A 19-year-old man presented with a cough but no sputum production that he had had for a few days. He had no fever or other upper respiratory symptoms except for mild shortness of breath. He had no problems with taste or smell, diarrhea, or known exposure to SARS-CoV-2. He had not been tested for COVID-19.
He was afebrile and other vital signs were normal, including an oxygen saturation of 97%. He was not dyspneic or wheezing. His CBC and metabolic panel were normal, but his chest x-ray showed bilateral infiltrates consistent with COVID-19.
Had this been October 2019, he would have been started on antibiotics and most likely admitted to the hospital. In this new era, however, he was not ill enough to be hospitalized, and according to CDC and NIH guidelines, there were no specific outpatient treatments for this patient except maybe medication for his cough.
The pneumonia was viral, so antibiotics were contraindicated, and no specific antiviral medication has been approved. The only other recommendation was to encourage the patient to return if he felt like he was dying. We are sending patients home with a deadly disease without any real management. How helpless have we become as health care providers.
Unfortunately, like everything else in this country lately, COVID-19 has become politicized. President Trump has, from very early on, touted hydroxychloroquine as a treatment for the virus, and has been met with praise and scorn for that endorsement. Some have even questioned whether his motives were financially based.
The final verdict on hydroxychloroquine has yet to be delivered, but no evidence currently recommends its use. Like President Trump, I am here to tout my own set of drugs for outpatient use in COVID-19. Zinc, vitamin D, and melatonin can possibly aid in the fight against COVID-19. Many studies and reviews support consideration of these supplements as protective or associative therapy for COVID-19.
Zinc is an essential mineral involved in numerous aspects of cellular metabolism. (NIH. July 15, 2020; https://bit.ly/33ZODRl.) It stabilizes cell membranes, may inhibit viral replication, affects viral attachment and uncoating, and acts synergistically with other antiviral medications. It also has the potential to enhance antiviral immunity, especially in elderly and immunocompromised patients, and it modulates the regulation of T-cell functions, which may also limit excessive inflammatory response. (Med Hypotheses. 2020;144:109848; https://bit.ly/2E6VSMA; Int J Mol Med. 2020; 46:17; https://bit.ly/3gWaYTq.) The oral dosage range of zinc is 8-12 mg daily, and absorption may be increased by the addition of glucose. (Am J Physiol. 1989;256[1 Pt 1]:G87.)
Vitamin D is a nutrient normally responsible for healthy bones and teeth. Vitamin D2 is absorbed from fortified foods like cereal and milk, while D3 is obtained from sunlight. Lack of vitamin D is associated with COVID-19 risk, and is not well produced in the elderly and Black people. (MedRxiv. July 1, 2020; https://bit.ly/3kJMLC1.)
It also modulates cytokine profiles of autoimmune disease in animal models by limiting excessive production of proinflammatory cytokines, such as tumor necrosis factor and interleukin-12, and it plays a major role in the immune defense of the respiratory system through direct inactivation of viral pathogens and increased recruitment of phagocytes. (Endocr Pract. 2009;15:438; https://bit.ly/34cQ7YL.) Vitamin D also especially confers benefit in patients with low vitamin D levels. (J Clin Virol. 2011;50:194.)
The oral dose of vitamin D is 800-4000 IU per day, and it is better absorbed when consumed with meals containing fat. (Nutr Rev. 2018 1;76:60.) Vitamin D level measurement is itself a controversial topic.
Melatonin is a hormone produced mainly in the pineal gland. (Int J Endocrinol. 2017;2017:1835195.) While known for its ability as a sleep aid, melatonin has been widely studied for other conditions. It reduces vessel permeability, has anti-inflammatory and antioxidative effects, exerts regulatory actions on the immune system, and directly enhances the immune response by improving proliferation and maturation of natural killer cells, T and B lymphocytes, granulocytes, and monocytes. (Life Sci. 2020;250:117583.)
Melatonin also exerts antiviral effects against several viruses, including Ebola, obstructing its replication, and it has preventive and controlling roles in oral cancer caused by human papillomavirus. It is a potential adjuvant to improve outcomes in individuals with obesity and diabetes and co-existence of COVID-19. (Eur J Pharmacol. 2020;882:173329.) The oral dosage range for melatonin is 5-40 mg per day, and it has been found to be safe even at higher dosages.
Many physicians recognize the benefits of zinc, vitamin D, and melatonin. Studies are ongoing to determine their benefits and effectiveness in COVID-19. It is absolutely essential that advice given to the public be evidence-based, accurate, and timely. (BMJ Nutrition, Prevention & Health. 2020 May: doi:10.1136/bmjnph-2020-000089.) We are in a novel era with a virus that is causing havoc rather rapidly, however. Do we wait many more months for appropriate studies to be completed, reviewed, and replicated before we provide some level of management that may be beneficial and cost-effective with few side effects?
Dr. Gaskinis an emergency physician at Atrium Healthcare in Charlotte, NC.