My self treatment plan for Covid
With a focus on limiting damage and the chance of long haul syndromes
It’s good to be prepared. To game out scenarios before they occur. My personal plan for dealing with Covid infections has changed over the past 4 years. Thankfully we have much better options and lower risks than when this first started. Cocktails of hydroxychloroquine, ivermectin, and famotidine were never a good idea, but I understood the desperation. Now we have evidence-based treatment protocols from sources such as the National Institutes of Health [www.covid19treatmentguidelines.nih.gov]. They are pretty cautious and conservative, and mostly recommend treatment for high risk individuals.
But if you look at the list of what qualifies someone as high risk, it includes being overweight. At least 75% of the US population is overweight, and 42% are obese. Even people who are physically inactive are considered high risk. Only 50% of the country meets minimum targets for exercise, and only 25% for aerobic and muscle-strengthening activity. 57% of us are over age 50, and risk steadily increases with age. And there is nothing magically protective about being 48.5 years old compared to a more rounded number of 50.
I’m not telling you what to do, and I provide no personal advice herein, but many of the clinicians and thought leaders I follow consider these guidelines for treating high risk individuals a bare minimum. Many highly motivated patients expect more. I’m going to show my cards. First I’ll review why I hate Covid, and why I’m not just focused on preventing hospitalization and death like most of the guidelines. Next I will review why viral load matters, why viral persistence matters, and how even mild infections can damage our chassis beneath the hood. I’ll discuss what my plan definitely includes, and a few other measured bets. And finally I’ll remind you that having a plan includes having rapid antigen tests ready, and knowing what you want when discussing treatment options with your doctor. Many trivialize Covid treatment, obsess over a “rebound” that the CDC has concluded is not a thing, or do not recommend antivirals beyond a casual mention because we are fatigued by skepticism. Or poorly informed.
I’m also writing this post now because several friends currently have Covid. They asked me what I would do when infected. Plus, there was an excellent editorial in The Washington Post this week by Dr. Leana Wen entitled “The under-prescribing of Paxlovid may be our biggest Covid policy failure.” She notes that only about 15 percent of high-risk individuals who contract the coronavirus are prescribed the drug. Elsewhere I’ve read 25%, which is still low.
Doctor treat thyself. It’s okay to look over my shoulder. Here are my answers for myself. You will see that I’ve been studying hard, and writing furiously all morning.
Firstly, I acknowledge that the majority of us will be fine during and after Covid infections. I think. Especially younger people. But I’m not sure long-term, with infection after infection. No one really is. Remember that we called this a “novel coronavirus” when it first came out. At four years it’s still novel compared to the viruses we have decades and centuries of experience with. I also acknowledge that socially, psychologically, economically, and rationally most people have moved on. To some degree I have, too, but I’m not a gambler by nature. As a middle-aged man, I’m not hedging my bets so much against severe disease and death as I am against billions of viruses taking a cumulative toll on my body. I’ll avoid it when I can, and treat it when I can’t.
Secondly, it’s important to frame why I hate Covid so much, as this underpins much of my thinking. Covid is still killing 1,000 to 2,000 Americans each week. Most of these deaths are in the elderly. It continues to cause long Covid symptoms and syndromes ranging from cognitive problems, shortness of breath, autonomic nervous system dysregulation, immune system damage, gastrointestinal problems, post-exertional malaise, chronic fatigue, chronic chest pain, and chronic cough to name just a few. According to a 2022 CDC study, an estimated 18 million Americans have experienced long Covid, with 8 million chronically affected. Higher numbers of viruses have been correlated with disease severity, and the persistence of viruses in our bodies has been proven to be one of the several mechanisms by which long Covid can occur.
I learned an aphorism in medical school attributed to Sir William Osler: “The physician who knows syphilis knows medicine.” In other words, syphilis can potentially damage everything, and so mastering knowledge of this condition goes a long way towards understanding the many faces of disease and pathology. So it is with Covid in the 21st century.
Still trying not to get Covid is worth it. We can respect the waves and have some behavioral flexibility. Ventilation rules. Good masks help when you want to deploy them. Vaccines have helped reduce short and long term risks tremendously. Boosters and updated seasonal Covid vaccines have helped even more. I stay up to date on every single one. I acknowledge that some people have been harmed by the vaccines, and we don’t know the long term risks of it repeated vaccinations yet either. But the evidence has been overwhelmingly trending towards this: vaccines overall good, Covid infections overall bad. Getting sick from worthwhile events that maintain friendships and family seems worth the risk to me. This virus will be here for a long time. Maybe future nasal vaccines will be game changers. Maybe they won’t.
And so now that I’ve laid a little groundwork, here is what I’m thinking about treatment for myself.
If I have symptoms, even a “mild cold,” I’m going to test several times. Covid is often not showing up on rapid antigen tests. As I highlighted in a previous post, tests are accurate only 30% - 60% of the time on the first day of symptoms, rising to 80% - 93% by the fourth day of symptoms. But other studies show this number decreasing in the messy real world; perhaps rapid tests pick up only 34% of infections. If a close contact or family member has Covid and I get symptoms, I’m going to assume that it is Covid, too. If I feel like I’ve been hit by a truck, I’m going to get tested for influenza via urgent care.
When I have Covid I’m going to treat that. I want to lower the number of viruses in my body by 10-fold as quickly as I can.
Dr. Leana Wen summarized the recent data on treatment quite convincingly:
According to research from the Centers for Disease Control and Prevention, people who took the antiviral pills were 51 percent less likely to be hospitalized compared with those who didn’t. A 2023 study from the Kaiser Permanente health system found that when taken within five days of symptoms emerging, Paxlovid was nearly 80 percent effective at preventing hospitalization or death.
A new National Institutes of Health study involving more than 1 million patients supports this. The paper, which is online but not yet peer-reviewed, reports that Paxlovid reduces mortality from covid-19 by 73 percent, but it also found that the medication was prescribed to less than 10 percent of eligible, high-risk individuals between December 2021 and February 2023. If uptake were 50 percent, nearly 48,000 deaths could have been prevented during that time.
48,000 deaths would be like a 9/11 terror attack in 16 cities. Can you imagine the rage and mobilization that would occur if New York, Los Angeles, Chicago, Houston, Phoenix, Philadelphia, San Antonio, San Diego, Dallas, Austin, Jacksonville, San Jose, Fort Worth, Columbus, Charlotte, and Indianapolis each lost 3,000 people to planes flying into skyscrapers? It’s outrageous that we don’t care about a simple prescription going unwritten or unfilled that could prevent this. If uptake were 100%, that would have saved about 100,000 lives - the equivalent of preventing a 9/11 style attack on 32 American cities all the way down to Albuquerque.
I’m going to take an antiviral. I have no contraindication to taking Paxlovid. I’m taking a full 5 day course, and maybe 10. There is much speculation that 5 days is not enough. People love 5 day courses of treatment like Z-Paks, but there is nothing universally valid about the number 5, except that we have 5 fingers on each hand and are partial to base 10 numbers. I want my immune system to crush SARS CoV-2 viruses, and I want to disable their protease enzymes used in replication. Paxlovid reduces viral loads by 90%, and the sooner the better. Less viruses everywhere in my body. Lower viral loads are associated with less severe disease, less transmission, and less collateral damage from infection. Paxlovid has been shown to reduce long Covid by up to 25% in several studies, although consistent proof of this involves some real challenges in data collection, syndrome definition, and ruling out other medical problems as there is no consensus diagnostic test for long Covid. A recent study showing Paxlovid did not reduce long Covid was poorly designed, not randomized, and full of potential confounding variables.
(If I were higher risk and could not take Paxlovid because of medication interactions, I would probably take molnupiravir. Remdesivir is great, has been shown to work in an oral formulation, but has not been FDA approved or licensed as a pill yet. It’s hard to find health care systems that still offer outpatient IV infusions. Simnotrelvir is a similar medication that works well, is taken orally, but is not yet available in the U.S.)
There will be no prospective, randomized, placebo controlled study to assess whether taking an antiviral like Paxlovid each time we get Covid over the next 20 years reduces our overall mortality rates, risk of cardiovascular disease, Parkinson’s disease, or immune system depletion and dysfunction. It’s just not feasible. So we ponder the puzzle pieces and vague contours and use our logic, faulty as that might be.
Addendum: here is a compilation I made of studies in defense of Paxlovid. We really should not have to be “defending” this medicine at all. The evidence is freaking clear that it helps.
Addendum - some very astute commenters pointed out that insurance coverage of Paxlovid can be an expensive problem for some. And tens of millions of people have no health insurance in America. It is a good idea as part of a pregame to call your insurance and check out hypothetical prescription coverage under your plan. If not good, or not covered, or not insured, I would also check out Pfizer’s PAXCESS program, which might take the financial barrier down for many people.
I should also mention that Paxlovid can cause GI upset, and often leads to a metallic, gross, temporary alteration of taste while taking the medicine… and always read through possible side effects of any medication. At least they are listed as compared to OTC supplements.
I’m going to take metformin. Although the evidence for this is not overwhelming, an influential but overlooked study called the COVID-OUT trial was published this summer in The Lancet and showed:
…a large, placebo-controlled randomized clinical trial which enrolled volunteers across the United States. The study found:
Those who received metformin were more than 40% less likely to develop long COVID than those who received an identical looking placebo.
For participants who started metformin less than four days after their COVID symptoms started, metformin decreased the risk of long COVID by 63%.
Metformin has some plausible mechanisms for why it might help reduce long covid, including immunomodulatory effects, complement system protective effects, blunting damage of dopaminergic neurons, and mitochondrial protective effects.
The dosing used in the study was 500 mg of metformin on day one. 500 mg twice daily on days two through five. And then 500 mg in the morning and 1,000 mg at night on days six through fourteen. I wrote about this back in March of 2023. Most people are not interested in taking metformin. Recall that only 10-25% are even taking Paxlovid for one reason or another.
Addendum 12/2024: These studies also show impressive results for using metformin with Covid:
Research presented at IDWeek 2024 found metformin prescribed within 6 days of infection reduced long Covid or death by 53% over 6 months in non-diabetic patients. The study used electronic health records to simulate a controlled trial, showing 4.0% of the metformin group developed long Covid/died versus 8.5% in controls. This builds on previous evidence that metformin has obvious potential as an inexpensive, safe treatment option for preventing long Covid.
Another randomized trial (of just 20 people) found that 60% of those taking metformin vs 100% of those given a placebo had detectable SARS-CoV-2 viral loads by day 4 of testing. This comports with previous studies showing one way that metformin works is by reducing viral loads.
I’m going to use a nasal saline spray. Such a low tech and time honored technique gets little respect, but anecdotally nasal saline sprays make me feel better when I’m sick with rhinosinusitis symptoms, and there is good evidence for benefit in most upper respiratory tract infections. One of the most widely read posts I’ve written was about the fancier nasal sprays like Enovid, Betadine Cold Defence, and Xlear. I didn’t manage to convince myself that they are worth adding to my self-treatment regimen, but they might have an accessory role in my efforts to prevent Covid when I’m not wearing a mask in high risk/density situations. Maybe they would help during infection, too, but for now I’m going to stick with boring nasal saline.
Addendum 8/2024: So this new study published in The Lancet Respiratory Medicine gives us even more confidence in the low risk, potential reward of nasal saline/beta-carrageenan: Researchers investigated the effects of nasal sprays on respiratory illnesses compared to usual care. Conducted in the UK with 13,799 participants at risk of adverse outcomes from respiratory illnesses, this randomized controlled trial found that both gel-based (beta-carrageenan) and saline nasal sprays significantly reduced the duration of illness compared to usual care (by 1.7 and 1.8 days on average, respectively).
That’s better symptom resolution than Paxlovid was able to achieve with Covid, by the way, and better than Tamiflu with influenza. Intuitively it makes sense that creating an unfriendly nasal mucosa for viral replication factories likely reduces the potential severity of disease, viral load, and other good things.
Addendum 8/2024: I also wrote about a study showing intranasal neomycin (Neosporin) paradoxically helped both prevention and treatment of Covid in mice and hamsters, with a similar mechanism of action but no proof in humans yet. I’m keeping an eye on this, but people are not recommending it as treatment as of this writing.
Addendum 1/2025: Nasal antihistamine sprays liked chlorpheniramine? Probably not as I review in this post.
If I were on a statin, I would either continue it, reduce the dose, or switch to pravastatin depending upon which statin I was taking. I wrote a note on Substack about this recently. While holding a statin for 5-10 days is probably not a game changer since statins are generally considered long game medications, I do have some concerns about that. We now have proof that coronaviruses can directly invade coronary arteries and plaque, inducing inflammation via macrophages that can contribute to worsening coronary artery disease. Statins not only reduce our cholesterol, but they also tamp down the inflammation in atherosclerotic plaque. As immunomodulators they are probably most critical to continue in the weeks and months after Covid infections. Indeed, a study found no benefit of starting simvastatin in hospitalized patients with Covid in terms of mortality in the hospital… but statins are a long game medication and it just makes intuitive sense to me that we should try to stay on them during Covid infections. Statins have been shown to be associated with decreased mortality after influenza infections.
Switching to pravastatin for a week or two, which does not interact with Paxlovid, would be easy enough. Here is a pdf I made using the University of Liverpool’s Covid-19 Medication Integration Checker (a resource endorsed by the CDC and NIH, among others). I’ve listed atorvastatin, rosuvastatin, and pravastatin for comparison:
Addendum 2025: In a meta-analysis (published in The American Journal of Medicine) of 7 RCTs (N=4262), adjunctive statin therapy for hospitalized COVID-19 patients reduced mortality with a 12% relative risk reduction and improved clinical severity scores compared to no statin therapy, with no increase in adverse events.
I might take a probiotic. We know that Covid messes up the gut microbiome, and that damage to the gastrointestinal system and microbiome are among the multiple pathways that cause long Covid symptoms. I’ll wait for better evidence before committing to this though. Maybe probiotics help, and maybe they don’t.
I’ll keep the prebiotics going. Possibly more important than taking probiotics is feeding the good bacteria we already have in our guts. Fruits, vegetables, fiber, whole grains.
I’ll drink plenty of water, and maybe some green tea. Compounds in green tea extract have been shown to have antiviral and anti-SARS CoV-2 properties, but not convincingly enough to recommend green tea as a treatment per se. But I like tea, warm beverages help with vasodilation and hydration anyway, so it’s all good. This conclusion from a research paper is fraught with confounders, but harmless enough to consider:
Using pharmacological and ecological approaches, we found that EGCG as well as green tea inhibit the activity of the omicron variant 3CL protease efficiently, and there continues to be pronounced differences in COVID-19 morbidity and mortality between groups of countries with high and low green tea consumption as of December 6, 2022. These results collectively suggest that green tea continues to be effective against COVID-19 despite the new omicron variants and increased vaccination.
I’m watching studies on aspirin, and while there are positive trends, aspirin carries an increased risk of bleeding. I am not yet convinced as few guidelines recommend it, but I'm watching (1, 2, 3). Given the increased risk of blood clots and thrombotic cardiovascular events during and after Covid, physicians naturally think of what thinning the blood might accomplish. We really need more randomized trials of longer durations here.
I’m going to avoid sugar. It’s just not good for us, and increases inflammation that is already sky high with Covid.
I’ll probably eat some mushrooms. I like shiitakes the best. Maybe they help. Mushrooms are known to boost the immune system which could be particularly helpful in the first 5-6 days of infection, but could theoretically contribute to the harmful cytokine storm that some people develop after that first week. A few mycology and immunology sources online were mostly pro-mushroom with respect to fighting infections.
I plan to exercise lightly, paying attention to my body, muscles, and how activity feels. If it feels bad, or if I’m really sick, I’ll chill but keep moving around and puttering.
After I emailed this post, an astute commenter pointed out that in some people, especially those developing long Covid, exercise can actually damage muscles and over stress mitochondria in the weeks during/after illness. This would be felt by the person as a new kind of post-exertional malaise, muscle pain or soreness out of proportion to the intensity of the exercise, or basically just feeling like crap after exercise. I also recall that early in the pandemic there were reports of athletes and others exerting themselves too vigorously in the month or two after Covid illness and then developing arrhythmias which can be lethal. So in summary, I’m going to listen to my body regarding exercise and not be dogmatic. I’ll probably take it down a notch for a month after illness.
Hopefully I’ll sleep 7-8 hours a night.
Addendum 12/2024: Melatonin? Probably not. I don’t think there is as much outcomes data supporting melatonin, though it has some promising mechanisms. I think it also goes through the same hepatic CYP enzyme metabolism as Paxlovid, which could be problematic. This seems right to me after a brief review of limited quality studies and Perplexity:
“Current evidence from clinical trials on the use of melatonin as a treatment for COVID-19 is limited and inconclusive. While some studies suggest potential benefits, such as improved recovery rates and reduced inflammation, these findings are based on small sample sizes and exhibit low certainty[2][3][9]. Meta-analyses highlight melatonin's anti-inflammatory properties but note no significant impact on mortality or consistent clinical outcomes[4][9]. Ongoing research is needed to determine its efficacy, and experts caution against using melatonin as a standalone treatment without medical supervision[4][8].
I’ll take a multivitamin once a day, since I’ll probably be home and remember to do so for a change. I don’t plan to buy anything else like Vitamin C or Zinc.
Summary
Hopefully this has been a helpful look over the shoulder. I’ll keep this conclusion ultra quick. I plan to keep trying not to get Covid, but realize that as a social human being it is important to live one’s life with friends and family and other people. I’ll ride the waves. Ventilation is good, masks can help, and respirators work very well. When sick I’m planning to take an antiviral and metformin. I’ll use a nasal saline spray, keep hydrated, and figure a way to minimize disruption of statin therapy if I’m taking one. I’ll focus on good nutrition, which provides vital nutrients and vitamins, and serves as a good prebiotic for the hungry good guys in my GI system. Shiitakes in the first week, mostly because I like them. I’ll avoid junk food, sugar, and other inflammatory foods. I’ll keep moving, and maybe lightly exercise if I feel like it’s a mild case. And I’ll respect my body’s need for at least 7 hours of sleep for a change.
Best of luck in developing your own game plan, and always work with your primary care doctor to do so. Hopefully this gives you some talking points!
What a sensible, well informed man you are. Thank you for sharing.
Thanks for all this! Have you found success with getting patients’ insurance to approve 10 days of Pax? Do you do 5 days and then ask for another 5 or ask for 10 days at once? Anything patients can do to help advocate for the longer coverage?