April 8

Coronavirus and Rheumatoid Arthritis – Rheumatology Panel Discussion and Q&A

In This Video

  • Clint welcome attendees, introduces panel, gives medical disclaimer, webinar agenda
  • Do patients with autoimmune diseases have an increased risk of contracting the virus
  • Should patients be seeing their Rheumatologists in person, or aiming for teleconferencing?
  • Medication considerations
    • Prednisone/Prednisolone
    • NSAIDS (Ibuprofen vs other forms)
    • DMARDS (MTX vs Sulfasalazine vs Plaquenil)
    • Biologics
    • Others?
  • Virus avoidance strategies
    • Supplements?
    • Other natural therapies
    • Lifestyle changes
    • General best practices
  •  Q&A from audience

Clint Okay, ladies and gentlemen, welcome, it’s 3:02 PM Eastern Standard Time here in the USA. And today we have got a panel of rheumatologists who are going to be taking live questions. And providing information around the Coronavirus and its relationship and implications with autoimmune conditions, in particular, inflammatory arthritic conditions. So I hope everyone’s pumped up and ready to go, I’m over in Florida. We’ve got one guest I’ll introduce in a minute. She’s over on the West Coast in California area, and we’ve got two on the East Coast. And we’ll meet our special guests in just a minute. But before we even do that, I want to start getting people posting some questions. And I’ll tell you how to do that before I go into our introduction. So that we’re loaded and ready to go with questions once we start our content. You’ll see on the navigation on the right-hand side whether you’re on a smartphone or laptop. There is a string of icons from the top down, it says Settings attendee’s and then chat. I want you to click on chat and you can say hi and tell us where you’re from or even a question to the guests. So that’s how this is gonna work. Today’s event although we have specialist medical doctors. It is not specific medical advice for individuals. Today’s event is to provide general guidelines based on the information available in the published literature. And in general, best practices for these special times that we’re in. But certainly to speak to your individual primary care physician rheumatologist to gain the specifics about your condition before making any changes, especially to your medications.

Clint Okay. So let’s meet our very special guest today. We have three. First of all, a good friend of mine, who I have respected and regarded for many years is Dr. Nisha Manek. She’s a rheumatologist and pioneer in integrative medicine and for the treatment of inflammatory diseases. She is also an alumnus of the Mayo Clinic in Rochester. Hello, how are you?

Dr. Manek Hey, good to see you, Clint. It’s really good to be on your program today. Thanks for jumping in for this very important webinar. And I also want to say thanks to my friends, Dr.Jose A. Pando and Dr. George Munoz. I know you’re introducing them, but glad to be here.

Clint Yes. And they wouldn’t be here except for you. So I’m very grateful that you co-organizing this for me and bringing in the A-Team. The A-Team consists of Dr. Jose A. Pando, and he’s a board-certified rheumatologist at Delaware Arthritis in Lewes. I’ll have him correct me there, but certainly in Delaware. He takes a holistic approach to care and taking into consideration his patients’ overall health, not just their symptoms or disease. Thank you, Dr. Pando.

Dr. Pando Thank you Clint. I’m glad we’re here, and thank you to Nisha, as well.

Clint Absolutely. And finally, Dr. George Munoz is a board-certified rheumatologist. He completed a post-op fellowship in integrative medicine at the University of Arizona Centre for Integrative Medicine. George personally possesses a wide skill of training, including traditional Chinese medicine, acupuncture, homeopathy, energy medicine and martial arts discipline. He is a national speaker on topics including nutrition, arthritis and inflammation. So thank you, Dr. Munoz, for joining us today.

Dr. Munoz Thanks so much for having me, Clint. And I have my friends and colleagues, dear friends and colleagues, Nisha thanks for getting us all grounded together. You’re a great organizer.

Dr. Manek Thanks to Clint!

Clint Yes. Well, we’re all very happy to be here, and we’re all very grateful for the huge number of people who’ve joined us today. We’re well over 400 guests on this webinar. And the questions are coming through thick and fast. Now in anticipation for this, I’ve had fielded a lot of inquiries about this event. And the primary one, of course, concerns medications because of the risk of the Coronavirus and whether or not they are counterproductive for the prevention of getting this disease. So we’re going to get into the medications specifically, and for everyone who’s posting questions about their specific medications. We’re going to drill down on non-steroidal anti-inflammatories. We’re gonna look at the steroids. We’re going to look at the disease-modifying anti-rheumatic drugs and biologic drugs. We’re going to get into specifics on the guidelines around each one of these. So just sit back and we will get to those in just a moment. And just before, though, my first question to the panel, based on some of the pre questions that we have. If you have an autoimmune condition such as an inflammatory, arthritic condition, are you therefore inherently more likely to get the coronavirus?

Dr. Manek May I speak to this, if I may just give a perspective from the data that came out of China. And this is very interesting, this was published in The Lancet Journal on March 9, so it’s about three weeks ago. And what these Chinese physicians noted was that when people with serious COVID-19 were being admitted to the hospitals, they made a very interesting observation. And it was this, patients with systemic lupus were not among the people being admitted. So right away, this was a very curious clinical observation. The people that were being admitted to the Wuhan hospitals were people older age, over the age of 65, people with heart disease, high blood pressure, and diabetes. But why people with lupus get serious COVID-19. That doesn’t mean they don’t get infected, but the more serious infections were the other folks. And that’s where they started to ask a very important question, is it because people with lupus take hydroxychloroquine. This is a very, very well-known medicine in the rheumatology toolbag. It’s been known for over 50 years or more. So we have a good understanding in terms of clinical usage. And it’s the anti-malarial medication that has really got the FDA’s attention. So already we had some clinical clues from Wuhan that people with lupus who take hydroxychloroquine may have a milder disease or certainly not ending up on respirators.

Dr. Manek Now, this also harks back to SARS-2 the original SARS of coronavirus infection in 2002 and 2003. It was known at that time that antimalarials may have some protective effects in vitro. OK. This is test tube data that shows some protective effects. That means it seems to have antiviral effects. Viruses don’t replicate as fast in the presence of hydroxychloroquine. So now we come to this current pandemic. What does this mean? Well, there’s been some clinical experience in Marseille, France. They used Plaquenil with an antibiotic in people who were very sick with COVID-19. And the French experience that shows that if you treat people in hospitals with Plaquenil, then they seemed to clear the virus faster. OK, statistically faster. Now, if you add Azithromycin to that, they clear it even faster still. Why that should be, we don’t know yet. OK. So there are some unknowns here. Then we come to the USA experience, there’s a physician group in Kansas City. Okay. And they’ve really written some very nice op-ed in The Wall Street Journal and they’re using Plaquenil and Azithromycin in combination in their hospitals in Kansas City. And what they’re seeing, again, it’s not published, but they’re putting it out there is that it seems to work. That is the sicker people seem to clear the virus faster. And so the FDA had fast-tracked Plaquenil into approval. What that means is the sickest people in our ICU, the doctors have to decide. But they can use Plaquenil for about five days to help clear the virus faster in the sickest people. I hope that helps you give a little perspective into whether Plaquenil has entered into the mainstream armamentarium to deal with the pandemic. So I think that’s sort of positive news. But I just want to say something about this in terms of rheumatology. And that is just Plaquenil meaning you can use it to prevent virus infections. No, that doesn’t mean that it means a treatment. So our public health guidelines are still firmly in place. If you are a rheumatology patient and for whatever reason taking Plaquenil for lupus or rheumatoid arthritis, take it. Ok, but we’re running into a problem of shortages. And I think that is going to come. And I think efforts are being redirected. The supplies are being redirected to places that really need them. In fact, this morning I actually filled a prescription for Plaquenil. And we’re being told that it’s really for people now with urgent need. So I think when if you’re a patient with a rheumatic disease who has a supply, continue taking it. It doesn’t prevent the infection. You still have to do all of those wonderful public health guidelines in place, which are hand-washing, social distancing, really practicing good personal hygiene and so forth. And then we’ll go, you know, hopefully getting to some of the integrative practices that we three are very, very good at. We do this all the time in terms of education and integrative medicine, but I’ll stop there.

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Clint Okay. Thanks. That’s a great review on Plaquenil and that was to be discussed later on. So we’ve definitely check that one-off and we’ve had some questions coming up around that. So thank you. And I just want to ask Dr. Munoz these thoughts before we move past this question. Should people with autoimmune diseases just, in general, feel more concerned about this condition, about this pandemic?

Dr. Munoz So I think the common sense answer is yes. But we don’t have the data to support that common sense, fear, feeling, and prevalent thought. And it’s interesting what Dr. Manek just said about the initial observations out Wuhan regarding lupus patients. I will add that we have a cohort right now of about 150 infusion patients in the practice. And we’ve had two lupus patients in the past week who did get ill. And I just want to say that they were stable, they were not flaring. The one was on a biologic and was completely asymptomatic and had two young adult children. And I’m saying that for the obvious reason in terms of the issues with social distancing. And you know that it isn’t always the individual, the patient, but perhaps those around them. Nonetheless, she was asymptomatic, stable and really in 24 hours was admitted with double pneumonia and was intubated within 48 hours. She’s doing well now. Now she was on Plaquenil. So I bring that up that, the generalities or the initial observations, we have to wait and see. We don’t know if that’s going to bear out as a real preventative. I think that the public health recommendations are number one. The other patient was not on a biologic. She had stable lupus was on imuran, and not on steroids. And she, too, was admitted with a much attenuated, milder case that we actually found by accident. She had an atypical presentation that had nothing to do with truly respiratory symptoms. And we found a pneumonia on a CAT scan looking at her belly. And so then the patient got very anxious. We directed her to the E.R. and she was tested, admitted stable and then put on azithromycin and being discharged, doing well. So just like non-immunologic patients, we have asymptomatic, milder cases in all the population. I believe that’s how it’s going to bear out.

Clint Ok, that’s well. I mean, it’s obviously not good news to hear about those two patients of yours, but it is refreshing to hear that they’ve done and at least as well as what the common responses that others have had not gone all down the diseases. Dr. Pando, do you have any patients you be able to report who have contracted COVID-19 and how they may have done?

Dr. Pando Fortunately not, we have been very lucky in our state. I live in Delaware. Our Governor implemented the isolation or recommended isolation early on. And we have reinforced that with our patients as much as possible and they are staying home. So far we have a large population of inflammatory patients. They have all been healthy. So we’re very pleased with that. Following up on I know that you’ve got maybe coming to this point later. Something that we are advising family members of patients that usually call us not to take Plaquenil prophylactic going back to plaquenil issue. If you are a patient, you continue taking it. If you are not infected or you’re not in the hospital, you should not start this medication. That’s something that probably will come up later. But since we’re addressing Plaquenil now, I just wanted to mention that.

Clint That’s a really good point. And Dr. Manek and I were having a chat about other matters on a separate private call another earlier this week. And she also said that is that she was getting questions from family members saying, hey, I want some of your Plaquenil. When the family member did not have any other health conditions, just wanted to use it preventatively against COVID-19. And what you’ve just said that it is not a recommendation. We shouldn’t be doing that. We should leave that only to those who have been prescribed by their rheumatologist to take this drug and otherwise leave it alone. Correct?

Dr. Pando That’s correct. Because we’re beginning to see is a shortage of medication. Patients go to a pharmacy and have been taking this medication for years and now it’s not available or they’re receiving 15-day supplies at the time, which is not optimal. But that’s what they’re doing. Right.

Clint Okay. I’ll stay with you. Dr. Pando, would you tell us so what’s the general guidelines at the moment with regards to your patients seeing you in your practice? Do you only do telemedicine at the moment? And do you believe that that is the way that our audience should also be communicating with their rheumatologist?

Dr. Pando So we are doing telemedicine and we invite patients to come if they have an acute problem that needs an injection. Let’s say some if they have a problem with their knee and they can walk and they need, an aspiration, they will come and we’ll do the procedure. But if it’s up a follow up routine or they have questions. We’d rather do it like what we are doing now. I think it is safe for everybody?

Clint Yes, absolutely. Okay. Well, thank you. Now, just for our audience, where we’re going to go from here is we’re now going to drill down on each of the medications. We’ve got an enormous number of questions have come through. And what I’m hoping to do in the questions keep coming and that and we will get to questions. What I’m hoping to do is to cover off as many of the answers to those questions as possible by drilling down on each of the medications. Now, one at a time, and I hope that we touch upon the medication that you’re on during this sequence that we go through. And that may cover the answer to your questions in that sequence. And then we’re going to look at virus avoidance strategies as you have it in the biographies, as I read out of each of our special panellists today. Each has a great knowledge outside of just the conventional medical approach that they practice, but also have these strategies that can complement ways to improve your ability to be virus-resistant. So we’ll get to those shortly. Let’s drill down these medications. Who would like to talk about the steroids?

Dr. Manek So, yeah, go ahead.

Dr. Pando In general, patients that needs the medications are the ones that prescribed steroids. If you are taking steroids and hopefully you’re taking the lower dose that you can, you should be. You should not stop them, you should continue taking whatever medication you need to maintain yourself stable from a logical point of view. I don’t think that the low dose of steroids, most people in our practices will be taking a low dose. We’ll be at a higher risk of developing coronavirus. And if they develop it, that they will they compensate any faster. Right.

Dr. Manek Ok, so I think it’s if I may also echo Jose. When we use something like prednisone, it’s a very powerful anti-inflammatory. And at a certain dose, it becomes immunosuppressive. And I think that’s the balance we’re always looking at. And generally speaking, doses of 10 milligrams of prednisone and higher would be considered immunosuppressive. And in fact, for certain conditions such as Polymyalgia rheumatica or rheumatoid arthritis, we do give prednisone initially for a very full minute arthritis. You know, sometimes we actually give anti-bacterial called Bactrim to reduce the likelihood of them getting infected while they’re taking prednisone. That doesn’t mean everybody should be doing this. But in selected cases, especially older people on steroids above the dose range of 10, you are reaching into immunosuppression. Below 10, I think then you see the more anti-inflammatory effects and certainly below 7 and 5 and so on. I think they’re pretty much okay. And I don’t think their risk is higher to get COVID-19 than the normal person. Ok, so again, I would say to echo Jose, if you’re on a low dose of prednisone, keep taking it. And if you’re really worried, talk to your rheumatologist to try and see what condition you have. And how do you stepwise very cautiously. If you should reduce your dose under 10. That’s a sensible way to approach the question.

Clint Ok, fantastic. So what we’re hearing there for those who didn’t quite get the summary. The summary is that high doses of prednisone is not necessarily a good idea. And I think if I can get some nods from my panelists. it’s not a real good idea to do high dose of prednisone for long periods of time. So we want to not really be doing that regardless. But we want to, not especially not be taking more than 10 milligrams if we are trying to minimize our risks of this virus. So let’s move from the steroids across to ibuprofen. There’s some data that I’ve seen just in the news around ibuprofen and its recommendations not to take this. Someone asked the question. I just saw they are taking Aleve and I’ve never taken Aleve. But I want to know, confirm if that’s ibuprofen or not. So, Dr. Munoz, would you like to field this question?

Dr. Munoz Yes, as I press my little speak button. Okay, having fun with the controls here on the side. Okay. That’s the child in me. So, yes, early out of Wuhan and perhaps out of the European experience, we started to hear grumblings about OTC anti-inflammatory, specifically Aleve Advil. So to make a long story short, we have no data confirming this. This is not been confirmed. Ergo, if you are a patient taking an anti-inflammatory, we don’t have any specific reason that due to COVID specifically, this is a problem in spite of the early reporting. And one thing for all of us, I believe is true as we’re doing this, I know for you, Clint too, anything we say is our experience or opinion evidence-based as best we can. Always consult your doctor, your doctor, your rheumatologist who’s treating you. So I’m currently telling my patients not to worry about that specific aspect of medication in this regard. Clint Okay. And with regards to any of the other non-steroidal, there’s nothing that’s really a red flag as we head off into the other brands and other types.

Dr. Munoz Correct. But I will I’ll add this caveat that perhaps we as rheumatologists a little more cognizant of than the general population in terms of physicians and communities. Not that I’m putting them down, it’s just that we’re dealing with inflammatory patients. We deal with patients of all ages, but we have patients, many patients over the age of 60 or 65. So a standard in my mind of care is, well, I used to always prescribe an anti-inflammatory in my early years and practice. I pretty much never say never prescribe one to somebody 60 and older because of the potential risk of cardiovascular complications, G.I. bleeding and kidney problems. So if you were to get infected with COVID and you are in this higher susceptible group, that’s already been pointed out. It seems to me even more logical that you specifically should avoid nonsteroidal. Because all the organ functions that we’re worried about are secondary complications of infection, sepsis, secondary bacterial infection are exactly what we want to avoid that setup.

Clint Fabulous information. Thank you. Any further comments on that?

Dr. Manek I agree with George. I mean, really, we avoid nonsteroidal,  ibuprofen, naproxen, ketoprofen and there are many diclofenac in the older folks because of the vascular and the kidney problems. You have a high risk for stomach ulcers and high blood pressure and then consequent cardiovascular disease. So it’s interesting The National Health Service has commented on this. This is the United Kingdom NHS, and they also responded to some early reports or grumblings about nonsteroidal, in the COVID-19. And they said if it’s a younger person with arthritis and you’re on the nonsteroidal, not to stop it, ok. But if they were to get infection, they said, well, why don’t you then take acetaminophen, which is Tylenol. So they just give an alternative in case you get, you know, aching. But most of our folks in the younger age groups who are taking nonsteroidal do have inflammation. And if you need it by all means with safety in mind, take it.

Clint OK. Fabulous. Yes, go ahead.

Dr. Pando I want to mention that it is important to source the information. Right. I mean, what George was mentioning was originated from a case study from a young person. I think he was in France. And from then they extrapolated that non-steroidals were no good. So you have to know where where everything is where the threat originates. Because one patient does mean look. Right. It was unfortunate for this person. But you can not generalize a case report.

Clint Yes. Understood. Thank you. And now let’s get into a topic that’s very popular amongst our questions here, and that’s a Methotrexate. So let’s talk about people who have been taking let’s say someone’s on Methotrexate. And then we’ll even get into some of the other disease-modifying drugs. But let’s start with Methotrexate. If you’re on Methotrexate, does this increase your risk of getting this virus?

Dr. Munoz Jose, you want to take that?

Dr. Pando Yeah, I do not think so. Methotrexate will affect your immune system is set in ways, and I think that doesn’t necessarily at least I’m not aware of any information that will increase your risk for a viral infection. I don’t know if you guys can read anything about this, but I have not seen any information that will increase your risk.

Dr. Manek Jose, you know, the way I look at Methotrexate is that it regulates the immune system. It’s immunomodulating and not so much immunosuppression in the doses that rheumatology uses. And I think Clint and I talked about this in our conversation that I think people on Methotrexate, they have normal white counts, generally speaking. And they’re in a competent right? So I don’t think, as you said, Jose, they’re at higher risk. And my literature search, I didn’t come up with any either. Yeah.

Dr. Munoz The only caveat I’d like to add to that and I agree with Jose and Nisha on this. I don’t believe it’s immunosuppressive, but there is a subgroup of patients who are more susceptible to Methotrexate in terms of toxicity and they can develop blood abnormalities, white cells, anemia, low platelets, any other cell lines in the bone marrow. If they are inherently deficient of folate for any reason, and then we have to think about these mutations that are common in the general population. They’re called SNP mutations, and therefore they are of the variety of about half the population carries them some more in certain ethnicities. But there are these so-called MTHFR Amazon mariota’s and Tom HS and Harry F as in Frank or as in Robert the method Tetra Hydro folate reductase system is responsible for energy in the cell. So if you have this mutation and you have the whole mutation, meaning you have the whole mutation from your mum and your father, you are therefore homozygous. Then Methotrexate could become a problem for you if you were not taking the right type of folate. And what can happen there is that when you take the Methotrexate, your white cells can go down, your red cells can go down, your platelets can go down. So therefore, if your white cells go down enough, then you are more susceptible to infection. That aside, I agree with our commis.

Clint Okay, great. Again, this then comes back to your comment before and what I said at the top, Dr. Munoz, about needing to get this specific information from your rheumatologist. Because that level of detail is obviously very case-specific.

Dr. Munoz Correct.

Clint Okay, great. Okay. We have a question someone has come off their Methotrexate because of the fees that they have and is asking now that I’m not on my immuno controlling modulating medication and I’m on no medication. Am I in a better situation? Well, I think we talked right at the start that, you know, Dr. Munoz, you said that common sense or at least intuition applies that generally. If you have an autoimmune disease, whether or not you’re on medication or not, you tend to be at an increased risk. So I don’t believe we need to go further into that. We’re all into grants with that, even if it’s just an intuition that’s not obviously confirmed because this disease, this virus only been around a few months and the studies are not being done, correct?

Dr. Munoz Correct.

Clint Good. Okay. So moving along to just the other range of disease-modifying drugs before we close out with some biologic discussion. The Sulfasalazine is one that I had on my list. Any comments around that being anything out of the ordinary?

Dr. Pando No, not really. I mean, it’s not. It’s with other medications, it will not. There’s no information and my understanding is other countries have looked after as Nisha said, yes, they go off to SARS, they have look at different antibiotics and the only one that shows that invitro. An effect decreasing the replication of the virus has been Plaquenil.

Clint Okay. All right. Well, let’s move on to the biologic drugs. Dr. Munoz, you may lose a little grunt when I mentioned them. People are concerned about their biologic treatment. You know the questions. I’m just watching questions. By the way. I know that I haven’t specifically read out people’s names and questions at this point. That’s because of the bulk of what we’re going through now, I anticipate is answering a lot of these questions in a sweeping way. That’s what I’m hoping to do. But I’m what I’m noticing is questions pops up on my screen here. Several people are taking different types of biologic drug symposia, humira, Enbrel, etc.. Can you please pass and commentary around that extent likelihood of risk?

Dr. Munoz So I’m going to start this by saying once again, it’s like the ultimate disclaimer. Please always discuss this with your rheumatologist. Again, there are stylistic differences, there is experiential differences where one practices what city you live in, your age, your general health, so many variables. So I’m going to speak in generalities. I am of the school and I know that if we had 10 rheumatologists, we might get 10 different answers on this. OK. I think Dr. Pando, Dr. Manek and I tend to in general be pretty well aligned. But this is one area where we meet maybe a little different.

Dr. Munoz So the biologics and what their effect on COVID is, in my view, is as follows.  We don’t have any data really as to the safety or lack of it with COVID specifically. What we have in my opinion, is some generalities about the auto immune diseases and what happens with uncontrolled inflammation. If we have a patient that is uncontrolled, their risk of infection is actually higher. So, therefore, one is weighing the risk of the treatment versus the risk of the disease uncontrolled. And again, that’s why this is so important in my opinion, that each patient be individually assessed by the rheumatologist who knows them, their history, their tendencies, their nuances, fears, and psychosocial situations. Which will either make it easier or harder for them to adhere to a treatment plan, whether it’s avoiding medicine or actually being on full board with medicine. So that in my opinion, this applies to pretty much all of them. I will say that B-cell depletion drugs for lupus, I think it can carry a little bit more risk than some of the other rheumatoid type medicines that are not be sold, the pleaders. And you know, again, I will point out to my case of one of my lupus patient unbend lists. And I’m not bashing bunless we have many patients on it, but that is a B-cell depleater. And that patient, one from very well to very ill in a very short time on Plaquenil. Does that mean that everybody on benlysta is going to develop pneumonia from COVID? No, I’m not saying that. I’m just saying that there probably are some nuances in the biologic mechanisms. But we don’t have all the data. And I think that we have to be very astute observers. We have to report everything to our physicians are doctors, our family. That’s why it’s good to have somebody else in the appointment with you as a helper. And yes, we’re doing a lot of telemedicine and we usually have family members in the visit. So I’m going up there but that’s my general opinion.

Clint Before we have another comment about that. Would you say, therefore, that C-reactive protein levels proportional to infection risk?

Dr. Munoz So one can say that we have the. That might be an oversimplification.

Clint Right.

Dr. Munoz Not CRPisn’t always purely autoimmune driven. There can be metabolic issues that are not primary immune inflammation, but rather other systemic inflammation. That’s one. Number two, we have other biomarkers that we use. I’m a believer in using a multi-biomarker called vectra, because it’s got twelve different parameters of which CRP is one, I L6 is another, TNF alpha receptor is another. And there are other markers. So using that in rheumatoid patients seems to have validity as to their disease activity, their prognosis. And also co-morbid situations. For example, inflammation of other organs outside the joint. So that’s important. CERP is part of it, but CERP alone without the other patient recorded questions. The outcomes, the metrics that we use are helpful. So there isn’t one test. You know, I think we as clinicians have to take the composite. Our patient, how well we know them. Our intuition and our experience and put it all together.

Clint Well. okay. Right before we move on to virus avoidance strategies. Would Dr. Manek or Dr. Pando like to comment further on that on biologics?

Dr. Manek Well, you know, the strategies that have really taken off for research around the world are three-pronged. One is anti-viral strategies. And these are the drugs that are used in HIV disease and Ebola. And in Wuhan, they had use antiretroviral with not much effect, but they’re still being pursued by several clinical groups. The second arm is a lot of people, the majority of people who get novel coronavirus infection actually develop immunity. They’re walking bags of immunoglobulin if you will. And so these are the folks that now they’re separating immunoglobulins as a treatment, as a passive transfer of treatment to people who are really sick. So that’s a second arm that has garnered a lot of attention. The third arm is where we as rheumatology community come in, and that is this COVID-19 in some people induces the immune response in such a robust way. As George said, you get a side, a kind storm, you get such an overactive immune system. And that’s where I think Plaquenil holds it back a little bit. And that’s where Interleukin 6, which is one of the cytokines implicated in this cytokine storm and lung damage. And so you might have read in the reports that kept Zarah and Actemra. These are the medications that block the interleukin response. They’re biologics, that we used a lot in rheumatoid arthritis. So what will turn out? Will they be really useful long term? We will see. And I think we’ll get data very quickly. Maybe in the two or three weeks from now, we’ll get a better picture. What’s going on with when you use Interleukin 6 inhibitors? I know, Jose has run a trial in your clinic using Kezar, id I’m not wrong.

Dr. Pando With it yes, in the past.

Dr. Manek Do you have any add on that?

Dr. Pando So what I know is that if FDA fast-tracked iL6 inhibitors and they’re being used in the hospital, in the ICU setting for having, as you point out, the cycle kind of stores. That there are preliminary data that came from China that it was helpful in those cases. The data in Europe and in this country is just evolving. So as you said broadly, the next two months will have a more robust set of points to interpret. But at this point, we’re not there yet. We know that. I know that the FDA has looked on fast track this and it has given its approval to use in ICU settings.

Dr. Manek Right.

Clint Okay, fabulous. Now, Dr. Munoz, as you look like you’re about to say anything. Would you like to comment before I try and wrap up and summarise what I believe I’ve understood from our discussions around the medications?

Dr. Munoz Yeah, I just remember seeing a little question on Actemra since we kind of veered in that direction. And I just want to point out again that I don’t think that Actemra is a preventative of COVID, nor does it really make it specifically worse. So, you know, it’s under the general rubric of what we already said. And again, if you have any questions, always ask your rheumatologist. So as to know individually what you should do.

Paddison Program For Rheumatoid Arthritis
Rheumatoid Arthritis Support

Clint Okay. Fantastic. Well, thank you. I’m going to try and summarise now and act on behalf as a participant and see whether or not I’ve understood these guidelines. And then you can comment as to if I’ve made any misunderstandings. So first of all, we talked about the steroids, prednisone. We didn’t talk about prednisolone. But I think we can categorize those together. And the general feeling was that over 10 mg of this medication is perhaps not the best idea to be kept safe against the virus. And just over 10 mg on a Long-Term basis, not a good idea necessarily in any case, for other reasons. But under 10 mg a day, getting down to five and so forth is not necessarily well or there’s no data to suggest that that is going to increase your risk of infection.

Clint Non-steroidal anti-inflammatory is including ibuprofen and any other forms. Also, no evidence to suggest other than some sort of highly extrapolated ibuprofen information out of someone who is young out of France. Other than that, it’s there’s no reason to become terribly alarmed about non-steroidal anti-inflammatory drugs unless you’re a person over the age of 60. And it’s because of those medications in their contra indications with other body parts not related to rheumatoid arthritis, but these other conditions that those drugs may exacerbate especially if you were to contract the virus. And so Dr. Munoz pointed out that he thought, you know, in his clinic he doesn’t prescribe these non-steroidal anti-inflammatory drugs anyway. And so that’s a discussion for your rheumatologist as to whether or not especially if you’re over 60, these should be used. And then we talked about disease-modifying drugs, Methotrexate. Dr. Manek talked about how they are immuno modulating, not necessarily immunosuppressive, meaning that we are going to increase our risk of infection. And then with regards to Sulfasalazine, there’s no no data and no reason to expect that it would be more than making you more risk susceptible.

Clint And then earlier in the call, we talked at length about Plaquenil and we came to the conclusion. That if you don’t have an autoimmune disease and haven’t been prescribed and don’t go trying to steal it off someone to take it. And then if you are on Plaquenil because of a prescription reason, then there’s been a couple of incidences in Dr. Munoz’s clinic where those people have actually contracted COVID and are recovering. Okay. In line with other people who have not been on the medication. And so Plaquenil has some interesting data that we’ve seen that suggests that it may be helpful. And in fact, supplies are running low because people are trying to take it as a recovery drug for COVID. But not to go on it if you otherwise have not been prescribed. And it’s not a preventative drug to avoid getting infected.

Clint Finally, we talked about biologics and what we gathered in the biologic discussion is that a controlled, inflammatory, arthritic condition through biologic drugs is a safer situation to be in than coming off the biologic drugs. As a mechanism to reduce your risk of infection and then having an uncontrolled high inflammatory state that shows up a high marker on a vector score, which is going to actually make you more at risk than what you would have been if you were on a biologic drug in controlling your symptoms. So that’s what I picked up. Have I missed anything or do I need correcting?

Dr. Pando So at this point, it’s pretty clear. Good.

Clint All right, good. I did finish your 12th. OK. So now let’s move across to variance avoidance strategies. And this is an area where the three of you have many strengths. We have some time here to get into this. And I know that everyone who is watching this wants to avoid getting this condition. Dr. Manek, you’ve got some great guidelines around this. Let’s move through this fairly quickly. Just give us the do this, do this, do this, and then we’ll take some questions from our audience here, too.

Dr. Manek Right. And George and Jose, just jump in. But how I see it is that you have in your kitchen right now many, many things you can implement right away to have anti-viral effects and immune-boosting effects right away. So, you know, ginger root, my favorite. I always have that drink lemon water, wonderful stuff. Hot teas and hot drinks. Throw out the junk food. Folks throw out the junk food, throw out the soda pop, forget the sugar. Just those few things. You’re already really in a good position. Ok, then we have many, many other botanicals and supplements that really add on to really keep your immune system in tip-top shape. And I want George and Jose to say some things on that because I want them to have a chance to speak. They weigh in on this.

Dr. Pando So the basics, because probably your audience, Clint are asking you what the basics. What can they do? If they take their zinc and vitamin C, that’s a good starting point. Right. Just to take a combination of zinc and vitamin C. In some cases eating elderberry. I don’t know if it’s widely available here in the States it is, so adding elderberry is helpful. And also it’s important to keep in mind that vitamin D is helpful as a preventive. But if you, unfortunately, got sick you need to stop the medication that. Vitamin D. You don’t take it if you have the virus.

Clint Okay, so that’s a key point. I’d never heard that before. Okay. So if your vitamin D preventative. But if that and everything else doesn’t stop you from getting it, then you’ve got to stop the vitamin D.

Dr. Pando Yeah. Yes. So all this information has been shown to be effective in known as the say coronavirus, but in some other viruses. And we’re extrapolate information that we have gathered from other bio diseases and use it. I’m hoping that it will work for coronavirus as well.

Clint Yeah, that makes sense. Okay, so we’ve got zinc, Vitamin C, which I take using the lipos ferric vitamin C. Dr. Manek and I spoke about that seems to be a good way to go. Elderberry and Vitamin D. Have I missed anything? That’s a no brainer. Like go and do this for sure.

Dr. Munoz You know, I take curcumin as my usual that’s an anti-inflammatory, natural botanical that has many properties, many upstream properties in the nucleosome inhibiting inflammation, very high up the chain of command we might say. I like Boswellia, I take vitamin D, and I take omegas. So basically during COVID, I’m just doing what I always do, which is I take Omega, zinc, curcumin Folate, and vitamin C. I like an extended-release. That’s Barford for me. Why do I do that one? Because it lasts all day and I don’t have to think about taking things multiple times.

Dr. Munoz What else? I’m going to say that besides the botanicals and the things we’ve mentioned, some of the minerals and vitamins, I’m going to say that for me and for my patients this COVID time period, the lockdowns, I try to recommend that people get into a routine that they’re comfortable with the mix of their life. Because if you do what I believe has happened for many people, myself included is the disruption in the regular pace of the day creates stress. So stress reduction, breathing, meditation, getting back into exercise, getting my routine back into an organized way. It helps me cope with the constant change because there’s gonna be a constant change here. The story is evolving. We are not in control of many things, but we can control how we react to this situation. So I’m going to stop right there.

Dr. Manek Can I just give it just like that? Have a routine. Have a routine. If folks are worried about, you know, the supplements and doses. I had written a little guide around my book, Bridging Science and Spirit and Vitamin D. Many people are deficient and I usually take ten thousand international units for this period of time for the next couple of weeks. That will jumpstart your immune process. I agree with zinc, take 50 milligrams daily. And I would add selenium 200 micrograms. Vitamin C I like lypo spheric because it’s very quickly absorbed. Lypos-ferric means it’s encoded with a lipid layer and it’s absorbed very fast. Take a thousand milligrams, at least more if you can. If you don’t feel so well or even stress, take a couple more grams, it’s fine. Curcumin, yes. And if you’re looking for a good turmeric product matrix, standardized, OK, it’ll say standardized on the label and usually the dose is 750 milligrams, up to two thousand milligrams daily. If you don’t get standardize make sheets with black pepper because it’s absorbed faster, but it has very nice anti-viral properties. So. Yes, turmeric. Yes, yes. Yes, absolutely. And then we can talk about all the mind-body. Absolutely. Yes. And it actually comes down to the fact we now know this, that we all do the nervous system, the autonomic nervous system controls the immune response very powerfully. So sympathetic and the parasympathetic arms actually feed into the immune system. And you every person has control over the autonomic nervous system output just by breathing. You’re already engaged. The relaxation response and you’re actually down to calm down the immune and inflammatory response. So this is very scientific. It’s not. Well, what’s that going to do? But actually does. And we need to teach our patients and teach ourselves these very powerful techniques. And I know Jose has a very beautiful. I remember Jose when you taught us in that conference the breathing technique and you could share it with us.

Dr. Pando So that’s something that I learned from the(inaudible). If you want a demonstration, we can do it here. Or you have time. But it is a force of a breath, which is you take a deep breath. And I got to for you. Hold it for seven seconds and then you sail over eight. Right. With that, you achieve two things. You decrease your rate of breathing and that will stimulate the vagus nerve. And as you estimate, the vagus nerve that with great. Back look into your brain to cool down and create a better balance of the autonomic nervous system, as Nisha was mentioning before, that it this time, as George was mentioning, of higher stress. We all can use a little quiet time and a little breathing time to calm down.

Clint And as part of my recommendations to my audience. For the past seven on years, exercise has been right up there as one of the most crucial factors for much as our health and more mental well-being, but also inflammation reduction. I’ve found exercise just outstanding for myself and for my clients. Thousands of people who just exercise as if they’re really working towards a strong physical health, physical body. And now is a great opportunity to do that when we have so much more time on our hands and we can exercise it at home. There’s countless opportunities to watch videos of yoga or home workouts and so forth. Even Arnold Schwarzenegger’s posting them on Instagram and he’s in his 70s or something. So we can all take the opportunity to breathe more, which, of course, is going to strengthen our lungs. So even if we were to, unfortunately, get the disease, we also then have stronger lungs and become more resistant to its effects. But also in a preventative way. So I’m all about the breathing side of things. I think that is fantastic and just the calm as well. So these are great strategies. I have we have been checking off many of the many questions that have been coming up just by going over the strategy that we put together here. Tilly says, “Thank you so much for answering my question about it.” Tamara merely said, “speak about drugs like Xeljanz.” Well, we’ve done that mainly. We’ve covered the biologic drugs. And I hope you’ve gathered the response there. We’ve talked about Humera for Pam. But someone’s asking about Ivy levels of vitamin C. I’ve actually done that myself way before this pandemic happened. I didn’t notice anything with regards to any aspect of my health at all. It was like it didn’t even occur. But you think Ivy levels of vitamin C? Is it something that people should try to consider?

Dr. Munoz I know that we’ve been using intravenous vitamins for a long time. I take care of a large cohort of athletes who are autoimmune patients. Some many them have fatigue, while fatigue is a multi-factorial condition, sometimes intracellular mineral and intracellular vitamin deficiencies do occur. I think there’s a strong placebo effect and it’s part of utilizing a whole person approach, not the single curative approach. Patients request some, patients request this continuously and we continuously try to teach them and taper off that dependency and really be independent in their nutrition. Normally the through enjoying good, wholesome food that’s nutritious, that has many colors, that is high in antioxidants and minerals and vitamins and supplementing only when needed, basically. So I think there’s a place for it, but it’s not something I recommend for everybody all the time.

Clint Okay, thank you. I just want a bullet. Just go. Bang, bang, bang through a couple of extra questions here before we wrap up in a few minutes. Low dose naltrexone comments on that from anyone.

Dr. Munoz Safe, helpful and fatigue helpful for some people with fibromyalgia. That’s a condition where I’m always looking for an edge to be able to help somebody. Haven’t had any untoward events, have used it in autoimmune. Lupus patients without problems have no opinion about its specific utility and Kogut.

Clint Okay, fabulous. Jen says, “thanks so much for organizing this.” Now Kate says, thank you so much for doing this. It’s very much appreciated. Glutathione. I take that I’ve only been taking that for about six months or so. Again, I can’t say these things are old, these micro contributors. I don’t necessarily think there’s one thing that just suddenly changes your life. When it comes in a bottle from a company. But glutathione, I saw one study about this in the published literature that it was about, you know, rodents, but it showed that after they were artificially created, inflammation states that supplemental glutathione reduced the autoimmunity response and reduce their inflammation. So that was enough for me to think, oh, well, I’m going to give it a go. And again, like, how do you know whether or not it’s doing it much or not? But I just wanted to get any feedback. If or if any, from one or two of it.

Dr. Munoz Safe use prescribed that a lot along with Ben A-C, it’s a precursor. We don’t have large controlled trials again. This is the problem. Is it a contraindication to use? I don’t believe so. I do think it carries significant or type anti-inflammatory anti reductive capability. I’ve used it in people with getting ill with the flu. I’ve not used it in COVID. I’m not saying to use it in COVID. I’m just telling you about my past experience with it. And some people really respond well to it, intravenously, intramuscularly or sublingually.

Clint Fantastic. Okay. Now flicking through some more questions, a lot of people are just saying what they are doing, which is great and communicating with each other. People are giving each other phone numbers to call each other and offer like a community kind of feel, which is fantastic. And again, a lot of the questions that I’m seeing here, we have covered in the bulk about content and they were posted before we answered these questions. Bob says, “I just can’t tell you how wonderful and helpful this is.” So that is really nice feedback and all. Someone’s asked, what about cortisone injections? Does this make you more prone to COVID?

Dr. Pando Not really. I mean, if you need to. What are the points that we all have made that you’d need to remain functional and meet with people moving? And if I call this an injection will allow you to strengthen the ongoing that will you it, right?

Clint I do. All right. I did manage to catch that answer as my one and a half year old came into the house. My wife is going to take him out there. Okay. We now are coming to the end of our discussion here. I just want to say thank you so much to our panellists today. It has been absolutely sensational. We’ve had no tech issues, to my knowledge. We’ve been able to hear and see everyone clearly and get some really fabulous information. And well, I want to say is very reassuring information and information that, you know, it doesn’t make us all think I know. And it’s so much worse with an autoimmune disease. I would say that for the most part, if your symptoms are well-controlled via a combination of lifestyle and medical treatment and you’re very cautious with all of the public guidelines. It’s okay and that just doesn’t lose more sleep at night because of the stress associated with that it will only going to be worse for your likelihood of getting the condition.

Clint So we into out we take those supplements and we get more exercise and we’d be mindful. We meditate, we keep moving, we keep positive and we see this thing out and we get back into our lives the way they were and we continue to be happy and positive. So I just want to say thank you to each of you. Dr. Pando, can you tell us how people can contact you? So I don’t know if you’re taking on. You might not even want to open up to new clients. But we’ve got well over 400 people here. And this replay is going to go out to a whole many more thousands. So before we go any further with this, let me rephrase this. Would anyone like to share their contact details?

Dr. Pando Let me give you my Web site, which is www.delawarearthritis.com and they can reach us through there

Clint www.delawarearthritis.com. And once again, which area do you mostly serve?

Dr. Pando I live in Delaware, so have the patients were the mid-Atlantic area

Clint Just okay. All right. But you would you take patients from further afield?

Dr. Pando Yeah. Well, we’re hoping to do now with telemedicine. We’re open to all possibilities.

Clint Open to possibilities. Okay, great. Dr. Munoz.

Dr. Munoz Yes. So I’m just putting it in the chat. I’m in Miami.  We are in greater Miami area. I’ve got a hybrid practise that is rheumatology and integrative medicine. So I’m going to give you the contact for the integrative medicine practise, which is more accessible, I think. And that is the www.theoasisinstitute.com

Clint Okay, great. Yes. If you could pop that into the chat bar. And Dr. Pando, if you could do the same and use the chat bar, which is the third icon from the top and just also put your details in there. That’d be great.

Clint Dr. Manic, tell us.

Dr. Manek I find myself in a rather unusual position. I’m in Santa Cruz, California, and I came here to set up the practice and the shelter in place came in. I was due to start practicing in brick and mortar next month. So that’s just now being pushed out. So I would just tell the viewers, stay tuned. Just look at Nisha Manek in the meantime. I have a new book, Bridging Science and Spirit. So some of my energies go into really forming the program, that routine that serves us in the long term doing all levels, the physical, the mental, the energetic and spiritual. You know, today Wall Street Journal said something I really enjoyed, Pray Up a storm, prayer work. So with it and it controls the autonomic nervous system. But coming back to my details, I hope you have a physical practice. I do telemedicine for patients who are underserved in the upper Midwest, South Dakota and Minnesota, where most of my patients are. So I do some clinical medicine through the telemedicine portal. And it’s a system that I am actually employed to. I will be looking at telemedicine on my own out of California and that I’m exploring some options here. So stay tuned and I’ll let you know, Clint, and you can put it on your site. So thank you for that.

Clint I think that’s a really good suggestion. Why don’t I have specialists here all just also email their contact information to me? And if anyone’s unsure, just email info@PaddisonProgram.com and I’ll be able to have a canned response reply and we can just have my staff just click that and it goes out and you’ll get the contact details of each of our special guests today. Let’s just close off with some comments before I say final thank you’s. So Guiney says I’m terrible at Spanish, “Muchas gracias a todas”.

Dr. Pando Thank you to everybody. That’s what it means.

Clint Diane says, Thank you very much. I echo that it has been very helpful. And she says hello to my kiddos and Melissa Melissa’s my wife that came in. Listen to this one. Teresa says, First time I have felt calm since this started. And the child. Yeah, I guess so. Like that. You can see how much benefit that is provided. First time she’s felt calm since this started. And the child in me smiles. Thank you. Okay. And then we’ve had a agree. This was very helpful in capital letters. Thank you, Clint and all. Hi to the little one. Hi. What a gift this webinar has been. Thank you so much. And then Joy, Joy is another question. I think we’re out of time for questions regarding L supplement L lysine, which is an amino acid, isn’t it? I don’t know if that amino acid either here or there. In terms of COVID, we would have no data on that. And then Donna says, thank you. What a gift this webinar has been, says Evelin. And I think that that will take us right through. Sherry says, Thank you, Stacy. Thank you so much. Kelly, many thanks to you all. Jill says heartfelt thanks to you all. So and Teresa. Thank you all so much. It has been wonderful resources, very reassuring.

Clint So you can see that the comments are really supporting supportive. And I want to echo everyone’s remarks and just say on behalf of our audience today and the rheumatoid community and the autoimmune community. Thank you so much to our guests. So. I’d really like to extend much gratitude to all of you. Thank you so much.

Dr. Manek Thank you. And muchos gracias back.

Dr. Munoz Pleasure. Thank you.

Clint Thank you. Thank you, Dr. Pando. Appreciate it. Thank you. Dr. Munoz, then. Thank you, Dr. Manek. I’m gonna close out now, my panelists. I’d like you to just stay on the line. And I’m just going to close off. We’re gonna go off the air. All the best. Stay safe. Thank you so much for joining us on this webinar. Very pleased to be able to bring this to you. And just stay safe, keep exercising, keep doing the right things. And. And I’ll talk to, another time.

Clint Paddison

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