This article is about the “8th Day Therapy” concept developed by Dr Shankara Chetty from South Africa, who has treated some 4,000 COVID-19 patients and has studied at the same time the pathogenesis of the disease and fine-tuned his treatments.
The article starts with an introduction, to put into context the importance of Dr Chettty’s findings. It then presents transcripts from parts of the webinar we had on April 30 with him, Dr Ira Bernstein and Dr Peter McCullough. The quoted material is about a) how to treat the disease; b) how to risk stratify; c) how this approach could help India; d) how to avoid Long COVID. You are of course invited to watch the full webinar, which can be found at the link at the bottom of the article.
Dr Shankara Chetty is a Family General Medical Practitioner in South-Africa. He has a considerable experience with the outpatient treatment of COVID-19. He holds a degree in medicine and surgery and also has advanced education in genetics, advanced biology, biochemistry and microbiology.
When it comes to outpatient treatment for COVID-19, the bulk of the attention has been given to date to the viral phase of the disease, and to treatment within say 3 days of the first symptoms. Many of the best known early treatment protocols combine drugs and supplements with the goal of reducing viral replication and curbing the progression of the disease.
On the other hand, much less attention has been given to how to best treat the inflammatory phase of the disease. For sure, we have heard about corticosteroids, such as dexamethasone, found effective in the RECOVERY clinical trial. We also heard about anticoagulants, to prevent thrombosis. Yet much less common is the consideration of this phase as a type of hyper-sensitivity reaction, calling for the use of antihistamine drugs such as promethazine.
In addition, the importance of the timely and “agressive” treatment of the second phase of the disease, with the appropriate drug regimen, has not been emphasized so far. This is something that Dr Chetty has uncovered for several months now. He stresses the need to aggressively treat on the eighth day after the first symptoms, if there are symptoms, even mild, on that eighth day. In other words, he urges to treat the second phase of the disease early and aggressively, with the appropriate regimen of drugs. This approach applies to all the variants, including the “double mutant” now spreading like wildfire in India.
A conventional approach to early treatment is to suggest that intervention in the first 3 to 5 days is key to curbing the progression of the disease. Here, what Dr Chetty indicates is that there is a second and maybe even more important window for implementing early treatment, which is not mutually exclusive from the first window. It’s to aggressively begin treatment on the eighth day of the disease, with corticosteroids and anti-histamines, if the patient has not fully recovered yet from the disease.
This symptoms oriented approach to treating COVID-19 helps to address the complex issue of risk stratification, and to answer the question of who to treat and who not to treat. For Dr Chetty, the severity of COVID-19 is likely related to a hypersensitivity reaction to a previous exposure to SARS-CoV-2 or a similar virus, rather than just age or presence of comorbidities.
According to Dr Chetty, this explains why there are younger people suffering from severe forms of the disease in the second wave of the pandemic. But this also provides for a therapeutic solution: even if no early antiviral treatment was given at first symptoms, or such anti-viral treatment did not prove effective, it’s still possible to treat aggressively the disease, on the eighth day, at the very beginning of the inflammatory phase, with a cocktail of corticosteroids and antihistamines. In most instances, this 8th day treatment can still be done on an outpatient basis.
This understanding of the pathophysiology of COVID-19 has important therapeutic and health policy implications. COVID-19 can indeed be controlled early through two separate interventions: one in the viral replication phase, and one in the beginning of the inflammatory phase, when symptoms such as dyspnea are observed.
From a health policy viewpoint, this strengthens even further the case for the disease to be treated at home, on an ambulatory basis, with these two types of treatments. The challenge of course is to get policy makers to understand and accept this outpatient approach. But the outcome would most likely be a quick drop in hospital and ICU admissions and a considerable reduction in severe disease, in Long COVID cases and deaths.
Even if the inflammatory phase would remain treated in hospital, which is not necessary, this novel therapeutic approach, centring on the eighth day, would need to be incorporated in hospital treatment protocols, typically requiring changes in the existing hospital level treatment guidelines for COVID-19.
About Treating at the 8th Day
“Before corona came to my country, I had the feeling that there were some parts of the pathophysiology of that disease that we were not understanding correctly, leading patients to hospitalizations. My focus was to understand the pathogenesis of coronavirus.”
“I endeavoured to see every positive patient from the first day, so I could understand the evolution of this disease before the patient got to hospital. I had particular interest on the dyspnea that was sudden in onset and leading patients to hospitalization.”
“Very early on, I understood that the dyspnea that sets in seems to have a specific time in the disease. It was very quick in onset, there was differences in speed and severity, but it always seemed to present on the 8th day.”
“Some of the patients recovered by the 7th day and had none of the symptoms that occurred from the 8th day onwards.”
“From very early on, I was of the opinion we were dealing with some kind of hyper-sensitivity reaction. … Quite early on, I started steroids and patients improved … and then I attempted antihistamines.”
“I tried, on a patient who was critically ill, a dose of promethazine and … oxygen saturation returned to 95% within 24 hours. There was a remarkable improvement. This got me to understand that we were dealing with an hypersensitivity reaction.”
“Remarkably, the majority of patients that I saw, excluding those with bacterial infections or co-infections, reported symptomatic improvements and recovery by the 6th or 7th day. There were also those patients who recovered within a day or two. A majority reporting feeling better by the 6th or 7th day.”
“Irrespective of that improvement, there were patients who developed dyspnea on the 8th day. The dyspnea that developed had no bearing on the severity in the initial 7 days.”
“I had patients that had a soar throat on the first day, it resolved on the second, they spent the rest of the week perfectly fine, engaging in strenuous activities. And then on the 8th day, they started to notice in the morning the onset of dyspnea, and by the afternoon, were completely breathless and showing drops in their oxygen saturation.”
“I started to treat this as an hypersensitivity reaction. I found that the antihistamines, particularly antihistamine 1 & 2 blockers, for the respiratory and gastro-intestinal tracts respectively, showed great benefit, immediately.”
“In the second wave, we had much more patients presenting with gastro-intestinal symptoms. Those who presented with a reaction on the 8th day presented with far more severe reactions.”
“My work showed that we are dealing with a bi-phasic illness: a viral illness during the first 7 days, and on the 8th day, some sort of trigger of hyper-sensitivity, that leads to a release of mediators, histamine being one of them.” …
“My protocol quickly evolved to include ecotrin/aspirin and montelukast” …
“With hyper-sensitivity, the most important thing is to start treatment early. The longer you leave it, the cascade of mediators will result in other sequalae and culminate into a cytokine storm.”
“But like with other hyper-sensitivity reactions, if caught early, they are easy to cut in.”
“So my entire focus became the eighth day. When patients came into my practice, I would Interrogate them about the onset of the symptoms, the exact day they started feeling unwell.”
“I would then advise them about what might transpire exactly a week later, which is the eighth day, and what symptoms to start looking for.”
“In the second wave, I notice there was a collection of symptoms that seemed to idle the onset of this hypersensitivity reaction, and not necessarily dyspnea, but body aches and pains.”
“This seemed to be very typical of an allergic reaction, that you would see with rheumatoid arthritis, with joint pain. There was fatigue, to the point that patients wanted to sleep, or the onset of dyspnea.”
“I educated patients about these symptoms, and that they should not discount these symptoms, even if it was a solitary symptom and mild. Any change from the 7th to the 8th day should be reported.”
“I think that patients understood the gravity of what I was saying, and reported back on the 8th day.”
“That allowed me to run certain testing, to see if I am dealing with a complete switch on that day. The common blood tests that I ran are CRPs and Interleukin 6. I found drastic changes from the 6th day to the 9th day. It showed something was happening at the time that was showing a spike in these inflammatory markers.” …
“With that kind of treatment, I had very good clinical recovery of my patients, and in a very quick space of time.”
“I did have those that presented too late, that required longer treatment to get the reaction under control. But all my patient showed quick recovery. A majority of my patients, 99% of them, had recovered completely within 14 days from the start of this reaction.”
“In all, I have seen close to 4,000 patients, excluding those I have treated over the telephone. None of my patients have had Long COVID symptoms. None of my patients have been hospitalized so far, they were always treated at home and managed at home.”
“To this day, I have no oxygen in my practice. I never found the need for it. Patients recovered relatively quickly, even those with low, or even very low saturations. … Within a day or two, they were comfortable on room air.”
About Risk Stratification
“My perspective about risk stratification is different. In the first wave, we saw a lot of people over 55 getting this illness. I have had patients over 55 who were very healthy and ended up critically ill. And I have had patients who had 2 stents, diabetes, high blood pressure and the rest of comorbidities and they had very mild illness. So I did not look at risk stratification as the rest of the world did.”
“I looked at this that, in the first wave, people over 55 were probably exposed to an allergen similar to coronavirus and those that were allergic had developed the relevant antibodies to have an hypersensitivity reaction. The younger population were naïve and so for a first exposure would not react at all. So they would have a mild illness and this would pass off. But it was my expectation that, in the second wave, because these patients were sensitized, we would see a far younger population presenting with hypersensitivity or mortality or morbidity.”
“That’s exactly what we saw in South Africa. In the second wave, I found a large proportion of the population, of the younger population, infected. It was more the age group from 25 to 45 that were infected in the second wave. My take on that is that it is a proportion of the population that was previously unsensitized, and got sensitized in the first wave, and in the second wave, on re-exposure to the allergen, that presented with hyper-sensitivity.”
“I got a 9 year old patient, the youngest patient I had, who had a very severe reaction on the 8th day. He is one of the few kids that I have had to treat. But I had 25 year olds presenting very severely ill, and if they were not attended immediately, would have ended up in critical care in hospital. So I think my way of looking at this is to treat whoever presents with symptoms on the 8th day. That needs to be addressed.”
What Advice for India?
“I think that a lot of the patients who are presenting in India are in the hypersensitivity phase of this reaction. I think prompt treatment is vitally important, and it would negate the need for oxygen, hospitalization, and take off all the pression out of the health care system.”
“I would actually suggest that doctors set up a system where they could examine patients, but start immediately on simple treatment that could stop the reaction from progressing. I found that a healthy dose of steroids, of anti-histamines to treat the symptoms … I have seen clinical recoveries in a few hours. This is the type of interventions we need: simple, yet addressing the call, that would curtail lots of these deaths and pressure on the hospital system.”
“We got to understand that, past the 8th day, killing a virus is not going to solve the problem. It’s going to waste time. Every day lost will create a lot of problems in the way we deal with this. We got to be quick to it. We got to be simple to it. And we got to be effective in treating it. And I think that’s what needs to be put on. A simple dose … 80 mg of prednisone; with a simple anti-histamine. Treat the symptoms as you see it. … it will at least buy you time to address the complications.
About Long COVID
“As well, mild symptoms untreated show there is Long COVID. I think that Long COVID is mild hypersensitivity going untreated, and it would result in all these sequelae that we see. Because in the patients that I have treated, I haven’t had one come back with a complication. And I haven’t had a case of Long COVID yet. Every patient that came to me with symptoms on the 8th day got treated. The action stops right there. So I haven’t had patients coming back with fatigue and all the things I have heard about around the world.”
Watch Our (2 Hour Long!) Webinar:
Watch also this webinar by Philipp McMillan, focusing on India
http://www.modernmedia.co.za/modernmedicine/DigitalEditions/mm2008-2009-august-september-2020/html5/index.html (go to page 23 and turn the page)