It wasn’t until about the end of April 2020 we started to get Covid cases in Arkansas. We had probably the first case in Washington County with a young man who had returned from New York City with Covid symptoms. Shortly thereafter with the large outbreak at the local poultry plants, we had approximately a 1/3 of the first 100 cases in the state as our Lowell office has a high percentage of Hispanics and Marshallese that work in poultry. With it taking a while to hit Arkansas my coworkers and myself were able to read up a bunch on Covid treatment options others were using all over the country and all over the world for that matter. From reading about the experiences of others, reviewing older studies involving Doxycycline and Montelukast, and having experience with viral infections for the last 20 years, our initial treatment regimen for Covid positive patients was Doxycycline 100 mg bid x 7 days, Montelukast 10 mg a day for 7 days along with Vitamin D3 5,000 I.U. three times a day, Vitamin C 1000mg three times a day, and zinc 50 mg three times a day all for 1 week. For patients being exposed to Covid at work or home we initially recommended Vitamin D3 5,000 I.U. twice a day, Vitamin C 1000 mg twice a day, and Zinc 50 mg twice a day. Our initial management of Covid with these regimens seemed to work well. About the time of the poultry plant outbreaks there were also the large deadly outbreaks around the state at other correctional facilities. Knowing what a disaster it would be for Covid to break out at Washington County Detention Center, the states 2nd largest jail, we started giving all inmates upon intake a prophylactic vitamin regimen of Vitamin D 3 5,000 I.U., Vitamin C 2,000 mg, and Zinc 100 mg daily for 14 days. While other Arkansas correctional facilities were devasted by early Covid outbreaks and the Marshal project showed Arkansas had the second-highest prison infection rate in the U.S., we were able to keep Covid out of the detention center until ???
During that time period we had approximately 30-40 of our clinic patients that ended up in the hospital with 6 of them passing away. We made contacts with almost all of the local hospitals and followed most of our patients daily by talking with their physician’s or nursing staff. All of this was a valuable clinical learning experience in the presentation and natural course of Covid. At some point in time when the hospitals in northwest Arkansas were very full with primarily poultry plant workers and their families, I recommended on a Facebook post that the local plants temporarily close for safety precautions.
The initial wave of Covid passed by and we were hit with a second Arkansas wave primarily among college students around the start of September 2020. We were extremely busy with this and there were days when we had 90 patients lined up waiting to be seen before our doors even opened at 9 a.m. at our Fayetteville office. This wave the patients were younger and healthier, and I don’t remember any seriously ill patients during this time. We kept with our initial treatment regimen. It was during this college wave that myself and my family contracted Covid. My wife and I took the regimen of meds plus I did IV vitamin C as well. My teenage son did fine with no treatment.
It was shortly after this that studies from England started showing steroids were effective in lowering mortality in treating Covid during the second path immunological/immune dysregulation phase of the disease. Some of the first patients I remember using high dose steroids on were my turkey hunting partner and his wife. They had exposure and had cold symptoms for about 7 days and were both getting sicker. They tested positive and I gave both of them DepoMedrol 160mg IM, plus the previously described medicines.
The third wave which was the general community wave started in October, 2020. Information and studies continued to come out on repurposed medicines that might be beneficial in treating Covid. After further reading and discussion with a colleague of mine that was the most well read and up to date on Covid pathology, I decided to first try ivermectin on about a 50-year-old Hispanic gentleman that came into the Lowell clinic with a high fever and low oxygen saturation. He was very sick and I hooked him up to an IV of vitamin C 25 grams and while it was running in, I went over to the pharmacy and had them fill his prescription of 10 ivermectin 3mg tablets and gave it to him and he took the first dose. A few days after this, one of my employees’ father- in- law came in looking very sick and I started him on all the meds plus ivermectin and IV vitamin C. At that time from the different studies I’d seen, physicians were using Ivermectin .2 mg/ kg on day 1 then repeating that dose on day 3.
During this time a patient had told me about the Frontline Covid Critical Care website. It was a very thorough and professional website. I also watched some educational YouTube videos with a Dr. Paul Merrick M.D., a medical school professor and one of the founders of the Fl-CCC. At that time, their protocols were similar to the ours with the main difference being we were using montelukast and they were using an over-the-counter medication called quercetin. I discussed this with my pharmacist friend John Lykins, the owner of the Lowell pharmacy. He said that quercetin and montelukast have similar properties that probably help with the cytokine storm that takes place in Covid. I actually emailed Dr. Merrick in regards to this and sent him one of the articles I had on montelukast. He responded back that he had heard of Montelukast use in Covid treatment but hadn’t had a chance to review the literature on it.
Since then, I have had many correspondences back and forth with Dr. Merrick and other members of the FL-CCC. During the general large public wave in Arkansas, I came down with my second covid infection Christmas morning. This second infection I was much more symptomatic like influenza and bedridden for two days but my symptoms resolved quicker than the 10 days of fatigue associated with my initial infection. For my Christmas infection on top of our regular treatment meds and two days of IV vitamin C, I also took ivermectin on day 2 and day 3. My 11-year-old son who hadn’t gotten infected the first go round ended up getting a mild infection this time and did well with no treatment.
The start of 2021 there was more literature coming out on the use ivermectin for prevention of primary infection. At this time, we started offering it to our patients and I started taking it myself and had my mother, step dad, step mom, step aunt and uncle’s and my wife’s mother and father on it while they were waiting for vaccines to come out. We followed the FL-CCC dosing guidelines for this with the 0.2 mg/kg on Day 1, then Day 3, and then every two weeks. We changed our guidelines to weekly around April and have kept them here. The FL-CCC now recommends twice weekly dosing for prophylaxis but after discussion with Dr. Merrick and a search of the literature we kept our regimen at weekly Ivermectin dosing for prevention.
Another major adjustment of our treatment regimen came in February of 2021. From the very start of Covid there had been strong correlations with low vitamin D levels and poor Covid outcomes. Hence our early treatment of Covid with what I considered high dose Vitamin D. One of the great sources I found early on was a 100-page E-book by two retired professors of medicine, https://vitamindwiki.com/tiki-index.php?page=Vitamin+D+Deficiency+and+Covid-19%3A+Book+by+Drs+Anderson+and+Grimes+-+July+2020. Then in February 2021 good studies came out of Spain and India where they using very high dose vitamin D resulting in significantly decreased mortality in hospitalized patients. Having done some follow up labs on some of our clinic patients that were getting what we considered high dose vitamin D and seeing that their levels were still low, we started using Vitamin D 50,000 for 3 days on our higher risk patients. Through all community wave we had great results with our treatment regimen and only had a few hospitalizations and no known deaths.
The prolonged community wave came to our area and for months we used our regimen with the addition of ivermectin with great success. By the end of this wave, I was very confident of our treatment regimen and thought that we could get almost anyone at any stage of their illness. We then had a relatively good few months, April, May, and June in Arkansas where we had little covid. It was during this time that we stopped our two weeks of vitamins for prevention at the jail and switched to a one-time dose of Vitamin D3 100,000 I.U. on first day of intake for inmates. Then in late June we started to get a few cases of Covid and Southwest Missouri was getting hit very hard with the new Delta variant. We initially started with the same regimen we had been using that worked perfectly on the previous 330 cases at the jail. Through our first 20 or so new cases at the jail, the inmates did great with them having little to no symptoms and recovering quickly. While fear was spreading about the Delta variant hitting Arkansas, I was really optimistic. I did an interview with the local news station which they did not air. On that Friday with one of my normal Facebook updates, I posted exactly what we were seeing with this new variant and how everyone was responding well to treatment.
Unfortunately, I woke up Saturday morning to a desperate Facebook message to Karas Healthcare from the wife of a 29-year-old patient we had treated two Fridays before. She was begging me to do anything I could help with her husband. He had come to us on day 7 or 8 of his illness. He had been diagnosed about a week earlier in the local ER and sent home with no treatment. When we saw him in clinic, he looked pretty good clinically but had an oxygen level of 94% and had a heart rate in the 120’s. We gave him a shot of DepoMedrol 80 mg IM, Decadron 10 mg po, and started him on all of our other meds, including Ivermectin, Singulair, Doxycycline and vitamin C,D, Zinc. The wife informed me that he got to take one dose of the meds but the next day was admitted to the local hospital where his treatment meds were discontinued. The wife stated he was intubated on Wednesday and that they were trying to get him on ECMO at UAMS. I talked with the local attending and they weren’t able to get him on ECHMO as he was already in renal failure and that was exclusion criteria. I kept in contact with the wife almost daily until he passed away.
It was the next week in the clinic where we started to see multiple really sick patients. The Delta variant was hitting harder and faster and making men age 30 to 55 extremely sick. After seeing this along with talking to some of my local colleagues working in the hospitals, we started implementing our current MID-D3 100,000 and C-Caleb (some of the C-Caleb guidelines come from direct discussion with Dr. Merrick and the current inpatient FL-CCC guidelines as patients that would normally be admitted to the hospital were now being sent home with home 02) regimens more uniformly with all our clinic patients and implemented the current jail protocol. The slight difference between jail protocol and clinic regimen being we kept the .2-.4 mg/kg Ivermectin dosing on our jail patients. We did this as none of our initial 20 to 40 cases of Delta at the jail where we have men primarily in the high-risk category for Delta, showed any clinical signs of severe disease. Our jail patients are treated extremely early in the disease and we monitor their pulse and oxygenation twice daily for 10 days. Our jail protocols have worked perfectly including approximately 170 cases of the Delta variant. Unfortunately, this new Delta variant has been brutal on our clinic patients. We have averaged about 200 patients a day for the last 6-8 weeks and I have worked every day since July 10th and been physically at the office all but 2 of those days. We are ready for Covid to go away. This brief description of Covid in Arkansas and our treatment approach can be supplemented with pictures by reading all of my Facebook Karas Healthcare posts since this started. Ironically when Covid first started my mother called all panicked from Indiana asking if I were taking care of Covid patients. I responded jokingly, “Yes Mother, thousands of them.” Unfortunately, at this point it’s probably 10,000.
The prolonged community wave came to our area and for months we used our regimen with the addition of ivermectin with great success. By the end of this wave, I was very confident of our treatment regimen and thought that we could get almost anyone at any stage of their illness or of trouble.
We then had a relatively good few months here in Arkansas where we had little covid.
Dr. Robert Karas