Cases Surge, Chloroquine and Zinc Treatment Combo, Italy Lockdown (Lecture 34)
Welcome to another MedCram covid-19 update. We see here that the total recovered is 16 times that of the total deaths, and we can see here that the Active Cases are once again starting to come back up again. That’s because of the activity outside of China.
In terms of today, March 10th, we can see that there are a number of cases in multiple countries all over the world. Of course, the news from yesterday is that Italy has decided to extend its lockdown to not just the north of Italy but to all of Italy.
In terms of yesterday in Spain, the number of cases has essentially doubled, with 557 new cases, and that seems to be a new hot spot.
I can tell you as of yesterday, I was able to get a lab test out of a commercial test company that I needed to have done in a patient in the emergency room. So I’m hoping that that is going to increase dramatically here in the next week or so.
We’ve talked about zinc here a couple of updates ago, but the story is not done. It’s kind of an exciting story that gives me some cautious optimism in terms of covid-19, but to understand this better, we’ve got to go back and look at the molecular biology of the cell once again.
Here is the nucleus of the cell. In the nucleus of the cell is the DNA. The DNA is a double-stranded string of nucleotides, which are the codes. Those codes are transcribed using RNA polymerase into RNA. That RNA then goes out of the nucleus, gets to a five Prime cap and gets to a 3 Prime poly A tail, and it’s ready for ribosomes to come on to read that code, and that code is then translated into the code of amino acids. Amino acid after amino acid will turn into a polypeptide, which turns into a protein. Proteins are how the cell gets things done.
这是细胞的核。 DNA在细胞核中。 DNA是核苷酸的双链字符串，即密码。使用RNA聚合酶将这些密码转录为RNA。然后，RNA从细胞核中出来，到达5个Prime帽，到达3个Prime poly A尾巴，并准备好让核糖体继续读取该代码，然后将该代码翻译为氨基酸代码。 。氨基酸之后的氨基酸将变成多肽，再变成蛋白质。蛋白质是细胞完成工作的方式。
So moves by proteins actin and myosin, it can bind oxygen through hemoglobin; it can do cellular metabolism. All of those enzymes in glycolysis in the citric acid cycle. All those things that you learned in biochemistry. Those are all enzymes. Those are all proteins. So that’s the normal situation.
Now enters coronavirus. Coronavirus has its own genome. It is made out of RNA, and that RNA just happens to have a five-prime head and a poly A tail. So when it pops into the cytosol, it’s going to be read by those same ribosomes that can’t tell the difference except this time, instead of making a protein that’s useful to your cell, this RNA that comes out of the virus is going to make something called an RNA-dependent RNA polymerase.
It’s this enzyme right here that is going to read from the 3 Prime end to the five Prime end of the viral RNA and replicate it. So this RNA-dependent RNA polymerase makes more viral genomes. It’s also known as replicase for that reason. There’s something that has been shown to inhibit this replicase, and that is zinc. Zinc will shut down RNA-dependent RNA polymerase or replicase. That is what we learned.
The problem is how do you get zinc inside the cell. The problem with zinc is that it’s an ion. It’s a 2+ ion, and ions cannot get through the cellular membrane unless there’s a transporter that allows it to come in. In fact, the way that they tested this in the paper is with an ionophore, which allows the zinc to come into the cell so they could see that the activity of this RNA-dependent RNA polymerase was reduced.
This is the paper “Zinc inhibits coronavirus RNA-polymerase activity in vitro and zinc ionophores block the replication of these viruses in cell culture.” When they looked at the SARS-cov virus, that was the one that was seen back in 2002, as the zinc concentration inside the cell went up, you can see that the byproduct of the RNA-dependent RNA polymerase went down, clearly demonstrating that zinc intracellularly is going to block this very important enzyme of the virus.
Well, that’s great. We’ve got zinc that’s going to block it. But how we gonna get zinc inside the cell? It’s one thing to say that you’re going to take zinc supplements. But how do those zinc supplements, first of all, get absorbed into your body, into the blood, into the extracellular space? And then finally how you going to get that zinc from the extracellular space into the intracellular space in the cytosol where it needs to work on these infected cells and these viral proteins?
Well, that’s another thing, altogether. What you need is some sort of ionophore, or some sort of gated mechanism, to open and to allow that zinc to come into the cell, increasing the concentration of zinc into the cell, so it can block RdRP.
Well, enter this paper. That was pointed out by some of you commenting: chloroquine is a zinc ionophore. This paper was published back in 2014. The point of this paper was something completely different. They weren’t thinking about coronavirus. They probably didn’t even know perhaps that’s zink blocks RNA-dependent RNA polymerase. What they were looking at here is that zinc may help some of these cancer cells basically eat themselves in the lysosome, which are the trash compactors of the cell.
By giving chloroquine, you could have these cancer cells disappear. Well, in doing that research, they found out something that’s very interesting to us because of that finding. This research came out of the University of Oklahoma and some institutions in China.
So this is what they used: chloroquine diphosphate. Here’s the structure of that compound. This chloroquine is a medication that has been around for decades that is used to treat malaria. It’s not under patent, and it’s pretty dirt cheap and widely available. However, you do need a prescription to use this, and it doesn’t come without side effects.
What they show is that they were able to detect intracellular zinc by checking its fluorescence. Here on the x-axis, we have increasing concentrations of chloroquine. The white bars represent those cells that were bathed in only 5 micromolar solution of zinc chloride, and the black was in ten times that amount at 50 micromolar ‘s concentration of zinc chloride.
What you can see here is that in the normal situation, if you’re able to get some zinc into the cells, this is the amount of zink you ‘ll see inside the cells. So this is the amount of concentration outside the cell. This is the amount of zinc you see inside the cell.
Let’s just look at this same concentration, 5 micromolar. When you bathe the cells in chloroquine, you can see how much this intracellular zinc concentration goes up. In fact, if you look at the amount of zinc inside the cell, by just adding a small amount of chloroquine here at 10 micromolar, we would get more zinc inside the cell than if we increase the concentration of zinc outside the cell tenfold. That’s how powerfully chloroquine will increase intracellular zinc concentration. Remember, this is chloroquine. This is a medication that’s been used by millions of people already with known side effects, and it’s pretty well tolerated.
Here’s another example from the article. Here, we have the control group, the five micromolar of zinc chloride. Then what we do is we multiply that extracellular zinc concentration tenfold, so it’s now 50 micromolar. This would be the equivalent of just saturating the extracellular fluid compartment with zinc and see if it tries to get into the cell, which is what you’re trying to do when you take zinc lozenges essentially.
You can see there’s hardly any effect. It is minimal, and that’s because zinc is an ion; it’s a positively charged ion. Positively charged ions will not get into the cell unless there is a gate that allows it to go in. There are gates that allow it to come in. That’s how it’s very tightly regulated. But chloroquine activates those gates, so you can see this is at 50 micromoles of zinc chloride, we can go back to the 5 micromoles here.
Just adding 300 micromoles of chloroquine lights this thing up like a Christmas tree. You can see here if we go to 50, it lights up even more. But the biggest effect is not the jump in the zinc concentration. It is opening those gates that allow you to get the zinc into the cell. Presumably, when that zinc gets into the cell, it’s going to block that viral enzyme.
In the discussion, we’ve got the conclusion of the matter. The conclusion that chloroquine is a zinc ionophore is based on the detection of significantly elevated intracellular zinc levels when both zinc and chloroquine were added to the cell culture medium.
So the question is: is this being used. To that I turn to Korea Biomedical Review: “Physicians work out treatment guidelines for coronavirus.” Notice that this is published here on the 13th of February when they were starting to see an uptick in their cases in Korea. The article goes on to say Korean physicians treating the patients infected with the new coronavirus, covid-19, have established the treatment guidelines for the unprecedented coronavirus.
The key guidelines are the following. If patients are young and healthy, then they will be observed. If more than 10 days have passed since the onset of the illness, they’ll continue to watch them. But notice what happens if the patients are old, have underlying conditions, or sick and have symptoms. They say here for antiviral treatment, the doctors recommend lopinavir and ritonavir. This is basically the medication kaletra, which is an HIV medication, and they recommend two tablets twice a day, or they can use chloroquine, 500 milligrams per day orally. In Korea, chloroquine is not available. So they use a very close relative of chloroquine, which is hydroxychloroquine. That’s at 400 milligrams orally per day.
Now the reason why you would not want to use both is that they interact with each other in a negative way in terms of prolonging the QT interval. For those of you who don’t know what the QT interval is, this is a measurement of electrical conduction in the myocardium in the heart. If the QT becomes too prolonged, you can get fatal cardiac arrhythmias.
In this article, they do talk about the antiviral treatment lasting about 7 to 10 days, but it could be shortened or extended. Here is one of the keys that I want to mention. This is all being used empirically. We don’t have randomized, controlled trials looking at chloroquine in patients with covid-19.
That being said, there have been some publications interestingly coming out of China, which talk about the efficacy of chloroquine. Now I have to say at this point that it’s a little bit interesting that that’s happening from my standpoint and from the standpoint of somebody who understands what a randomized controlled trial. That’s blinded sets, because if you are truly doing a blinded study, you will not be able to tell if an intervention is working or not. That’s the whole point of a blinded study, and that is to avoid bias.
For instance, if you know that someone’s getting the intervening choice, you might be doing a better job of taking care of that patient without even knowing it. So it’s a little interesting to hear that there may be some efficacy. So the improvement in some of these patients, unless it was unblinded study, and if it’s an unblinded study, then it has to be taken with a grain of salt, and that’s why we really need a randomized, placebo-controlled, double-blind, ideally type of study.
Anyway, here is an article that is indexed: “expert consensus on chloroquine phosphate for the treatment of novel coronavirus pneumonia.” This was published in February 2020, and says here the previous studies have shown that chloroquine phosphate or chloroquine had a wide range of antiviral effects, including anti-coronavirus.
Here found that treating the patients diagnosed as novel coronavirus pneumonia with chloroquine might improve the success rate of and improve patient outcome. In order to guide and regulate the use of chloroquine in patients with novel coronavirus pneumonia, the multicenter collaboration group developed this expert consensus. It is recommended chloroquine phosphate 500 milligrams twice per day for 10 days for patients diagnosed as mild, moderate and severe cases of coronavirus pneumonia and without contraindications to chloroquine.
So interestingly, the Koreans are using, according to the literature, once a day, and the Chinese were using it twice a day. Now that is all to say if we look at South Korea numbers. Of course, we know that they have extensively tested, and this is my hypothesis. If you extensively go out and try to find as many cases as you possibly can, then you set up a standardized treatment regimen and get people on that regiment early, you can see here that even though Italy and South Korea have very similar total cases, the number of deaths is an order of magnitude different.
The number of serious and critical is more than an order of magnitude different between them. One has to wonder either the tip of the iceberg is much much smaller on a very, very large iceberg in terms of Italy, or there is some sort of systemic treatment difference between what is going on in Italy and what is going on in South Korea. At this point, I don’t know how widespread chloroquine use is in Italy, but it’d be interesting to find out.
We will end on this where they talk about the trials of coronavirus. Data from the drug studies showed certain curative effects with fairly good efficacy. Chinese National Center for Biotechnology Development Deputy Head Sun Yinrong said that chloroquine, an anti-malarial medication, was selected after several screening rounds of thousands of existing drugs.
According to Sun, patients treated with chloroquine demonstrated a better drop in fever, improvement of lung CT images, and required a shorter time to recover compared to parallel groups. The percentage of patients with negative viral nucleic acid tests was also higher with the anti-malarial drug. Chloroquine has so far shown no obvious serious adverse reactions in more than 100 participants in the trials.
Getting back to our idea here of what’s going on in molecular. We’ve got zinc here that needs to shut down RNA-dependent RNA polymerase. What we’re saying here is that chloroquine is going to somehow open up this ion gate and allow the zinc to come in to block and shut down viral replication inside of the cells. I think that’s exciting. I’m cautiously optimistic that this may lead to something. But again, I have to stress that we need randomized controlled trials to prove this.
Many times we come up with ideas that make sense, and look like they should work, but the proof is in the pudding, and we need to do the randomized controlled trial. We’ve got a lot more areas to hit on this coronavirus. One of the things that we’re going to look at is the ACE 2 receptor. I have a lot of questions about the ACE-2 receptor, and I will talk about that in the upcoming updates.