking. Using large military aircraft to move military equipment and thousands of troops across the globe is a logistics problem that is quite different from shipping boxes of vaccines from a handful of suppliers to a few vaccination centers across the country. The “logistics” of shipping vaccines from suppliers to vaccination centers is the easiest part of the overall vaccination distribution. The challenging part is how to get the vaccines from vaccination centers into the arms of millions of people. Who was going to administer the shots? Nurses were overloaded with Covid cases in the hospitals. Would additional people be recruited? Who would train them? How would people get their vaccinations? Would they line up for hours in ad hoc locations such as community centers or would modern technology be used so that people could reserve in advance at a time and location of their choosing? What about the many people who couldn’t use the Internet? Would there be enough phone lines and people to answer the phones to provide information and help people book a reservation?

The high rank military generals had many years of experience in the military but no significant experience working in civilian life. The values and orientations of the military focussing on preparing for battle or securing defensive positions is quite different. This was clearly born out when General Hillier suspended the vaccination program in Ontario in December 2020 so that people could enjoy their holiday season. He clearly did not understand the urgency that civilians wanted to proceed with vaccinations as quickly as possible. A pause in vaccinations was as absurd as firefighters leaving a five alarm blaze for a lunch break. The public outroar was furious and Hillier had to walk it back quickly, issuing an apology and promising not to take off any more days in the vaccine rollout. Hillier resigned three months later. He was replaced by someone with a medical background, Homer Chin-nan Tien, the president of the air ambulance service Ornge.

In spite of the grandiose statements about the expertise of the Canadian military, there seems to be only one case of military planes being used, to deliver 5 freezers for Canada’s North. 

On the other hand there were many interviews and photo ops with the Minister of Procurement Anita Anand on the tarmac meeting large cargo planes arriving with vaccines. They were always FedEx planes.

Lessons Learned?

“Lessons from the outbreak of SARS-CoV-1 in 2003 which impacted Canada more than any other country outside of Asia went unheeded and left the country’s governments and health authorities ill prepared for Covid-19. An independent, national inquiry is needed to review Canada’s Covid-19 response, draw lessons, and ensure accountability for the past and future pandemic preparedness.”
… British Medical Journal

There is no commitment or announcement from the Canadian government to undertake such an inquiry. 

Is Canada going to learn from the lessons of history, or is  Canada doomed to repeat history, again?

There have been scattered reports about increasing Covid cases. As explained in the previous blog article, case counts are unreliable now so hospital admissions are the best statistic to watch. This statistic shows a 15% uptick in August 2023 in Canada and a 24% increase in the U.S.

Hospitalized Covid patients Canada  

Daily Covid hospital admissions U.S.

A rapidly rising Omicron subvariant EG.5 (“Eris”) which is circulating in many countries was designated as a “variant of interest” by the World Health Organization (WHO) on August 9, 2023. It is now becoming the dominant variant in the U.S.

Variant Proportions

EG.5 is a variant in the XBB branch of Covid mutations which have been the main variants in circulation in Canada and the U.S. since they started to spread rapidly in January 2023. XBB is a mutation of the Omicron variant. The original Omicron variant is no longer in circulation.

Covid-19 Mutations

However, Pfizer and Moderna are developing new vaccines that target these Covid subvariants.

It’s generally recommended that you don’t get a Covid booster until 6 months after your last booster or Covid infection, whichever is later. If you are due for a booster, it is probably better to wait for the new Covid vaccines which promise to be more effective against the current variants that are circulating. While Pfizer and Moderna expect to have their new vaccines ready by September, with the typical delays in getting approvals they likely will not be available until October.

On the vaccine front, more exciting news than the improved Covid vaccines is the new vaccine for RSV. 

RSV is Respiratory Syncytial Virus, a common respiratory virus that causes cold-like symptoms. It is seasonal lung infection, a common childhood illness that can also affect adults. Most cases are mild and last only 3 to 7 days but a severe infection can lead to pneumonia.

RSV is highly contagious. After an infected person sneezes or coughs, you can get the airborne virus through your eyes, nose or mouth. RSV can survive on hard surfaces so if you touch something like a counter or a toy that has the virus on it and then touch your face or mouth, you can get infected. 

Severe RSV can be unpredictable and is the leading cause of hospitalization in infants. Adults 65 and over and adults with chronic conditions or weakened immune systems are at high risk for developing severe RSV.

Autumn 2022 saw a surge in RSV cases in children and adults. It was a “tripledemic” year of RSV, Covid and influenza. This pattern is expected to repeat in Fall of 2023.

But … 

A new vaccine for RSV has just been approved!
(FDA May 2023, Health Canada August 2023)

The clinical trial results for the RSV vaccine Arexvy were pretty impressive:
82% efficacy in preventing lower respiratory tract disease caused by RSV and efficacy of 94% in older adults with one or more underlying medical condition.
Health Canada approves RSV vaccine

This is the first vaccine for RSV after decades of research. Scientists started working on a vaccine soon after RSV was discovered in 1956, but some disastrous clinical trials in the 1960s that led to the deaths of several children and more failed attempts later stymied progress for years.
RSV vaccines are finally here

With the onset of winter 2024, we could be heading into another tripledemic year of seasonal respiratory illness, but you can counter that with triple vaccinations – flu, Covid and RSV. To get an RSV vaccination, contact your doctor.

News about Covid and the pandemic have been out of the headlines for months. The last post on this blog was August 2022. There are still plenty of people getting sick with Covid and dying but cases have generally been declining. It has become more difficult to get statistics. A lot of organizations and websites that used to update information daily stopped carrying Covid news. Case counts became unreliable in 2022 since many people were not being tested and public health does not have a record of those who test at home with a rapid test kit. The most effective way to gauge the spread of Covid is through hospital admissions and death counts, statistics that are backed by records and are fairly reliable. 

In the US, the New York Times still maintains a fairly comprehensive  Covid page with national graphs and statistics and breakdowns by state. Their summary page shows the strong downward trend in daily Covid hospital admissions after a bit of a winter peak in January 2023. Note that the breakdown by ages shows that the rate for people 70+ is four times the daily average for All ages.

Track Covid-19 in the U.S.: Latest Data and Maps

In Canada I’ve relied on Public Health Ontario for hospital admissions and death counts (other provinces may maintain similar statistics). The weekly hospital admissions in Ontario for the last year shows a strong downward trend.

https://www.publichealthontario.ca/en/data-and-analysis/infectious-disease/covid-19-data-surveillance/covid-19-data-tool?tab=tren

Covid was back in the headline news recently. On May 4, 2023 the World Health Organization WHO declared that:

Covid-19 is over as a global health emergency. Even though worldwide, someone dies of Covid every three minutes, the downward trend of the pandemic with population immunity increasing from vaccination and infection, mortality decreasing and the pressure on health systems easing has allowed most countries to return to life as we knew it before Covid-19. This means that it is time for countries to transition from emergency mode to managing Covid-19 alongside other infectious diseases.
WHO declares end to Covid global health emergency

Although the WHO declaration just confirmed what many countries had been doing in reducing various health and financial supports for the pandemic, the timing of this announcement proved to be very ironic for us. About a week later, after having stayed healthy throughout the whole pandemic, we succumbed to a Covid home invasion.

Covid Case 1

On the evening of Mother’s Day May 14, my wife N said she had a bit of a sore throat. The next day it was more persistent, but without additional symptoms it did not warrant doing a Covid test. However, the following day she woke up with a really congested sinus, a headache and she was very tired. A rapid test revealed that she was positive for Covid. N was up to date on her Covid vaccinations but “breakthrough” cases of the Omicron variant that infected vaccinated people had become common and was a big part of the reason that there was a large Omicron wave in the winter of 2022.

The incubation period for Omicron is 2.5 – 4.6 days. Counting backwards this number of days from Sunday night, the most likely event that would have exposed N to Covid in that period was the day that she had returned to an in person class. With the decreasing Covid cases we felt that it was safe enough to attend more in person events after three long years of zooming.
COVID-19 Omicron Variant of Concern and Communicability

It was still very early in the Covid infection cycle. Because of her age N would qualify for an antiviral, which must be given within 5 days of the first symptoms to be effective. She called up our local pharmacy and after a short screening questionnaire with the pharmacist, she was approved for Paxlovid. It was ready for pick up in an hour. 

Paxlovid was developed by Pfizer in record time based on some earlier work they had done on SARS (severe acute respiratory syndrome), the 2003 outbreak that was caused by a new coronavirus. They were convinced that a protease inhibitor would prevent a coronavirus from replicating. They synthesize hundreds of unique chemical compounds and then tested them against the Covid virus in the lab.
How Pfizer developed a COVID pill in record time

The clinical trial that supported the FDA approval for Paxlovid in Dec 2021 had an 89% reduction in the risk of hospitalization and death in unvaccinated people. A later real-world study showed that people who received Paxlovid had a 51% lower hospitalization rate.
Paxlovid Associated with Decreased Hospitalization Rate Among Adults with COVID-19

N got a package of Paxlovid, 3 pills taken twice a day for 5 days. In a few days she began to feel better and the Covid symptoms were less severe, but there were side effects from the Paxlovid. She found it hard on the stomach and had some back muscle pain.

Covid Case 2

N had started to self isolate. She confined herself to the bedroom and her office and used other rooms, like the kitchen, wearing a mask and only when no one else was there. We also opened windows in most of the rooms for improved ventilation. I moved out of the bedroom into the spare room but it was all too little too late. Omicron is incredibly contagious and two days after N had tested positive I woke up with a headache and a real cold. As expected, I tested positive for Covid.

I am immunocompromised and so at high risk. My immune system is compromised and not as effective in detecting and attacking disease as in a person who has a well functioning immune system. 

There are many different reasons that someone may become immunocompromised. In my case it’s because I have multiple myeloma, a blood cancer. Although it has been well controlled with different medications over the years, the cancer as well as the treatments suppress my blood counts and my immune system. Most of my levels in a complete blood count (CBC) are below normal, from red blood cells to white blood cells, as are all of the important components of the immune system, from B cells to T cells. Although blood cancer patients are severely immunocompromised, the people who are most severely immunocompromised are transplant patients who have to take immunosuppressant drugs to prevent their immune system from attacking the foreign transplanted tissue. 

Immunocompromised people are more susceptible to all kinds of infections. People with blood cancer do not die from the cancer itself. Generally they die from an infection that overwhelms their immune system. Even pneumonia which a normal person can recover from, perhaps with the help of an antibiotic, is the cause of death for many people with blood cancer.

In addition, people who are immunocompromised do not mount a very strong immune response to the Covid vaccine. A vaccination is not an injection of antibodies that will then protect you from disease or infection. Rather, a vaccination is designed to stimulate your immune system to produce antibodies which are created by white blood cells and then circulate in your blood to attack a specific virus. With a weak immune system you don’t generate very many antibodies. After my fourth Covid vaccination I got a blood test to measure my level of Covid antibodies and it was lower than most people had after only their first vaccination. So for all intents and purposes I had been negotiating the coronavirus pandemic as an unvaccinated person. 

I checked in with my hematologist at Princess Margaret Cancer Center and she directed me to the hospital Covid Clinic. A telephone screening with a nurse practitioner recommended remdesivir, the second of the two Covid antivirals available in Ontario, because the blood thinner that I take for atrial fibrillation (afib) was a contraindication for Paxlovid. Remdesivir also had impressive clinical results, reducing the risk of hospitalization by 87%. It has fewer side effects than Paxlovid, but it can only be given as an intravenous (IV) infusion over 3 days.

Remdesivir was originally developed to treat hepatitis C and was subsequently investigated for Ebola virus disease. It wasn’t very effective for either of them.

In 2007 Dr. Mark Denison discovered that coronaviruses have a “proofreading” system. He and some other experts thought it might be possible to trick a virus with a drug that dodged the proofreading system and blocked the virus’s growing RNA chain, making it terminate prematurely. Denison learned that Gilead Sciences had dozens of drugs that might do this. In a series of lab tests, most worked to shut down coronaviruses. One of the best was remdesivir. “I like to call it the Terminator,” Denison said.
How Remdesivir, New Hope for Covid-19 Patients, Was Resurrected

With the COVID-19 outbreak spreading rapidly and a lack of alternative therapeutics, the first clinical trials using remdesivir were begun in China in February 2020. As Covid-19 began to grow into a pandemic, many scientists realized that remdesivir might be the best solution at hand. It had already undergone animal testing and safety testing in humans. So doctors began giving it to patients in studies without controls and even outside of studies altogether. Anecdotes fueled demand. Gilead sponsored some of these studies and gave the drug to doctors who treated hundreds of patients under compassionate use, a legal exemption permitting use of an unapproved drug to treat patients. In May 2020 the FDA issued Emergency Use Authorization (EUA) for remdesivir.

Gilead had flown their entire stock of remdesivir left over from Ebola research to its filling plant in California in February. They began working on restarting remdesivir production in their manufacturing plant in Edmonton and finished the first new batch of remdesivir in April 2020.
Gilead Drug Remdesivir: Rare Example of Foresight in the Pandemic

Full FDA approval for remdesivir was given in Oct 2020, the first drug approved for Covid. However clinical trial results were not that strong and some trials did not show any real benefit. The approval of remdesivir was very controversial.
The bad look of remdesivir, the first FDA-approved COVID-19 drug

In January 2022 the FDA expanded the indication for remdesivir to include its use in non-hospitalized adults. Used much earlier in the Covid infection cycle instead of only with patients sick in hospital, remdesivir had impressive clinical trial results comparable to Paxlovid, reducing the risk of hospitalization by 87%.
FDA Takes Actions to Expand Use of Treatment for Outpatients with Mild-to-Moderate COVID-19

To get started on my remdesivir infusion, the nurse said she would get someone to call me to make arrangements. I received a call back a short time later from an administrator who said there were two hospitals in Toronto where I could go. The closest one had time slots for the following morning. I was a bit flabbergasted; in a large city the size of Toronto that has about 30 hospitals, were there only two that were able to deliver a simple intravenous infusion? 

I was anxious to get started as soon as possible so I told the administrator that the second hospital was not that much further and I would prefer to go there if I could get started that day. She called back a little while later and said that this second hospital did not have any openings until the following day but she had found out that the first hospital would be able to take me if I could get there in an hour. I replied that it would be no problem. I had just finished my lunch and so I headed out. 

I drove down to Women’s College Hospital in downtown Toronto in good time. The hospital had had a major reconstruction a few years earlier and it looked like a gleaming new, modern facility. It had the best parking of any hospitals I’ve ever been to; right in the building with a short elevator ride up to the main lobby. I went to the Ambulatory Care Clinic. It was very quiet. I didn’t have to wait too long to be shown into a treatment room. On my way down the hall I saw only one other patient and otherwise not a soul. This was really kind of unexpected. The Canadian news had been full of reports about the shortcomings of healthcare budgets and services for many months. Yet here was this practically brand new hospital that seemed kind of empty. Were people having trouble finding this hospital? It was around a quiet corner on a small back street but it wasn’t that hard to find.

A nurse came in dressed in full PPE (Personal Protective Equipment) with gown, mask, visor and gloves. She gave me an information sheet on remdesivir and explained the procedure. It was going to be a 1 hour infusion followed by a 30 minute flush and observation for side effects. She proceeded to set up the IV, a small plastic tube, a catheter, that is inserted into the vein with a sharp needle. Then the needle is removed with a quick spring release, leaving the catheter inside the vein. After flushing the line with saline solution to make sure that fluid will flow through the line into the vein, she connected the valve at the end of the catheter to the tubing that was connected to the bag of fluid containing the medication on an IV stand. 

Meanwhile a young doctor came in to see if I had further questions. I asked if they had been administering remdesivir to many patients. She said that they were not very busy and in fact many of their Covid activities were being curtailed or shut down as budgets for Covid were expiring and were not being renewed.

I lay back on the bed waiting for the nurse to come back and start the infusion. When she returned she apologized for the delay and said that their pharmacy no longer prepared this drug so she had to mix it herself and it took some time for it to dissolve properly. After checking my vital signs – temperature, blood pressure, oxygen – she started the infusion. 

During this time I received a call from Home Care to arrange the next two infusions as they would not be done in the hospital. I had initially been told that because of budget cuts Home Care would not actually come to your home if you are ambulatory and instead you would have to go to a public health care clinic. However, when I spoke to them to confirm a time, they informed me that in fact for this treatment they would send out a nurse to my home. We arranged a time for the following afternoon. 

When the infusion and flush were completed, the nurse removed the tubing but left the IV line in my arm and wrapped it carefully in gauze so that it could be used again on subsequent days without having to do another needle insertion. Even though I had basically been lying in a bed for a couple hours and actually dozed off a few times, I was pretty tired. I was lucky to just miss the peak of rush hour on my drive back home. When I walked in the door it was almost 5 hours since I had left for the 90 minute treatment.

After a real nap, when I got up there was a message on my phone. It was from some pharmaceutical company who said that they would be delivering medical supplies that evening up until 11:30 p.m. At 10:00 p.m. I was pretty tired and ready for my night time sleep. I turned on the outside light and asked N to wait up and answer the door for the medical delivery. 

The next morning when I woke up I was feeling about the same. I wasn’t really expecting to see a big improvement after just one treatment but at least I wasn’t feeling worse. I hoped that was an indication that the Covid infection was not advancing. I did have a little more chest congestion but I think it was an overnight accumulation. I took some Robitussin Cough Control which was quite effective in loosening some of the mucus and phlegm buildup in my chest and later in the morning I started to feel a bit better.

Downstairs I found that three packages had arrived. One box had the medicine, one box contained all kinds of hospital equipment: syringes, various types of intravenous lines, alcohol cleaning pads, packages of sterile gauze and various other items. Wrapped up in a long package was what I guessed was the IV stand, a pole to hold the IV bag.

In the afternoon the nurses arrived in full PPE dress. It was actually two nurses because one was in training. They came into my office room and checked all the medical supplies that had arrived. Everything seemed to be in order. 

I asked the nurse if she had administered remdesivir before. She said no but the instructions were pretty straightforward. She took the bottle of remdesivir and extracted it into a large syringe and verified the volume. Then she added another liquid into the syringe and finally injected the contents of the syringe into an IV bag that was prefilled with saline solution. Unlike what I understood had been done in the hospital, this drug was mixed from liquid not from a powder and so there was no waiting time for it to dissolve. 

Meanwhile the nurse trainee had set up the IV pole. It was a simple pole that was made from cardboard, the kind you find on the inside of a roll of paper towel or toilet paper, but somewhat heavier. It was designed to be disposable so that after being used in an environment where there was an infectious disease such as Covid, it could be easily and safely discarded. 

After setting up the tubing and connecting it to the IV line in my arm, the nurse simply adjusted the valve for the right drip amount. Unlike an IV in the hospital, this IV had no pump and it was going to work strictly by gravity feed. That’s the reason that I think that the IV pole was so high.

Here’s a picture of my private hospital with my two nurses in attendance.

On Sunday I woke up with a lot of chest congestion. After using the Robitussin again and coughing up a fair bit of phlegm I felt that most of my symptoms had distinctly improved. For the first time since testing positive I was feeling better. However my breathing was somewhat labored, like a mild wheezing without any sound. And I had shortness of breath after walking up the stairs. 

I knew that people with Covid could have a sudden drop of oxygen which was a sign that you might need to go into the hospital for medical assistance such as oxygen. I got out my pulse oximeter and clamped it on my finger. It quickly climbed up to 95% oxygen. No worries there.

Should You Use a Pulse Ox When You Have COVID-19?

Then I got concerned that the Covid virus may have now reached deeper into my lungs and that it was affecting my breathing. I was really in a classic race condition. This chart shows the race between the Virus and the Antivirus. In this model the Antivirus is the combination of Covid antibodies (which are very low in my case) and the antiviral drug remdesivir given on Days 3, 4 and 5. The Virus was replicating and the Antivirus was attacking it and reducing its ability to grow. This was my last day of remdesivir. Would the drug continue to work after today? If not, the Virus could win the race. This picture did not look promising.

(The numbers on the left axis are not real world measurements of Virus or Antivirus levels, they are abstract numbers used in the spreadsheet to show this chart.)

On the other hand, vaccinated people with healthy immune systems might do just fine in this scenario. Their immune systems responded to vaccinations and prior Covid infections and generated a higher level of Covid antibodies that circulates in their blood when Covid is first contracted. The combination of higher Covid antibodies with the antiviral drug on Days 3, 4 and 5 is enough to kill off the virus.

So a critical question was “How long would remdesivir remain in my body and continue to have antiviral benefits?”

I did some Google searches and could not find a clear answer to this. However there were some articles that said the half-life of remdesivir was about an hour. That was worrisome; it didn’t seem like that would be long enough to win the race against the virus.

To get a better answer I did what I have been doing for the last few months when I did not get a good answer from Google search for more complicated questions. I posed the questions to ChatGPT. It gave a very good explanation and reassured me that remdesivir would probably work long enough for me to recover.
____________________________________________

Question: How long is remdesivir active in combating Covid after infusion?

Answer: Remdesivir undergoes a process called intracellular metabolism, where it is converted into its active form which works by inhibiting the replication of certain viruses, including the SARS-CoV-2 virus responsible for COVID-19. It is incorporated into the viral RNA chain during replication, leading to premature termination of viral RNA synthesis.

The half-life of remdesivir is relatively short, averaging around one hour in plasma. However, the drug’s effect on combating COVID-19 extends beyond its half-life. Remdesivir’s antiviral activity is primarily driven by its active metabolite, which has a longer half-life and remains in the body for a more extended period.

The exact duration of remdesivir’s activity in combating COVID-19 after infusion is not precisely defined. However, clinical studies have shown that the drug’s beneficial effects can persist beyond the treatment period. It is believed that the active metabolite continues to exert its antiviral effects on viral replication even after the infusion is completed.
____________________________________________

In the afternoon my nurses arrived for the final infusion. They were now experts at it. In no time the head nurse had mixed the remdesivir and set it up on my IV pole. It was again scheduled for a 1 hour drip. The nurse said they had quite a number of calls that day, about 19, and she wondered if I would be able to remove the IV line by myself at the end. I had done this in the past so I said OK so that they didn’t have to wait around for an hour. I bid them goodbye as they went off on their next mission to provide home service for people in need. I thanked them profusely and told them what a great service it was. 

When the drip stopped I took the bag and tubing off the IV stand and brought it over to the sink in the bathroom. I got N to press a piece of gauze over the insertion point while I removed the holding tape and pulled out the line. There was a big squirt of blood into the sink. I got a large fresh piece of gauze and put it in a better location, applying enough pressure to stop the bleeding. My arm was pretty bruised around the vein after having been in place for three days and used for three infusions. But that was a pretty minor inconvenience, all things considered.

Later on I gathered together all the leftover medical supplies that had been delivered. Even after allowing for spares for each item, there was a huge amount of extra, most of which hadn’t even been needed. This all had to be thrown into the garbage. Even though most were in protective sterile packaging, a clinic or the pharmaceutical company wouldn’t take it back, especially since they had been in a house infected with Covid. The pharmacy had an exact order of what I needed for two infusions. Why they packed so much extra into the box is beyond me. This was just another example of terrible waste in our medical system. Here’s a picture of all the extra medical equipment that had to be dumped into the garbage.

The following day I had a follow-up phone meeting with the nurse practitioner at the Covid Clinic. I reported that most of my original symptoms had improved and she seemed to think that I was doing pretty well. I told her my concern about the new difficulty breathing. She said that it was likely due to the inflammation that had been caused by Covid infection in the lungs. I asked if ibuprofen, which I’ve always found to be the best medicine to combat inflammation, would help but she said she didn’t think so and that I would just recover with time. Overall she did not seem to be too worried about my case and just scheduled another follow-up call for the end of the week.

As the week progressed, I seemed to be getting better each day. I still had some chest congestion accumulation overnight but it usually cleared without resorting to Robitussin. My breathing wasn’t fully back to normal but I knew from a past bout of pneumonia that lung infections are a slow recovery process that can take a month or two. 

However I didn’t know if I was out of the woods. Many people who had Covid have reported “Long Covid”, symptoms that persist for three months and more. 

Statistics Canada reported that nearly 15% of people who contracted Covid after Dec 2021 experienced lingering symptoms such as fatigue, shortness of breath or brain fog three months or more after their initial infection. This was a marked improvement from earlier in the pandemic when 25% of people who had Covid reported symptoms three months after their infection. It seems that the likelihood of Long Covid increases with the severity of the initial infection. Only 6% of those who rated their initial case as mild came down with Long Covid.
What studies reveal about long COVID

Not a lot is known about what causes Long Covid or how to treat it. Research is being done but there do not seem to be very many conclusive results that lead to reliable treatment as of yet.

On my phone call at the end of the week with the nurse in the Covid Clinic, I asked about my risk for Long Covid. She said that I didn’t fit the profile. I was showing distinct improvement while people with Long Covid don’t get better at all. I was still concerned about relapse since my Covid antibodies are so low. She said I wouldn’t likely get reinfected by the same Covid virus that was still circulating in our house as we were recovering. There was a risk of reinfection from a different Covid variant but that would have to come from the outside. 

The guidelines for self isolation for immunocompromised people were to stay at home for 10 days and until your symptoms were improving for at least 24 hours. I now met these conditions. It was the weekend and finally some nice, sunny weather after a rather long winter and dreary spring. Open Doors Toronto was on and we went out to see a few buildings of interest: the Ismaili Center which is adjacent to the Aga Khan Museum and the Canadian Film Institute which is the old estate of E. P. Taylor. It was nice to get out like a normal person.

News of the pandemic and Covid-19 cases have dropped off the front pages and largely out of the news for most of the last several months. You would think that the pandemic has passed and that not very many people are getting sick or dying.

However, if you look at the daily death rate from Covid in August, you’ll see that Covid deaths greatly outnumber deaths from automobile accidents and guns. 

You can quickly see the Covid case counts in your area by clicking on the Layers icon in Google maps and  selecting “Covid-19 Info”. Here’s the map for the New York City and New Jersey area, showing several counties in red that have high case counts (this feature is not available for Canada).

Google map with Covid-19 cases

However, case counts are no longer a very reliable statistic for understanding the exposure risk in your area because Covid testing is not as widespread as it was in the beginning of the pandemic. One of the best indicators to see the extent of Covid is the number of hospitalizations.

Daily Covid-19 Hospital Occupancy in Ontario

The above chart shows the basis for the declaration on August 5th that Ontario’s 7th wave of COVID-19 peaked.

So you still need to be careful about getting infected with Covid, especially if you are elderly or have any health issues. The best protection is still from a Covid-19 vaccine. But vaccines generally wain after 5 months, so if you are approaching that time since your last vaccination or booster, you should be considering getting another shot.

Quebec announced that it will be providing 5th doses of Covid vaccines in August.

However all existing Covid vaccines were developed to combat the original virus. That virus has not been in circulation for a long time. Currently almost all cases in Canada and the US are Omicron variants. Pfizer and Moderna have developed a new vaccine that specifically targets the Omicron variant. This vaccine will be a lot more effective than the current vaccines.
https://globalnews.ca/news/8959603/moderna-seeks-approval-canada-bivalent-boosterd-booster/

However it is not clear when this vaccine will actually be available. So should you proceed with a 4th or 5th dose of the current vaccine or wait for the new one?

The following article suggests that you should get a 4th or 5th shot if you have not received a vaccine or recovered from a Covid infection in the past six months, because your immunity has probably waned.

However, if you have received a booster shot in the past and are under 50 without any underlying health conditions or have recovered from a Covid infection you can wait for the Omicron-specific booster.

https://www.nytimes.com/article/covid-omicron-booster.html

The Omicron BA.2 variant is steadily increasing as a proportion of all cases and is dominant in some regions of Canada. This has started a sixth wave in Quebec and Ontario. The rest of Canada will follow soon. The same signs are not as strong in the U.S. right now but will likely follow this same pattern that started in Europe In January.

Here is a frank report by Colin Furness who doesn’t dance around to avoid criticizing government policy but tells it like it is. 

“There’s no doubt a sixth wave of Covid-19 is sweeping across Ontario being driven by the highly transmissible BA.2 subvariant. At the same time restrictions have been lifted. We’ve opened the doors to a new variant, then eliminated all of our defenses.”
Sixth wave in Ontario driven by lifting restrictions

Like most of the other pandemic waves Doug Ford ignored the recommendations of doctors and his own Science Table and implemented controls too little and/or too late or controsl that didn’t make sense (such as closing playgrounds!) because of his own political reasons, ignoring the principles of public health safety.

As any dummy with two eyes or even one eye can see, even though the number of hospitalizations in Ontario have come down a lot from the peak on Jan 23, the current number of people in hospital is still quite high and has started to go back up. 

Removing the vaccine mandate was not actually a bad decision. The Omicron variant can inhabit the nasal passages of people who have been vaccinated. They might not get very sick with Covid or even know that they are infected but they can still pass on the virus to others. The rationale for a vaccine mandate was to provide safe spaces for people who were vaccinated where they could congregate with a low risk of being exposed to the virus. Since people can now catch the virus from other vaccinated people, a vaccine mandate no longer offers the same protection.

However, ending the mask mandate was really a bad decision. There is not a single doctor who agrees with this Ford government policy. .Masks are your last line of defense as summarized in this diagram from an earlier blog. 

Everyone who cares about their health should be using a K/N95 mask for maximum 83% protection as summarized by the results in this recent study.

I have pointed out the shortcomings of public health and government policies on many occasions. Many doctors have also been critical of the poor decisions that have been made and recommended actions based on medicine and science. That is what one would expect. However, it seems that under the Ford government, political pressure has been used to “shut up” doctors who are too critical. When people hear about this type of suppression in China and Russia, they are incensed. So how can it happen here?

This is another dimension of how badly Ford and his government have handled the pandemic. At 8:17 in this video the doctor reveals that Doug Ford called the CEO of his hospital to complain about the medical facts that the doctor was saying to warn people. The doctor was soon fired from his role as Director of Critical Care at his hospital.
How politics muzzled a doctor.