March Newsletter
In This Issue
Does Having Diabetes and Hypertension Increase Risk?
Fake Tests
Protect Yourself
A Better Model of Medical Care
Old-fashioned medicine with 21st Century convenience and technology
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Welcome to the March newsletter. The goal of this newsletter is to prove information and analysis of timely topics from recent articles published in the medical literature. I hope you find this information useful and helpful in your health journey.   
We are stuck in the all coronavirus (or COVID-19 disease caused by SARS-CoV-2) all the time world whether we want to be or not. I have been looking at putting out my newsletter for several days now but have found it difficult because things are changing so quickly. In 10 days we have gone from no restrictions to a "safer at home" status with the governor ordering all of us to stay home and closing all "non-essential" businesses. Most of us are confused and a concerned both on health related and economic related terms. I will try to give you some of my take on things as they stand at this point and offer some tips that you can do to protect yourself and your loved ones.    
Why are we so worried about this? From the CDC: "This is a novel virus and there is much more to learn about transmissibility, severity, and other features associated with COVID-19. Unlike influenza, there is no vaccine to protect against COVID-19 and no medications approved to treat it. And there's essentially no immunity against this virus in the population because it's a new virus. Mortality for COIVD-19 also appears higher than for influenza, especially seasonal flu - so it's important that everyone do their part to help respond to this emerging public health threat."  
The issue is that we don't know much about this virus. It is more contagious than influenza. It appears to be more deadly in the elderly and people with chronic health problems, but less deadly than influenza for children. Will it be more deadly than influenza overall? It is thought that it will be, but we may never know the true numbers as there are many people who have mild symptoms and may not even know they ever had it.  
I'll start with some statistics for the 2019-2020 season from the CDC and COVID-19 numbers from John Hopkins. Please remember that these are constantly changing.   
Number of cases in the US (3/23/2020) 
  • COVID-19: 42,817
  • Influenza: 38,000,000
US deaths
  • COVID-19 : 579
  • Influenza: 23,000
US deaths among children
  • COVID-19: 0
  • Influenza: 149
Global deaths
  • COVID-19: 16,411 
  • Influenza: 290,000-650,000
Understand that the flu season has peaked in the United States. There will still be cases (and we are still seeing cases here in Wisconsin) but the main peak is past. Our local hospitals have been overrun with flu cases for the past several weeks. They are just now returning to stage green (low levels). The COVID-19 peak has not been reached and we don't know if there will be a seasonal peak or when it will peak. In 2009, a new virus H1N1 infected over 61 million Americans and caused up to 575,000 deaths worldwide, 80% of which were people under age 65. We don't know where COVID-19 will end up, but think back 10 years and see if you even remember this. I'm giving you these numbers to give some perspective. 
If you are feeling sick, please call me first. We can discuss your symptoms and decide the best course of action for you. We want to avoid exposure to health care facilities for your protection as well as the protection of our first responders and health care workers. Please continue to follow the guidelines from the CDC regarding hand washing, avoid touching your face, and avoid going out if you are sick, even if it does not seem to be COVID-19.   
Does Having Diabetes and Hypertension Increase Risk?  
Controversy regarding whether common medications are influencing susceptibility to COVID-19 infection
One of the things noted during the coronavirus outbreak in China and elsewhere is that there is a high propensity of severe infections and death for people with preexisting health conditions. Statistics show people with 2-3 preexisting health conditions have a much higher rate of severe illness and death. The health conditions noted have included diabetes, hypertension, heart disease and obesity.  
A letter published in The Lancet, brought this idea to a head and prompted questions from some of my patients so I would like to run through this for you. The authors proposed that people taking ACE inhibitors (examples are lisinopril, enalapril, benazepril) or angiotensin receptor blockers, also known as ARBs (losartan, olmesartan, telmisartan, valsartan, candesartan) could be at higher risk of infection. This was proposed to be due to an increase in the enzyme ARB2 which is thought to be the enzyme the virus attaches to when it enters the body. Cells with high levels of ARB2 line our airways and COVID-19 tends to be a respiratory virus. So it would seem that higher levels of ARB2 would increase risk of infection and that perhaps consideration should be given to having people stop these medications. This was proposed in a letter to the editor in the medical journal The Lancet. Are patients with hypertension and diabetes mellitus at increased risk for COVID-19 infection?  
In contrast, a study from China found that ACE inhibitor and ARB medication "use did not affect the morbidity and mortality of COVID-19 combined with CVD" (cardiovascular disease). Additionally, the European Society of Cardiology issued this statement: "there is no clinical or scientific evidence to suggest that treatment with ACEi or ARBs should be discontinued because of the Covid-19 infection" We have these groups suggesting that these medications are neutral or are at least not negative on use of these medications in the face of the pandemic.
A third theory has come up. Could these medications actually be protective or therapeutic in more severe cases? Please bear with me as I cover some human physiology. Angiotensin-converting enzyme (ACE) and its close homologue ACE2, while both belonging to the ACE family of enzymes, serve two opposing physiological functions. ACE activates a receptor to constrict blood vessels, thereby elevating blood pressure. This is why ACE inhibitors are useful in the treatment of high blood pressure.
In contrast, ACE2 inactivates enzymes having a potent vasodilator function which makes increased ACE2 good for blood pressure.The ARB type medications used to help control blood pressure, improve heart failure, and protect the kidneys in diabetes have been shown to increase cardiac ACE2 expression around three-fold after 28 days of treatment. Chronic blockade results in ACE2 upregulation in both rats and humans. So we see that ARB medications increase ACE2 levels (and the ACE inhibitor medications likely do as well).
ACE2 is the common binding site for both the SARS-CoV of the 2002-2003 SARS epidemic and, most likely, also the SARS-CoV-2 strain underlying the current COVID-19 epidemic. The paper in
The Lancet suggests this would be bad and we don't want more ACE2. The suggestion to treat COVID-19 patients with ARBs and ACE inhibitors by increasing their ACE2 expression seems counter-intuitive (and maybe crazy!). However, several observations from studies on the original SARS-CoV, which very likely are relevant also for SARS-CoV-2, seem to suggest otherwise.
It has been demonstrated that the binding of the coronavirus spike protein to ACE2, its cellular binding site, leads to ACE2 downregulation (less ARB2), which in turn results in excessive production of angiotensin by the related enzyme ACE, while less ACE2 is around to convert it to the vasodilator enzyme. This in turn contributes to lung injury, as more ACE results in increased pulmonary vascular permeability and increased lung pathology and eventual acute respiratory distress syndrome (ARDS). ARDS is the lung injury resulting in the need for mechanical ventilation seen in COVID-19 patients.
So we see that higher ACE2 levels seen in people taking ARB or ACE inhibitor medications may protect them against acute lung injury rather than putting them at higher risk to develop ARDS.
The ACE/ARB medications may help in two ways: first by blocking the excessive ACE activation caused by the COVID-19 infection which can lead to pulmonary failure, and secondly by increasing the ACE2 level which will lead to more vasodilation and less lung injury. There is an additional thought that there could be soluble ACE2 which at higher levels may serve as a decoy binding site for the virus and avoid the lungs.
The tentative suggestion to apply ARB/ACE inhibitors as COVID-19 therapeutics for treating patients prior to the development of acute respiratory syndrome remains unproven until tried. However, at this point we can already start to review records on people who are sickened by the virus and start to see if there seem to be better outcomes in people on these medications. We can also look at the percentage of people chronically medicated with these medications in the general population and compared with the percentage among hospital admissions of COVID-19 (SARS-CoV-2) infected patients presenting with serious symptoms. If the latter percentage would be found to be significantly smaller, this would support the notion that the medications confer protection from severe symptoms among SARS-CoV-2 infected individuals and contribute to our ongoing gain in knowledge crucial for reducing the mortality and morbidity of SARS-CoV-2.Third, we could design a therapeutic intervention to examine if placing people on these medications is helpful. This is an approach that could likely be done now. It certainly should be done moving forward if not being done already in a retrospective fashion.  
Bottom line, if you are taking any of these medications, please don't stop them.  
Fake Tests
Fraudulent COVID-19 tests being marketed for home use

Many people are understandably concerned about getting tested for COVID-19. We have heard about asymptomatic athletes, celebrities, and politicians getting tested when doctors, nurses, paramedics and firefighters on the front lines of care are not being tested due to lack of resources. This has led to unscrupulous vendors marketing direct to consumer tests which have not been shown to be accurate.   

"The U.S. Food and Drug Administration is actively and aggressively monitoring the market for any firms marketing products with fraudulent coronavirus (COVID-19) diagnostic, prevention and treatment claims as part of our ongoing efforts to protect public health during this pandemic. As a result of these activities, the agency is beginning to see unauthorized fraudulent test kits that are being marketed to test for COVID-19 in the home.

We want to alert the American public that, at this time, the FDA has not authorized any test that is available to purchase for testing yourself at home for COVID-19. The FDA sees the public health value in expanding the availability of COVID-19 testing through safe and accurate tests that may include home collection, and we are actively working with test developers in this space."

Please contact me if you have questions about the need to be tested. Tests are available for appropriate situations.The same holds true for any "miracle" cures or preventive substances. If you have questions, please contact me. See the next article for more recommendations. 
Protect Yourself 
Is there more than washing your hands, social isolation and hoarding toilet paper that can be done?   
What can we all do to stay healthy?  
  • We are getting information through a fire hose. Lots of the information out there is inaccurate or misleading. Fear sells. Many people (including some doctors) are passing along inaccurate information. It isn't malicious, it's people trying to help but not knowing what is true and what isn't. Pause and verify before you share.
  • Keep your stress levels down. I know, easier said than done. The stress hormone cortisol turns off cells in your immune system. Practice deep breathing, meditate, walk in nature, pet your dog. Turn off notifications. Try a social medial hiatus, even if it is just for 24 hours. You will feel much better.
  • Moderate exercise naturally lowers cortisol levels and aids immune function. Try to get 30-60 minutes daily. Combine exercise and nature to get an extra boost. If you normally go to the gym, try doing sets of body weight exercises. Remember, you don't need much room for burpees...
  • Get enough sleep. Don't binge watch Netflix until the wee hours.
  • Stop smoking or vaping. Smokers and those with compromised lungs are at much greater risk of serious illness and complications from COVID-19. Let me know if I can help you quit.
  • Consider a vitamin D supplement. Many of you know that vitamin D is the one supplement I recommend for many people. There is some evidence that it could be helpful for reduction of cases of influenza A, as a boost to the innate immune system including respiratory epithelium, and a meta-analysis showed it to be protective against acute respiratory infections including serious acute infections. I generally recommend 5000 IU daily but it can be taken in a bolus form as well. Let me know if you have questions regarding dosage.
  • Eating a healthy diet is beneficial. Prioritize whole foods. Avoid excess sugar and processed starches. These substances can increase inflammation in the body and potentially compromise your immune system.
This will pass. It will get worse before it gets better. But it won't be long and there will be something else the media will be telling us to be afraid of...  
We are starting to hear about some potential treatments that could be beneficial. One of these is hydroxychloroquine. This has shown promise, especially in the presence of azithromycin which showed clearance of the virus in 3-6 days. There are hospitals using hydroxychloroquine as part of their treatment protocols currently. It has also been shown to potentially be helpful as a prophylactic and I am hopeful that it will be available to many front line and first responders soon. I have seen reports that generic drug companies are making more of this so it should be more readily available soon. Individuals cannot get prescriptions currently. Even people with rheumatoid arthritis (the usual use of hydroxychloroquine) can't get their usual medication. It simply isn't available as all supplies have been redirected for use with ill patients. But this medication shows promise as a method to "bend the  curve" rather than just aim to flatten it.  

Thank you for taking the time to read through this newsletter. I hope you have found this information useful as we work together to optimize your health. Feel free to pass this on to anyone you think would benefit from this information. 

You can find previous newsletters archived on my website here


As always, if you have questions about anything in this newsletter or have topics you would like me to address, please feel free to contact me by email , phone, or just stop by! 

To Your Good Health,
Mark Niedfeldt, M.D.