Dr. Kevin Winthrop 5 Questions Save

Hi, I'm Jack Cush with RheumNow. I have on the line Doctor. Kevin Winthrop from Oregon Health and Science University in Oregon, Portland, Oregon. Kevin, how are you today?

Good. Thanks, Jack, for having me. How are you doing down in Texas?

Doing great. We're surviving the COVID siege. For those of you who don't know Kevin and you should know Kevin I refer to him as the master of disaster. He knows what to do when things get rough. You and Apollo Creed, right.

I wish.

So Kevin is an infectious disease consultant who's worked with the CDC and is worked with a lot of rheumatology projects over the years and really well versed in many of our issues and our drugs. Ask them to come on and talk about some COVID issues. So Kevin, first, what do you first, this is a two part question. What are you telling your patients? And what's your version of social distancing?

Yeah. Well, those are great questions. Everything's an evolution, Jack. I think everyone's, the answers to those questions seem to be changing every couple of days as the perception of risk changes. I'd say my patients have grown much more anxious the last two to three weeks, as I'm sure yours have as well.

And what I'm telling my patients is, hey, this is time to hit the pause button. It's time to focus on you and your health and try to figure out how to be the healthiest you can be with regards to nutrition and exercise. Really, I'm encouraging my patients to go outside, one hour a day and exercise. Now, I'm also encouraging them to do that alone and to maintain social distancing, which I guess plays into your second question. But particularly as the weather gets nicer and particularly older people, people who really honestly, it's not beneficial for them to be sitting around the house all day doing nothing.

They need to really try to be exercising to the best ability that they can, you know, physically. And so, some of that can be done inside obviously, but I think it is healthy to get outside. Obviously, where I live in Portland, it's a little different than say New York City. I mean, we can all pretty much go outside and we're not gonna have a crowd of people all around us. And that might be different in places like Madrid or New York or other places.

But I think by and large, I'm really trying to focus patients on, or focus my message to patients on really focusing on themselves and their health and really a message of primary prevention. You don't want to get this stuff, particularly if you're older and have a variety of comorbidities that you're aware of. So a lot of rheumatology patients are in this category of high risk. And then there's immunosuppressants, which we can talk about later. But a lot of these folks, you just wanna avoid this stuff.

So the way to do that is to focus on your own health and make your immune system as strong as it can be by yourself with nutrition and exercise. And the other thing is just to stay away from people as much as you can. So most of us are in these stay at home type, shelter in place type orders. I don't know if you guys are, we are, a number of states are. And I think pretty much everyone will be if they're not already.

But that doesn't preclude going outside and exercising with the social distance. So, now social distance is six feet. That may be one or two more feet than you need to be. I mean, I think the risk of catching COVID on a hiking trail or on a beach is unbelievably small if you're at least three, four feet away from someone. I mean, chance that someone coughs or sneezes, and that droplet hits you in the right spot from that distance under, you know, with wind and sun and all those things going on is pretty low.

So, mean, right now, public health authorities have kind of settled on the six foot distance. I think that's a great distance. It's very, think it's probably very conservative in terms of the estimate. But I think five or six feet away seems really reasonable. Obviously, if you're with your spouse, it's different, or if you're with your kid, it's different.

You're quarantined with that person, you can probably hang out with them. But I have a lot of patients who are older. They're not seeing their grandkids right now. They're not seeing their kids right now. And I think that's warranted.

I think I would lay low if I was at high risk for the next four to six weeks until hopefully some of the dust settles.

So I want to underscore a few main points there. One, hit the pause button. Two, exercise. Three, lay low. Four, we should be having this conversation on the beach, meaning me and Grenada, you and Maui, and we could do this very effectively.

Oh, it'd so much nicer six feet away from you, Jack. Right now, feel too distant.

Well, know, we hear a lot of talk about the drugs that we use, you know chloroquine hydroxychloroquine the IL-six inhibitors but you talked last week at room now live about baricitinib and the research on baricitinib showing that it is a inhibitor of which is important and viral endocytosis which is how the virus gets into the cell and they're working on drugs that basically inhibit viral endocytosis. My question is how good is that data for paracitinib? Does this also extend to the other JAK inhibitors and what else should we be looking for in new therapies or things that are good for our patients?

Yeah, that's a great question. I guess my answer is tripart. One is, you know, the question is always coming up, what the patient is on and whether they should stop it. And my answer, think has been consistent with your answers and others experts that we think disease control is really important and we think interruption of disease control potentially leads you to other therapies we're less excited about like steroids in terms of risk. So, think stopping or starting DMARDs because of the fear of COMAR right now, I wouldn't recommend it.

Number two, are some riskier than others? And obviously the JAKs as a class have this issue with increased viral infections. Most of that has to do with, I mean, really all of it, at least what we've appreciated so far has to do with reactivation of latent viral infections, which really has to do with cell mediated immunity and some other factors. But really, we don't know a whole lot about the risk of new viral infections. And is it elevated?

We think it probably would be, knowing how the JAKs work. And I think it probably should be, but we don't know really. And we don't know that even if you have an elevated risk of getting it, what is your risk of getting bad, having a bad outcome? They're really two separate concepts. You have this increased risk potentially of getting something, and then you have the risk of once you've got it, are you going to have a bad outcome?

Are you gonna get really sick or not, or die? And they're kind of two separate concepts, and you can see like somehow these drugs are being looked at. The IL-six inhibitors are being looked at in people who are already in the second concept. They're already really sick. We're trying to see if we can limit the badness associated with being really sick, limit ARDS and sepsis and death.

And the risk or the benefit of that type of drug might be very different on the front end than it is on the back end. And so you can make these hypothetical ideas or statements with regards to a lot of the drugs. Baricitinib is one of those. So I don't know that there's any data. I know that there's some theoretical understanding about how berry works that I, to my knowledge, is different than the other JAKs in terms of inhibiting the kinase you mentioned, which is important to viral endocytosis.

So I think theoretically, berry could be protective in terms of initial infection, whereas the other JAKs might not. But again, that's completely theoretical. I don't know of any data looking I at mean, there's We

other more research. We need to hear more before we make a definitive Yeah. Assessment on

I was just going to say losartan. I mean, there's a lot of drugs this Losartan, what? Yeah, exactly. More Thank God I have hypertension. I'm on losartan.

You know, I mean, there's an RCT for losartan too for the same reasons. It seems to, theoretically, it might diminish endocytosis of the virus and protect pneumocytes or alveolar cells. So these, again, these are just ideas, that deserve to be tested. But there's a number of other compounds on this list too. There was a nice publication two or three weeks ago in Lancet that kinda went through this mechanism of what drugs might diminish viral entry into cells and therefore be protective upfront.

So baricitinib was on that list. All right,

we'll find that citation and tweet it out to people. You know, a number of us are getting questions about getting tested, truly on the basis of sort of like seven degrees of Kevin Bacon contact meaning, you know, I was in the grocery store and then I had I found out one of the check the clerks there came down with COVID. Do I need to be tested? How do you handle that kind of issue and the need for testing?

Yeah. Since you're in the paper today here, I mean, have been critical of our health department because they haven't been releasing that type of information about people who've been tested. And I'm in complete support of the health department. What are you gonna do with that information if you're a person that shopped at whatever grocery store and last week someone positive. Well, first of all, here you can't even, until recently, you couldn't even get a test.

So, mean, just knowing that wasn't gonna help you because you couldn't get tested unless you're really, really sick and a high suspect for COVID. Now, that's changing now that we're starting to have more testing capabilities. I don't know what yours are like there. Ours are still very limited. We can order, I can order a test on a patient in the clinic, but I won't know the result for three to five days.

So this is changing rapidly. Next week, it's gonna be different. We're gonna have a lot more capacity as a lot of these universities come online. I mean, we're gonna start doing our own tests. One of the hospital systems here started doing their own tests.

So we're gonna have a lot more capacity locally. And I'm sure that'll be the case across the country. But, you know, I would not, use that kind of information to go seek out a test. Certainly, if you're symptomatic, you should be going to seek out a test. I don't really see the rationale at this point for testing mass numbers of asymptomatic people, even if you could.

Someone has to keep track of the test results. Someone has to report them to the health department. The health department has to take some action and have a plan to deal with positive tests. And so, certainly folks and people who are sick or symptomatic makes sense, both as a clinician, as well as a public health entity. And then, you know, in terms of testing asymptomatic people, that might be something that has great value in certain settings where you're trying to, you know, maybe release a quarantine around a certain setting or allow a certain group of people to do a job or do something like a healthcare worker, testing healthcare workers, for example, to make sure they're clear before they go work.

I mean, you can come up with a lot of different settings and scenarios where that type of targeted testing might be useful, but we're not there yet. We're still weeks away even from that capacity to have that conversation. So we should probably talk more in a couple of weeks.

Yeah, you might've just noticed I put my hand up to my mouth and I realized, oh, I'm gonna have to edit that out. You know, this past weekend, Chuck Todd on Meet the Press asked two political people. What is this what does success look like in this story and they both flubbed the question I had no idea what the next best thing was to look forward to. My answer was pretty quick and easy. The first success we need is a change in behavior.

Once we have changes in behavior, we've got a chance at doing what we're trying to do, which is blunt the curve and all that. Do you have a version of what's the next thing we should look forward to and say we're doing, we're doing well? What's that benchmark for you?

Yeah, I got asked by a reporter yesterday, what, when are we going to get back to normal? I said, which normal, like the new normal or the old normal? I think we're gonna have a new normal after this, Jack. I know you probably think the same. I mean, our healthcare, the way we deliver healthcare is gonna be different.

We're gonna be doing a lot more of this virtual stuff. And there'll be different ways that people interact with each other. And maybe some of our behaviors are gonna permanently change because of this. I think we'll get back to somewhat normal, but I think it's gonna be a while. I think honestly, gonna be in this type of social distancing situation where, you know, most things are closed and people are supposed to maintain their distance, you know, for at least several months, maybe three or four months.

And then after that, I don't know. I mean, I think, you know, I think what you'll see is that we'll have to make a series of risk based decisions as we go along. It's always a benefit risk analysis around should people be able to do this? Or should we open this? Should we open schools?

Should we close schools? You can go down the list. There's all these decisions that health officials and politicians have had to make. And it's a constant risk benefit and it will change. And then, you know, the things that are gonna allow us to get back to more normal are increased testing, so we can actually know who's infected and who's not.

Therapies, if we develop an effective therapy in the next four to six months, which I'm quite optimistic about, honestly. And then eventually a vaccine. So all those things are really going to allow us to change the risk benefit profile in different settings and different populations, and allow us to change the way we're living, probably more close back to normal as we go here. So to me, is, you know, limiting the potential damage to the healthcare systems, which, which I think is, was a huge risk. And I think we're starting to see that in some place in The US now.

And the other success is minimizing the number of deaths. Because I think if the infection went widespread, you've seen all the modeling and the numbers, we'd have thousands and thousands of deaths. So, I think those are two metrics of success. And then who to listen to, I think that was part of your question. I mean, I think CDC's messaging from the get go has been excellent.

And I obviously am biased to work there and I know a lot of people involved in this, but I think their messaging has been excellent. I think our own health department at state level's messaging has been excellent. I think our governor, people are critical of her being too slow, but other people aren't. And I'm not. I mean, I think, if you look at the way she's made decisions, it's been very risk benefit based and very timely.

I mean, so you can always be a Monday morning quarterback in all these situations. But I think in terms of who to listen to, like listening to the public health officials. I think they've been giving good messaging around risk and ways to mitigate your risk personally, as well as a community.

Okay. Kevin, we have you on because you're who we listen to, and we're thankful for you to take the time today. We'll talk to you soon about this same subject, I'm sure. Take care of yourself.

All right, you too, Jack. Don't touch yourself or anyone else. See you.