White House physician Sean Conley (R) gives an update on the condition of US President Donald Trump, on October 3, 2020, at Walter Reed Medical Center in Bethesda, Maryland.

Brendan Smialowski | AFP | Getty Images

President Donald Trump‘s doctors are using almost every drug in the Covid-19 arsenal to treat him, worrying some physicians that they might be going overboard because he is a VIP. 

Trump’s team of doctors at Walter Reed National Military Medical Center said over the weekend that the president has taken Gilead’s antiviral drug remdesivir, Regeneron‘s antibody cocktail and the steroid dexamethasone in the past few days to treat his case of coronavirus.

The president could very well be the only Covid-19 patient to receive all three treatments, Dr. Leana Wen, former Baltimore health commissioner, said. She added it could be due to a medical phenomenon known as “VIP syndrome” in which the pressure to treat high-profile patients could lead to experimental treatments and potential errors.

‘Overtreated’

“Having worked at the ER, I’ve certainly treated a number of individuals who would be considered VIPs,” said Wen, an emergency physician and public health professor at George Washington University. “These patients expect to receive the best treatment, but often that results in them becoming overtreated, and there is a risk to that.”

The newest drug given to Trump is Regeneron’s experimental monoclonal antibody treatment, which has only been given to a few hundred patients in a clinical trial so far and has not yet been authorized by the Food and Drug Administration for use in any patients. Early last week, Regeneron said the treatment improved symptoms and reduced viral loads in nonhospitalized patients who have mild to moderate Covid-19. That was based on results for the first 275 nonhospitalized trial patients. 

But the average age of patients in that trial was 44, Regeneron said, far lower than the 74-year-old Trump. The company said it continues to test the drug for the treatment of hospitalized patients and for the prevention of infection in people who have been exposed to a patient.

While antibody cocktails have long been used to treat other infectious diseases and doctors have seen them as a promising potential treatment for Covid-19, every drug has side effects, Wen said. She added that there’s no research into how this drug interacts with the other treatments the president has received, which could raise more questions about how effective and safe the treatment regimen is. 

The use of the steroid dexamethasone raises questions as well. The cheap and widely available drug has been found in clinical trials to reduce the risk of death for severely sick Covid-19 patients. But it “may increase the risk of death when administered to patients with non-severe” cases of the disease, according to the World Health Organization.

“There isn’t a clear reason for us to believe that there is some untoward interaction that they have with one another,” Wen said of the various treatments. “But it is a question to be raised: Do we want to be using experimental therapies on the president of the United States?”

‘Maximizing’ care

Trump’s physician, Dr. Sean Conley, vowed Saturday that he and his team are “maximizing all aspects of his care, attacking this virus in a multipronged approach.” 

“This is the president and I didn’t want to hold anything back,” he added. “If there was any possibility that it would add value to his care and expedite his return, then I wanted to take it.”

Conley is treating the president along with a team of doctors at Walter Reed. But Wen pointed out that just as more drugs do not necessarily mean better care, more doctors do not always make for the best strategy.

“VIPs usually have many doctors tending to their care, including many different specialists and people who would claim that they are the individual in charge of the patient’s care,” Wen said. “And so when you are attending to that patient, the coordination is rather challenging, too.”

‘Risky’

Dr. Lewis Kaplan, president of the Society of Critical Care Medicine and a surgeon at the hospital of the University of Pennsylvania, said VIP syndrome occurs when “the usual process of care is derailed.”

It’s difficult for him or any outside doctors to assess whether this is what’s happening to Trump since some question whether the White House has accurately relayed information on his condition, Kaplan said. If Trump is severely sick, he said, perhaps the treatments make sense, but if the president is quickly recovering, he may have been overtreated.

“This could mean he’s a lot sicker than what has been portrayed or it could be that this is a judgment based upon him being the sitting head of state. We just don’t know,” he said, adding that “we don’t really have any evidence for the melange of this particular brew. It may be perfect. It may not be right. We just don’t know.”

Kaplan stressed the importance of well-designed clinical trials that produce hard data and evidence on the safety and efficacy of drugs. He added, however, that trials do not always reflect the real-world situation of treating a patient and that it’s not uncommon for doctors to use drugs “off label.” The use of drugs like Regeneron’s antibody cocktail could be an extension of that kind of thinking, Kaplan said, adding that he doesn’t think that’s the best way to go about treatment.

“It’s risky,” he said. “And if he’s not that sick, or he’s not in the ICU on lots of supplemental oxygen, he doesn’t need to be mechanically ventilated, it makes you wonder why, because I don’t understand.”

‘Ironic juxtaposition’

The president’s appetite for experimental drugs is well documented. Earlier in the pandemic, Trump publicly pressured the FDA to approve hydroxychloroquine’s use on an emergency basis. Prescriptions for the 60-year-old medication surged 2,000% in March, but later studies found that it was actually hastening death in some patients and the FDA pulled its emergency authorization in June.

Trump, who once publicly asked whether Covid-19 patients could be injected with disinfectant to treat the disease, has not been prescribed hydroxychloroquine.

“The person who has a chute belief in science is now in the midst of receiving science-based therapeutics. That I find to be an ironic juxtaposition,” Kaplan said. He added that perhaps if the drugs benefit Trump, he may be “like the recent convert,” who develops a stronger belief in science.

“That would be the most wonderful outcome from this interesting combination therapy, which may or may not be perfectly warranted,” Kaplan said.

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