CORONAVIRUS (COVID-19)
UPDATE
As part of Southwestern Health’s commitment to providing you resources to meet the increased needs of your patients and to keep our community healthy, please read this information and share it with your colleagues and office staff. We will continue to produce updates with the latest clinical, operational and practice management information and tools. Thank you for all you are doing to meet the challenges of COVID-19.

PHARMACY UPDATE

Disclaimer: We are receiving frequent COVID-related questions about drug concerns and potential interactions. This information is as April 23, 2020. We will do our best to keep you up to date with this ever evolving situation. This is the most update information at the time of publication.  
VITAMIN D

Evidence that vitamin D supplements reduce the risk of developing COVID-19 is lacking, but having healthy vitamin D levels can enhance immune health. Despite some evidence suggesting a role for Vitamin D in reducing the risk for certain viral infections (below), no studies have shown a benefit in Vitamin D supplementation in the prevention or treatment of COVID-19 infections.

Background: Vitamin D is an essential fat soluble vitamin. It can be found in some foods, but is also produced endogenously from exposure to sunlight 1 . Vitamin D and calcium help to maintain bone health; however, it is also a part of modulation of cell growth, neuromuscular and immune function and reduction in inflammation. Deficiency is more common in the winter months because of lack of time outdoors and reduced daylight hours.
Vitamin D is believed to reduce the risk of viral infection in multiple ways and has been the subject of multiple reviews in the literature. Three main mechanisms for Vitamin D reducing the risk of the common cold and other viruses have been proposed: physical barrier via impacts on cell junctions, cellular natural immunity effects that include impacts on potentially reducing cytokine storm, and influences on adaptive immunity 2 . Most of the literature supporting vitamin D comes from observational studies with variation in outcomes seen within randomized clinical trials. The role of higher 25(OH)D concentration in reducing risk of infection and death from acute respiratory tract infections, including influenza, CoV, and pneumonia has been suggested by current evidence. However, additional well designed, randomized clinical trials are still needed to determine the optimal dose and populations who may receive benefit from its use, outside of supplementing those who may have a known deficiency 3

A recent randomized control trial with critically ill, vitamin D naïve patients with respiratory failure demonstrated that high dose vitamin D3 regimens given over 5 day days increased plasma vitamin D levels > 30 ng/mL by day 7, which was sustainable through day 28. The data suggested that high-dose vitamin D3 supplementation favorably influenced hospital LOS 4 .
  1. NIH fact sheet
  2. Rondanelli, M.; Miccono, A.; et al. S. Self-Care for Common Colds: The Pivotal Role of Vitamin D, Vitamin C, Zinc, and Echinacea in Three Main Immune Interactive Clusters (Physical Barriers, Innate and Adaptive Immunity) Involved during an Episode of Common Colds-Practical Advice on Dosages and on the Time to Take These Nutrients/Botanicals in order to Prevent or Treat Common Colds. Evid. Based Complement. Alternat. Med. 2018, 2018, 5813095. https://pubmed.ncbi.nlm.nih.gov/29853961/
  3. WB Grant, H Lahore, SL McDonnell, CA Baggerly et al. Evidence that vitamin D supplementation could reduce risk of influenza and COVID-19 infections and deaths. Nutrients 2020, 12(4), 988; https://doi.org/10.3390/nu12040988
  4. JE Han, JL Jones, V Tangpritcha, MA Brown eta al. High dose vitamin D administration in ventilated intensive care unit patients: a pilot double blind randomized controlled trial. J Clin Transl Endocrinol. 2016 Jun;4:59-65. doi: 10.1016/j.jcte.2016.04.004. Epub 2016 May 5. Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4939707/
MELATONIN

At this time, there is no evidence to support the use of melatonin for the prevention of COVID-19. Despite some evidence suggesting a role for melatonin in reducing inflammation and improving immune function (below), no studies have yet shown a clinical benefit with melatonin supplementation in the prevention or treatment of COVID-19 infections.

Background: Melatonin is an endogenous hormone that mainly helps regulate our circadian rhythm. OTC melatonin supplements are marketed as a natural sleep aid. However, melatonin has also been studied in various other indications, including depression, tardive dyskinesia, and cancer 1 . Studies have suggested that melatonin has anti-inflammatory, anti-oxidative, and immune enhancing features, which has resulted in alleviating acute respiratory stress caused by viruses and bacteria 2,3 . The assumed mechanisms by which this occurs are complex. It is proposed that melatonin plays a major role in suppressing the release of pro-inflammatory cytokines and pro-oxidative enzymes, while enhancing the response of natural killer cells, T cells, B cells, and macrophages 2 . Because of these properties, it is theorized that melatonin may be advantageous as adjunctive therapy for the inflammatory response and respiratory effects of COVID -19. Overall, melatonin is well-tolerated, even in high doses. It has very few adverse effects, including dizziness, headache, nausea, and sleepiness 2 . However, there is no evidence to prove that melatonin is effective in treating COVID-19. There is an upcoming clinical trial which plans to evaluate if melatonin will prevent COVID-19 among healthcare workers 4. 
  1. IBM Micromedex® DRUGDEX® (electronic version). IBM Watson Health, Greenwood Village, Colorado, USA. Available at: https://www-micromedexsolutions-com.ezproxy.ttuhsc.edu/ (cited: April 20, 2020).
  2. Zhang R, Wang X, Ni L, et al. (2020). COVID-19: Melatonin as a potential adjuvant treatment. Life Sci. 250(117583). doi:10.1016/j.lfs.2020.117583. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7102583/
  3. Nabavi SF, Habtemariam S, et al. (2017) Melatonin and Respiratory Diseases: A Review. Curr Top Med Chem. 17(7), 1-22. https://www.researchgate.net/publication/306947607_Melatonin_and_Respiratory_Diseases_A_Review
  4. Instituto de Investigación Hospital Universitario La Paz. (2020). Efficacy of Melatonin in the Prophylaxis of Coronavirus Infectious Disease 2019 (COVID-19) Among Healthcare Workers (The MeCOVID Study). (Clinicaltrials.gov Identifier NCT04353128). Accessed from: https://clinicaltrials.gov/ct2/show/NCT04353128 on April 22,2020.
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