By Esther Landhuis, Undark Magazine

In January 2020, Martha Eckey was working at a retail pharmacy in Champaign, Illinois, when she developed a sore throat, hacking cough, and stiff neck. A second bout of illness struck about a month later, leaving the pharmacist with a persistent fever and shortness of breath. Covid tests were unavailable at the time, but she tested positive for influenza.

The biggest challenge was “crushing, debilitating fatigue,” she told Undark. “No amount of sleep left me feeling even remotely refreshed,” she added by email. Three-and-a-half years later, Eckey has still not recovered.

Shortly after her initial illness, Eckey started reading about people with lingering post-Covid symptoms, and although she never knew for certain which virus caused her initial illness, those symptoms seemed strikingly similar to hers.

After connecting with patients navigating these conditions, Eckey wondered if she had developed myalgic encephalomyelitis/chronic fatigue syndrome, or ME/CFS, a long-lasting illness that can crop up after a viral infection.

She went to see several physicians, but they “told me they were not taught about post-viral illnesses,” she recalled. “It literally wasn’t in their curriculum.” Eckey had not learned about post-viral syndromes in her four-year doctor of pharmacy training, either.

Long Covid and ME/CFS are complex illnesses. Up to 2.5 million Americans live with ME/CFS, and more than 65 million people worldwide may have long Covid — though estimates vary and the dozens of symptoms across multiple body systems can make these conditions hard to define and diagnose. In some people, symptoms linger or intensify with time, but in others they occur weeks or months after recovery from the initial infection, which could be mild or undiagnosed.

In a recent analysis of 9,764 adults enrolled in the federally funded initiative RECOVER, long Covid patients fell into four subgroups based on symptoms, many overlapping with ME/CFS and other conditions. By studying biological samples from these participants, researchers hope to identify markers that can inform future trials of potential therapeutics.

Yet for now, despite an influx of research funding, there are no widely accepted treatments approved by the U.S. Food and Drug Administration to ease sufferers’ symptoms. In that void, desperate patients have turned to a range of proposed solutions — from microbiome treatments to vitamin supplements to experimental techniques like “blood washing” — to find relief. In this vast array of possible therapies, some are exorbitant and most are unproven.

Eckey quit her pharmacy job in August 2020 to search for useful patterns amid that chaos. Unlike most national initiatives and large academic research programs, Eckey is employing a bottom-up approach: She polls patients on which interventions they’ve tried and how they fared, in the hope that this crowdsourced knowledge might contain valuable insights for improving long Covid care.

While surveys like Eckey’s come with inherent limitations, some researchers think such grassroots efforts can help inform more rigorous studies.

“Large clinical trials cost millions of dollars, and it’s impossible to test hundreds of different things at once,” said Akiko Iwasaki, whose lab at the Yale School of Medicine studies the immunology of long Covid. “Knowing what has benefited the patients already provides us with insights that can be tested in future trials.”

Medications and Supplements

Late in the summer of 2022, Eckey, known to social media followers and Substack subscribers as LongCovidPharmD, created several surveys using Google Forms and shared them on Twitter (more recently rebranded as X).

One of the surveys listed about two dozen medications — including Paxlovid, statins, and beta blockers— and had respondents tick boxes for the ones they had tried. It asked them to indicate if taking the drug seemed to “moderately improve,” “vastly improve,” worsen, or have little to no effect on long Covid symptoms or quality of life. Other sections asked if they had conditions that commonly occur alongside ME/CFS or long Covid, such as dysautonomia, mast cell activation syndrome, or a history of blood clots.

Eckey also grew curious about supplements — a category that includes probiotics or enzymes, herbs, minerals, vitamins, and other over-the-counter products with suggested uses that are not regulated by the FDA. In social media posts, she noticed that people commenting on supplements would say, “‘Oh, that didn’t work at all for me,’ and then other people say, ‘oh, that cured me,’” she said.

So she created another survey, listing eight types of supplements and asking to what extent they seemed to help with fatigue, cognitive function, and other symptoms. Motivation for that survey also came from Eckey’s own frustration with being unable to get any prescribed treatments, she said: “I thought, ‘Well, I think I just have to figure out how to treat myself.’”

With more than 200 respondents, the surveys gave a sense for which types of supplements seemed most helpful. Additional surveys focused on the most promising supplements — which doses were used and for what frequency and duration, whether patients improved or felt worse, and which symptoms patients noticed seemed to be affected.

Eckey analyzed the results and started posting detailed summaries on X. Then, in late 2022, her work caught the attention of the Open Medicine Foundation, a California-based nonprofit that has raised $40 million to diagnose and treat complex, multi-system diseases including ME/CFS, long Covid, and others that have eluded doctors.

No Approved Treatments

ME/CFS and long Covid have no FDA-approved treatments, and neither has a definitive diagnostic. The situation echoes that of early days of AIDS, which, decades ago, was defined by symptoms rather than measurable changes inside the body, said Wenzhong Xiao, a computational biologist at Harvard Medical School who directs the foundation’s efforts on ME/CFS treatments.

Regulators typically validate medical treatments through a formal application that specifies the substance’s composition and how it’s made. The application also proposes further study in clinical trials, which generally won’t launch without supportive data from smaller pilot studies. When the Open Medicine Foundation came across Eckey’s work, the organization was already trying to decide which potential treatments to test in pilot studies for long Covid, and was making a registry from which to recruit patients. 

Building on her initial surveys with information gleaned from published trials, case studies, patient feedback, and her “own pharmacist intuition,” Eckey created a more comprehensive version, called “TREAT ME,” and tweeted it on Feb. 5, 2023. 

The survey — which, by Eckey’s account, took about 1,000 hours to produce — covered more than 150 medications and supplements. After collecting details about a person’s symptoms, lab tests, and medical history, the survey asked about treatments: whether they appeared to help, which symptoms improved, how long it took to see benefits, how long the benefits lasted, and whether they were outweighed by side effects. If a medication did not seem to help, the survey asked how long it was tried and at which doses.

“No one has done that deep a dive,” said Linda Tannenbaum, the CEO of the Open Medicine Foundation.

By the time the survey closed for analysis in late March, the responses had climbed to nearly 4,000.

Survey Bias

Despite the potential, surveys have unavoidable, inherent biases that can influence how data is collected and results are interpreted, said internist Lucinda Bateman, founder of the nonprofit Bateman Horne Center — a clinical care, research, and educational organization in Salt Lake City, Utah, that focuses on chronic, complex disorders including long Covid. First, there’s selection bias: Who decides to participate and why? There’s sampling bias: Who never hears about it? There’s also non-response bias: People for whom a treatment has little to no obvious effect may be less likely to participate. 

Surveys also hinge on participants’ own accounts, which aren’t typically confirmed with other sourcing. Eckey’s survey, for instance, relied on respondents to indicate whether they had an official or presumed diagnosis of long Covid or ME/CFS.

The approach also can’t typically account for the placebo effects that result from other factors besides a specific treatment or from other ongoing illnesses or treatments, which may skew the results. And beyond the difficulties with diagnosing long Covid, people may “think they got sick during the pandemic, and it’s entirely something else,” said Bateman. The uncertainty in the data is “just what happens when you do surveys,” she added.

Eckey agreed with these caveats, noting that she tried “to limit bias to the extent that I could.” For instance, to ease non-response bias, the survey instructions encouraged participants to rate treatments “even if they had no effect,” she said.

She also prompted participants to specify underlying conditions and treatments, and responses could be filtered accordingly. And Eckey included one supplement that she believed would have little to no impact on symptoms, figuring questions about it “could act as a sort of ‘placebo’ against which other treatments could be compared.” On a similar vein, she asked about several treatments that were hyped at various times and found their reported benefits to be “underwhelming” or not statistically different from related drugs.

The supplement industry is vast and largely unregulated, with many products lacking solid evidence for health benefits. Research to produce that evidence is a complex, costly process that requires FDA input, often participation from the company that produces the supplement, and approval by an independent ethics committee. What’s more, such trials must follow a company’s best guess on the right doses, optimizing the supplement’s benefit while minimizing side effects.

This approach comes with substantial risks for illnesses like long Covid, which cause a range of symptoms that differ from one person to the next, said David Putrino, director of rehabilitation innovation for the Mount Sinai Health System in New York. A single treatment won’t necessary work for all of them, Putrino, who studies and treats long Covid patients, added in an email, and “you feel like you only have ‘one shot.’”

Eckey’s survey, he said in a phone interview, “allows me to actually make data-driven decisions on what seems to be working.”

The approach is already prompting new studies. Some researchers think that certain long Covid symptoms stem from tiny blood clots; more than 60 percent of Eckey’s survey respondents said they felt better after taking supplements containing enzymes that break down fibrin, the main protein that forms the clots.

These results helped Putrino and colleagues choose one of the enzymes, called lumbrokinase, for a long Covid trial planned for early 2024.

The Open Medicine Foundation team is also using the survey results to inform drug trials. In a more typical trial, the group mines published scientific literature and uses machine learning to predict which medications might help. These analyses would have likely missed lumbrokinase, since it appears in relatively few academic research papers, Xiao said. Based on Eckey’s survey findings, he said, his team is “definitely thinking about doing follow-up studies.”

Beyond her dataset, Xiao added, Eckey is herself is an inspiration: “I can imagine how much effort she put, despite her own symptoms, to make this happen.”

Eckey’s lingering fatigue still keeps her mostly housebound — and, on some days, stuck in bed — but she told Undark via email that her cardiovascular symptoms have improved. On her better days, she said, she plans to volunteer at a free ME/CFS clinic that treats post-Covid patients: “My desire to get better and help others in similar situations is what keeps me going.”

Esther Landhuis (@elandhuis) is a California-based science journalist and a senior contributor to Undark. She covers biomedicine at all stages — lab discoveries, clinical trials, biotech, healthcare and its intersections with law and business. Her stories have also appeared in Scientific American, Nature, Medscape, JAMA, Science News, Quanta and other outlets.

This article was originally published by Undark, a non-profit, editorially independent online magazine covering the complicated and often fractious intersection of science and society. You can read the original article here.