About Our Guest- Dr. Mikhail Kogan- Exploring Long Covid

Mikhail (Misha) Kogan, MD, ABIOM received his medical degree from Drexel University, College of Medicine. He completed the Social Internal Medicine Resident Program at Montefiore, Albert Einstein School of Medicine and Geriatric Fellowship at George Washington University. Currently, he serves as medical director of the GW Center for Integrative Medicine, associate professor of medicine in the division of Geriatrics and Palliative Care, associate director of the Geriatrics Fellowship Program and director of Integrative Medicine Track program at the George Washington University School of Medicine.

Dr. Kogan is founder and executive director of AIM Health Institute, a 501(c)(3) non-profit organization in the Washington, D.C. metropolitan area that provides integrative medicine services to low-income and terminally ill patients regardless of their ability to pay.

Full Podcast Transcription

Dr. Mikhail Kogan 00:01
By putting on COVID more like a litmus paper, right? So the things that we, in the past, were never managing well, now it’s in everybody’s faces. It’s suddenly like, oh, we have the pandemic, well duh, we always had the pandemic of chronic problems that healthcare had no idea what to do with. It’s just really highlighting the fact that we have to have a better process here.

Diva Nagula 00:27
Hello everyone and welcome to a another episode of From Doctor to Patient. Today, I am pleased to have Dr. Mikhail Kogan, Dr. Kogan received his medical degree from Drexel University College of Medicine. He completed social internal medicine resident program at Montefiore Albert Einstein School of Medicine and geriatric fellowship at George Washington University. Currently, he serves as medical director of the GW Center for Integrative Medicine, Associate Professor of Medicine in the Division of Geriatrics and Palliative Care, Associate Director of the Geriatric Fellowship Program and Director of Integrative Medicine track program at the George Washington University School of Medicine. Dr. Kogan is founder and executive director of AIM Health Institute, a 501(c)(3) nonprofit organization in the Washington DC metropolitan area that provides integrative medicine services to low income and terminally ill patients, regardless of their ability to pay. Today’s episode is a special recast of my appearance on his show. And I thought we’d just air it today for you all to experience.

Dr. Mikhail Kogan 02:02
I’ve had some experience for the past year and a half with this condition, we have an increasing number of patients coming to the clinic. So we kind of decided that I’ll tell them what we do and he leaves it for the book. And we’ll record this so people can watch it. And hopefully it’ll be useful for everybody. So thanks to you so much. Let’s just start with what precipitated you writing the book? And maybe tell us a little bit about the context.

Diva Nagula 02:34
I had published a book about three years ago on my experience with cancer. It was a Wall Street Journal bestseller. And what precipitated this particular book, and the content specifically, is the fact that I had suffered through long COVID. I would say it was the experience that I have had and ongoing is worse than what I have suffered through cancer. It was pretty debilitating. I contracted COVID about September of last year. I’m not vaccinated. I don’t believe that that played a role in the process of me getting long COVID. It was just a percentage game because it’s 30%… I think it’s higher of people who contract COVID get long COVID. I took one of the protocols that’s out there. Using Ivermectin I actually did get the monoclonal antibodies. I had high levels of vitamin D prior, but I used quercetin, the issue that I think that might have contributed is that at that time, the recommended dosage of Ivermectin was much lower than what it is now. Back then it was .2 mcg per kg now it’s recommended to be .4-2.6 mcg per kg. And that may have played a role, I have no, there’s no evidence. This is just basically know my hypothesis. So to describe my situation with long COVID. After about a month of contracting COVID, I would say I was starting to have major panic attacks, extreme anxiety that just came out of nowhere. And I didn’t understand why it was happening. A lot of people that I talked with say it was sort of a spiritual process. And it’s just something that I was going through. And I was also getting to the point very angry. I don’t know why, I was just angry all the time, angry at things. My focus on life was just narrowed it to one thing, and I couldn’t get out of that specific goal concentration. As time actually progressed. Symptoms actually worsened to the point where I was starting to have headaches and severe neck discomfort. In about January of this year. Three to four month. Was when I started to have debilitating pain and lack of concentration. I kind of got to a degree where socially I was isolated because I had such problems with discomfort, depression, anxiety, and lack of sleep, lack of being able to focus on a conversation with an individual. And I literally spent my weeks going to physicians, going to practitioners, whether it was the Western medical practitioner, an alternative medicine practitioner, acupuncture, I was going to see… I was doing shamanic healing. I was doing everything that I could to figure out what the problem was, not even to figure it out, just to get me on the other side of it. No one had a diagnosis, no one, because everything showed that I cleared the COVID. I was never having any respiratory issues. All of those symptoms that I had the first week or so was gone. The only thing that really remained was the brain. And I didn’t know that that was long COVID because I had cleared all the other symptoms so it didn’t even dawn on me. And so months later, I would say April of this year, I happened to have someone refer me to get a QEEG, their daughter was suffering from a concussion. I said, You know what, let me get this. I don’t know why I just feel like I should get a QEEG. I got it done. And then week or two later, I got the results. And the guy was asking me, Do you suffer from depression? Do you suffer from chronic pain? Do you suffer from heart disease? I said, no, none of this was going on. And the pain that I was suffering was from COVID, headaches and the neck pain. And he says, are you healthy? And I said, pretty much. He’s like, well, this doesn’t make sense? And then he said, have you had COVID? I said, yeah, September of last year, and he said, ah, we’re seeing problems with severe inflammation of the brain secondary to COVID. And and then it was a big thing. For me, I was like, so yeah, and that was the big aha moment for me and everyone that it was long COVID That I was suffering from. And this was six months after I contracted COVID that we determined it was long COVID.

Dr. Mikhail Kogan 07:14
Do you think that cancer you’ve had before played a role?

Diva Nagula 07:17
I think I had some deterioration in my brain, inflammation issues, it was a gradual process, I think. I had chemo brain essentially. It was 2015 when I had my last round of chemo, and I have noticed over the years that my level of concentration, my level of focus, my memory, even my mood was was somewhat difficult. It was challenging for me, and I thought it was just situational. And no, it was just chronic. So my thoughts on long COVID, in spiritual basis, it brings out things that’s going on and can exacerbate things. And spiritually, I feel you are in a place where you don’t have a lot of self love. Long COVID is common with that condition as well. All of this hit home for me in a spiritual way, as well as physical and medical, I ended up getting a round of stem cell, this new technology.

Dr. Mikhail Kogan 08:20
I was just going to ask you about that. I’m beginning to see that that’s becoming more or less… there’s not enough evidence, but there’s definitely an increased number of patients who I have seen whether… it doesn’t even matter what the cognitive decline is from, but there seems to be a clear benefit. So what was your experience with that?

Diva Nagula 08:41
So we’ll talk about this later. But I’m performing this procedure that I had done on myself, I’m trained in it. And now I’m going to start offering that. So immediately, I felt a little bit of difference after the first weekend of my procedure was like the lights went off. And I didn’t understand if that was the case or what. But then I had to repeat QEEG a few weeks later, about a month after my first and it showed that there was increased power. So across the board, all the frequencies that were measured, there was a doubling of amplitude. And I see a lot that was secondary to the stem cells. And it makes sense because I felt more awake, I felt more alert, the cognitive issues in terms of like the concentration, depression and anxiety were still present. But I had been working on that a lot of that was secondary to not having a diagnosis. And a having a diagnosis. And knowing that I wasn’t crazy was really helpful in the sense that, I knew there was a rationale and there could be a way to fix this. So that coupled with just time. I also started doing some neurofeedback and that started to help me a lot. I started to treat the brain as a brain injury. So I started to throw supplements at it like, high doses of fish oil. Things like that, just things to help with with the brain. I was also doing a lot of cranial sacral therapy, that was helping tremendously, just my body was so out of sorts, and it had picked up so much, I want to say, like just a heavy load of energy that needed to be unwound.

Dr. Mikhail Kogan 10:26
This is great stabilizing therapy. Very good, not just grounding, but also just balancing for the autonomic nervous system, which is always goes haywire.

Diva Nagula 10:36
And then I started to increase my meditation practice. And then I started to do a lot of deep breathing exercises. So that increased my HRV. And I have some other tools that are based in energetics. We’ll call it as a glorified PMF machine for now. But if the science is the same, and I was using that often, and I feel that that helped get me healed on a cellular level. So all these things have been helping. So it’s been a year since COVID. I feel I’ve gotten through the worst of it. So I still find myself having concentration issues, and sleep issues, but that’s been resolved. I just came back from another round of stem cells last week, I’m feeling things are improving. Incidentally, I just wanted to bring this to your attention. I don’t know if you have people that are complaining, but I have visual issues since my since COVID.

Dr. Mikhail Kogan 11:38
I don’t think that’s very common, actually.

Diva Nagula 11:41
Yeah, I wasn’t sure. Like, that increased the floaters in my eyes. And then I’ve had a really rapid decline in vision where I have really bad astigmatism. I have other underlying problems pathology with the eyes, but it seemed like all of it just got exacerbated. And it doesn’t surprise me.

Dr. Mikhail Kogan 12:01
yeah, I mean, all of this is the brain, right? I mean, I think there’s so many underlying drivers there. And some of them are direct toxicity. Some of them are vascular, you become partially hypoxic, and all these things in combination. And I think what I want to comment immediately is, I think most of what we see, and this is just a prelude to sort of from my end, I joined, the GW had a long COVID program, the actual university, had a long COVID program for about a year and a half. So they started pretty early. And I was one of their Doc’s from the beginning. So that was just the standard clinic, they had a research going, they were doing kind of a comprehensive, intake labs that included standard inflammatory markers, just the reasonably comprehensive testing through the research protocol. And I think about year end, it became pretty obvious that the program was just not sustainable, and they ran out of the funds. And that was it. So they actually closed the formal program, the people who are running it, just seeing some long COVID patients on their own in their clinics. But we basically took that whole long COVID clinic, anybody who could afford out of pocket expenses or had a good insurance, so they can reimburse, and then they went to the to CIM, to GW CIM, So now we are seeing ever increasing influx of those patients. Basically what they were doing as the standard of care, they would diagnose, they’ll help with the disability paperwork. And then they would refer out, like they would refer out to PT, to the cognitive therapy, to specialties likely you’d say, somebody like you would probably end up with neurology and maybe cardiology, if there isn’t enough autonomic instability symptoms. But those methods are kind of a far cry from what we do. But it taught me a process and kind of oversee maybe in the beginning, I probably had few 1000s of patients that clinic saw over 1000 pretty quickly, and the backlog was a few more 1000 patients. So there’s a pretty sizable clinic. But we now probably have few 100 patients at CIM, who we’re following ongoingly. And a lot of them describe situation like yours, I’d say probably somewhere in the mid pack in terms of severity, because there’s a lot of people didn’t have a lot of actual functional disability, like, we have a lot of patients, we have one patient, completely healthy, 30 year old, can’t even walk a block like it’s that severe. And I think one really critical nominator… And I think somebody should talk about this, because I read regularly, some of the experts on the topic and I don’t see this a lot, it’s just the beginning of this being kind of pointed out. I think almost every patient we see has something underneath, like history of cancer, history of mold toxicity that was totally missed, like nobody ever thought of that. They have some fibromyalgia, chronic fatigue syndrome before. The list of the underneath drivers is probably as long as you can make it. And those are the patients who I think really are… They’re just not recovering. And I think that’s basically… so in that context, I put long COVID, more like a litmus paper, right? So the things that we in the past were never managing, well, now it’s in everybody’s faces, it’s suddenly like, oh, we have the pandemic, well duh! We always had a pandemic of chronic problems that healthcare had no idea what to do with. It’s just really highlighting the fact that we have to have a better process here. So I just wanted to open with that from my end, because it’s very alive in me, because I often see so much mismanagement. We had one patient, we still have her, we help her now. She comes from, I’m not gonna give details, because it’s gonna get too obvious. But she’s from kind of a rural, like far out Virginia, which is not close to any large university center, but it’s close to a pretty sizable healthcare facility. She had 75 ER visits.

Diva Nagula 16:33 Wow.

Dr. Mikhail Kogan 16:34
When we saw her, she had an advanced progressive diabetes that was missed, she had a pericardial effusion, that was missed. She had a pretty obvious, irregular heartbeat, that everything was missed. And they kept sending her to psychiatry. It’s not like a some random rural area with a small clinic, it’s a large hospital with 1000 beds, and no one took care of this woman. No one bothered to say, look, what if she’s not like, making stuff up? Right? What if all of this is real? And it’s a highlight of inefficiency. But it’s also highlight of the fact that even if a facility like this, they couldn’t figure this out. Think of the rest of the America. We have a massive problem going on, and nobody wants to talk about it. Your story, I hope, will get out there and be everywhere, because the reality is, this can be managed, right? I mean, with the right tools, and it should be managed. But more importantly, we know what to do. And I think the rest of an hour, we should probably talk about sort of how we’re doing it, what we’re doing, and that’s really the crux of it. So I think anybody who’s listening and have friends or relatives, or anybody who is struggling here, I think the critical first step is find a provider who actually knows what they’re doing. Don’t keep relying on failed system, because my favorite expression is you’re going to a butcher, you’re not going to buy a salad. And that’s sort of like that’s how healthcare system operates. And there’s nothing wrong with that necessarily, because it’s geared toward particular outcomes and geared toward a particular set of issues. This is a new issue. Medicine is very conservative, and it shifts very slowly, it has to follow evidence, accumulation of evidence takes time, often, what one person calls evidence that a person will not call evidence. So there’s also discrepancy as to what are we going to call evidence. So finding a person who’s going to say, look, I don’t care what the evidence is, I’m going to help you is really the critical aspect. Because without that this is not a set of problems that somehow magically gonna go away. I think there was a lot of hope in the beginning that all this patients in one year gonna get better. Like even some of our senior faculty was saying, oh, you just hang in there, and you’ll get better. No. You won’t get better. If you don’t try to improve your cellular health, as you said, if you don’t work on some of the techniques that help you to revamp the mitochondria and clear up toxicities and decrease inflammatory response, you’re not gonna get better, you’re gonna circle the same drain over and over again, probably getting worse actually. That’s what we’re seeing frequently, that people who have not been helped, they seem to be progressing and they tend to progress, in my opinion, into three directions. So one is inflammatory. They start getting more and more inflammation. It’s like a vicious cycle. Second, as metabolic. A lot of progression to diabetes. I don’t fully understand why. And I don’t know what percentage, I haven’t read the literature to know exact numbers but significant proportion of patients if they do nothing they eventually end up with a roaring diabetes. And the third is their mitochondrial health is so suffering, they get so fatigued that they kind of gradually start becoming less and less active, both cognitive but also physical. And that sort of use it or lose it model. Just a downward spiral there, too. So those are the three big things, I think we jump on instantly, optimize metabolism, drop inflammatory response in parallel with oxidative stress management, and then start working on a cellular health with whatever, like, however, whatever fits the patients.Yeah, so back to you. I know you have a lot of questions.

Diva Nagula 20:46
Yeah. This is great. For me, I haven’t had an opportunity to see patients. So I don’t know the sequela of the disease, why I really want to speak with you and have you on board, because of you or the university setting. You have a clinic dedicated to this. And so you’re seeing an array of cases from symptomatology from one extreme to the other extreme. So I’d like to be able to start first by maybe having you describe the sequela of symptoms, granted, it is going to be a little bit difficult, because stuff that you’re seeing has been around for some time for each individual patient. But like you mentioned, a lot of people are having rip roaring diabetes, a lot of people are having issues with mitochondrial cellular health, and people are having more issues… are becoming more metabolically unstable. So let’s start by describing some of the things that are commonplace with the patients that are coming to you with long COVID?

Dr. Mikhail Kogan 21:54
Yep. Let’s group them in a system based approach, I think it’s just more logical to do it that way. Otherwise, the list is getting a bit disjointed. Yeah, so the inflammatory conditions, an interesting… I think, by the time patients show up to see us they have a sequela of inflammation. They may actually not have an obvious like, CRP is higher or something like that, it actually ends up being more of the time that there have a undercurrent inflammatory response, that’s more in line with the service, chronic inflammatory response syndrome. So you measure CRP, and it’s normal. But then you measure things like TGF beta, or C4A like a, like a complement alternative complement pathways, and they’re all like through the roof. So those are the ones that have kind of, they had some biotoxin underneath, or they had something under there that was cooking that was missed for a while. And then the COVID brought this up. So now they’re a lot worse. But everybody’s saying, oh, yeah, but your CRP is fine. Your sed rate is fine. Like what do you want for me?

Diva Nagula 22:58
Which markers again? I don’t know these markers.

Dr. Mikhail Kogan 23:02
So yeah, so this is a standard mold, chronic mold workups. So what we call SIRs chronic inflammatory response syndrome, due to some of the biotoxins, whether it’s a mold, lyme, any lime infections, any kind of other biotoxin from house, it doesn’t have to be mold right now, active actinomycosis is a big deal, although some people consider that a mold, although it’s not really a mold. So there’s just a lot of biotoxins out there that people often have, from wherever, whether it’s their house, tick borne diseases, all kinds of things underneath and often they get better. So like, they would be treated for lyme, like I’ve had at least half a dozen patients like this, they know they had Lyme, they know they got better, everything resolved. Well, I questioned that by the way… most things resolved and then they hit the COVID and then a couple months later, they’re like this is how I felt three years ago when somebody treated me for Lyme except now it’s much worse and so that’s the first kind of big group inflammation, non-resolving inflammatory response and just kind of a chronic. They all get, well not all, but most of them also get some mast cell activation syndrome, which means they also have this kind of acute… like an acute allergy like syndrome where even a minor trigger causes rashes, hives, all kinds of things. And with that often they get like everything gets way exacerbated until the acute thing passes. So that’s there and you know, muscle activation, I think probably component of SIRs. There’s a lot of argument whether what’s the chicken and an egg here? It’s a little a little over my paygrade, I don’t actually… we have a our own mold experts in my practice. So I take care of some of those patients, but often we end up co-managing them So that’s one group. And within that group, I think the symptoms that are most common are kind of all over the map. I mean, they have a lot of GI problems generally, because the GI tract seems to be going off killed almost immediately. And then microbiome doesn’t bounce back, and everything is sort of… but then microbiome is secondary in that situation, not primary. So if you just address microbiome without addressing the toxicity and nothing’s happening. A lot of them have cognitive symptoms as a primary cause from the inflammatory response, because it affects the brain. Actually, some of these toxins easily cross into the brain, there’s good data on that. A lot of them, of course, get fatigue, I mean, fatigue is universal. Fatigue is universal and inflammatory response, because your system is bogged down and trying to take the toxin out. And you don’t have a lot, basically, cellular function left to manage things. And so hormones go down. adrenals often suffer, and people often say, oh, manage adrenals. But the adrenals are secondary, a lot of things become secondary here, which, in terms of process of management, you have to actually know what you’re doing otherwise, you will be managing issues that are
on a surface, they’re not necessarily the causality, there’s still their result of that cause. A lot of the times patients start getting different aches and pains. I think it’s similar to fatigue, your basically cellular function goes and anytime you’re trying to have muscles do something they’re screaming in agony is saying, look, we got no energy to handle getting up the stairs, two flights of stairs, it’s like at the basic level, even the common activity. And of course, a lot of people are used to a certain level of functionality, and now it’s gone. They think that they can just start exercising back. And that seems to make things way worse, that was actually a typical early treatment, that seemingly was one of the few things that was universally effective is a very careful gradual exercise build up with PT or just a good personal trainer helping patients. So that was, and it still is one of the mainstream treatments even in the standard of care. The second big component is for sure, is kind of, I would describe it as chronic vascular component. And that seems to cause a particular slew of symptoms, different pains, so that depends on where that microvascular hits a lot of headaches and neck pain, as you’ve described, a ton. And that’s probably top five symptoms. A different pain syndrome, evolving area of the head and neck but joints anywhere even even legs when you’re walking. Some symptoms are very typical, like when the blood supply drops to a particular muscle, then that muscle is going to be in pain. Quite a big component, it was pretty clear from the beginning that the microvascular component is a huge role. Early on, there was a lot of anticoagulants used, not just aspirin, but even lovenox and soheparins and things like that. I don’t think I use a lot of anticoagulants maybe with the exception of high dose fish oil, like you said, and then I do like nattokinase a lot. So those are the two things I use. For some patients, when things get medical, like they come in, you scan their brains, since we do this all the time, and there’s bunch of micro strokes, well, okay, well, those patients end up on something much more medical, like Eliquis. But that’s not actually a common thing. Most of it is subclinical. So like you do the tests and you don’t see anything, you may see some, more more or less unclear things, but they’re not necessarily, ok well, this requires medical management immediately. Like that’s actually minority of cases not majority. So vascular is big. Mitochondrial health in the standard of practice that’s hard to measure, unless patients come to see me and I ran something like neutraval or some other tests that that I can look at the Krebs cycle. And that is almost always affected. Like that’s heavily affected. Those are the patients who come in with primarily fatigue. So their predominant symptom is fatigue, and not just physical, cognitive. Remember you would describe the brain fog. So that is probably number one symptom in the frequency I would say. Now, it never comes as a separate as a stand alone. There’s always a bunch of other stuff. But that often is predominant when it’s predominant, usually, I just kind of immediately throw a lot of things at the patients. I tried to give them higher nutritional support. I tried to give them anything that revs up mitochondria, I may give them like intravenous infusions, for example, we definitely would do acupuncture in this setting instantly. We’ll try to convince them to come up with some kind of a graded exercise regime that’s not necessarily for muscles. Exercise boosts mitochondria quite significantly. And then you can do like heroics. You can do cold training, you can start doing, if they’re toxic, and you figure that out, like, let’s say Mercury underneath the hole that you have to get rid of that because all of that it bogs down mitochondria, Krebs Cycle suffers and then they have all this symptoms. And then just autonomia, I’m not sure if there is an underlying particular cause like microvascular. It’s probably all of the things I just mentioned there, partially leading to dysautonomia. Dysautonomia is often the hardest to treat. I think the part of it is because it’s very unpredictable. Like we have some patients who come and that’s all they have, like I have one young man. That’s all he had, like he had this weird thing where he would have rapid heartbeat when he moved, got up, and then he would have some headaches, and then he would have this bulging veins, and they would bulge every time he starts to do anything. And they’re like, yeah, so on the scheme of things, he’s relatively mild, because he’s functional. He does everything, but like, it’s pretty obvious that these problems are very concerning for him and there was not there before. So that’s a kind of a classic primary dysautonomia complex, but In more severe cases, patients would just have shortness of breath, when they tried to walk the move a little bit, then their heart rate is in 150s. And they get put on beta blockers and the thing is though, some of the basic treatments are helpful, like the beta blockers and all the typical graded exercises, but often that dragged for a long time, and it wasn’t getting better. There are some heroics like different, for example, there’s this treatment where I think they activate, I don’t even know exactly, but they’re just some kind of nerve block. And like, part of the vagal nerve gets blocked. And that’s worked for some patients like magic. I seen acupuncture for this patients work amazing. Like they do 8-10 sessions, and they’re like, 80% better. Well, think of it what acupuncture does, right? It’s a it’s an energy redistribution. Since pandemic hit, I stopped doing cranial myself and I couldn’t have them come back to it. And I’ve referred few patients out and few patients that have good results. So I think the cranial for dysautonomia is a great tool, like I know you did it. But again, some of this takes time, and it’s sometimes hard to convince the patients to go for it, because they’re gonna be out, none of those things are cheap. So they’re going to be spending money and you know, it’s easy to pop a pill. I think the biggest problem is it’s still, I would say, dysautonomia the least understood out of everything I just described, because there’s just not a lot of data on this. And more importantly, the treatments that are standard of care offers are extremely limited and patients often… Like let me give you an example. So the patients who have Ehlers Danlos Syndrome they present with dysautonomia, sometimes it’s called POTS, postural orthostatic hypotension, probably in about 50% of cases. And so those are the patients who got hit with a COVID on top. They are the ones that in my practice the most difficult cases to manage because they already had it underneath. They’ll never get fully rid of it, because that’s just their genetic makeup. And now COVID comes on top and we’re trying to do something for them. And they have been barely hanging on before and now they’re overboard and you’re applying all the same methods like okay, we’ll give them tons of electrolytes, we’ll do some Neurofeedback or biofeedback, like a Heart Math for example, that’s a low cost or something like that. And they get a little bit better but it’s not enough for them to get back to where they were. And so that seems to be a little tricky. I think a big component there I’m starting to notice is cannabinoids. So I start using increasing amount of different cannabinoids. I don’t know if I can give everybody like clarity as to sort of okay, you have to use this amount of CBD and this amount of CBG and this much THC. I think that’s TBD, no pun intended, but there’s definitely a role to play. I think that it makes sense because dysautonomia often triggers cannabinoid tone shifts. And we know that the low doses of THC for example, for general dysautonomia seems to have some significant benefits. But it’s in the real life. It’s a lot of trial and error. But some patients get a lot better. And I say if they’re coming in and they have a sleep disturbance and we can give them a touch of THC and sleep gets better. That goes a long way. And dysautonomia patients present almost universally with bad sleep. I’m not sure exactly why, some of this aspects, I haven’t researched in depth from basic pathophysiology standpoint, but that seems to be universal. So I think I probably covered most of the stuff.

Diva Nagula 36:06
Yeah most of the symptomatology. Okay, so we’re running low on time. So in span of the next 15-20 minutes, what are your treatment algorithms? I know it’s specific to the individual based on system dysfunction. But what is your first target when you’re sitting there with a very complex patient? What are you addressing first?

Dr. Mikhail Kogan 36:27
Yeah, actually, believe it or not, before we drop into, okay this is the process. I try to get them to understand that they’re going to be with us for a while. And I think with that in mind, and the fact that most of the patients, it will take a while to figure out the actual best process even, like, I may know all the pieces they need. But how do you prioritize it? And where do you start and how you continue, that’s seemingly an art. An art that even I’m still feeling like I’m just figuring this out still. But that’s why we started group process, because I feel like at the very minimum, if they can’t get from point A to point B, very quickly, at least I know they’re in the process. At least I know we’re going to try different things in no particular order until we say okay, well that worked. Okay, so that helps, because now we know that if your meditative practices, and biofeedback helped, okay, this is probably a big component. So let’s continue concentrating on that, and then figure out other pieces. So group seems to be… we just started one, it’s going really well, at the very minimum, it’s critical, because patients finally have somebody else to connect with and on a very deep level, they listening to other people’s stories, they’re learning in parallel, they develop buddy system, they can call each other and say, hey, I’m feeling this and that, and it the minimum just being listened to is huge.

Diva Nagula 38:06
I had no one to connect with. All the doctors that I saw, practitioners, thought I was crazy. And I
felt like I was going crazy.

Dr. Mikhail Kogan 38:12
Yeah. And so just the fact that we’re acknowledging that and the fact that we say, well, we may not be able to help you overnight, but we will help you. And you’re not crazy. And look, there are tons of people like you. Then I would say I try to very quickly figure out which pathway we go. And so typically the starting point of management… well okay, if I’m worried that they are mitochondrialy depleted, I’m going to run a bunch of tests, because I want to know, is there a nutritional driver underneath? We’ve seen a lot of methylation defects and just some basic treatments could be very useful. But I want to know this from the beginning, because that also helps me to understand other things, I tend to look into toxins at the same time, just easier that way, like the initial intake process you screen for a couple of things. And at least you either rule them in a rule them out so then, because if they’re toxic, I feel like you can’t go anywhere until you at least trying to offload some of the toxicity. A lot of metals, but metal, there’s a lot of metals to begin with mercury, lead… and so that is just the common. Then we often screened for SIRs like immediately and that’s because I don’t know if I can put exact percentage on it but very high percent of people that have biotoxin underneath, I mean, I’d probably say between the chronic fiber-like syndrome and SIRs-like syndrome, at least half of everybody, maybe 75% of people. Then, I think the rest of them had something like what you described like they had a some kind of a distant cancer treatment or something in the past that just causes this low grade process underneath that COVID exacerbates. So if we figure out there is a SIRs or a mono we just start treatment, like as if we would start treatment for those conditions immediately. And we know how to manage those. So if it’s a mold biotoxin we’ll just employ Shumaker like protocol, we don’t do all the parts of Shumaker, we do many, the VIP spray seems to be very effective as a last… just like the stem cells, I’m just starting to learn. But I think the VIP spray for patients.

Diva Nagula 38:17
What is the VIP spray? I’m not familiar with that.

Dr. Mikhail Kogan 40:35
It’s a vaso-intestinal peptide sprays so that’s like when you need to start finally, rebuilding most neurons, that spray seems to be an essential. It’s a peptide, just like we using now, all kinds of peptides in different settings, like the peptides for the gut. So this is one of the older peptides that has been in use for a very long time. There are a couple of compounders that make it. It’s a nasal spray. So you deploy that. And that seems to be often like that last piece, then finally, patient, we cleared them up, and then we give them stuff like give them no chance, as you said to rebuild the neurons, and then you give them hormonal stimulant to do that, and then if you can afford the stem cells, I think that would be sort of like the final, okay, like now we can go back to normal. But imagine how much time all this takes, right? So you have to… you can’t put VIP and all the really aggressive, regenerative support until the toxins are out, until mitochondria works better, because otherwise, it’s wasted. Because all of these things are out of pocket. More importantly, they take a lot of time and effort. And so like you can’t, you have to be systematically very precise. Like, let me give you an example, if I tried to do neuro- regenerative treatment, and they’re still in a toxic environment, like the house is bad, that’s the worst I can do for them. Because they’re going to be spending a lot of money not getting better getting more and more upset, and I failed to tell them, Look, you really have to get out of this house, or you really have to fix the house. That is a big problem. We struggle a lot because often patients just don’t get it, they can’t register that the house is the problem. We have some patients who understand them and did amazing, but that’s a difficult conversation always.

Diva Nagula 42:30
There’s really, I mean, it seems like you’re looking for underlying preconditions. We’re talking about where their livers compromised or compromised secondary to all this toxicity, whether it’s lead, mold or other heavy metals. So that’s the first thing that’s primarily looked at, and as an integrative physician, this is in your wheelhouse, you’re doing this on a regular basis. Right? So the secondary issues the dysautonomia, the brain fatigue, the other overwhelming systemic fatigue that people that are having. For me, what I anecdotally figured out is that, the cancer stuff was there and in my intuition, I felt the cancer resurface. And I had an immediate drop in my blood count, like white blood cell count a month after like I was hovering around 3.7 to 4.0, then went down to 2.9 a month later. This was scary to me, because I felt that this was a sign that my cancer was coming back. And my primary is like, no, it’s probably post-viral and will go away. Me I was like, I’m gonna hit the psychedelics hard, and I hit the psychedelics really hard. Later, my white blood cell count went back to 4.7. So I purge stuff out that needs to be purged energetically, it did not fix the COVID but I think it got rid of the cancer from an energetic perspective.

Dr. Mikhail Kogan 44:01
Yeah, that’s awesome. We tend to I mean, we do, we just started psychedelics, so we’re kind of learning this as we go. Plus it’s still a little tricky to kind of advocate on unbroken, but we definitely do a lot of homeopathy and Ayurveda. So that seems to be if you start looking at this from a constitutional perspective, I think you have a lot of different tools that can work. I completely agree. And sometimes actually, you have to start with this. I think often if the spiritual and energetic component is is not predominant, but blocks the progression if you don’t clear it. We often find out this in retrospect, like you tried to do certain things, nobody’s getting better. And then you’re like, Okay, you know what, I think the terrain is so blocked, that if we don’t clear the blocks that are energetically in there, nothing’s going to happen,

Diva Nagula 44:56
Which is why you probably do acupuncture to allow the energetic flow?

Dr. Mikhail Kogan 45:03
I often don’t even tell patients this, I would say, look, we’re gonna give you acupuncture because your pain is gonna get better. But underneath I’m sitting and thinking, forget your pain. I don’t care. It’s energetically blocked.

Diva Nagula 45:14
So two of the things that, for me started to really improve. The first thing that really was before the stem cells. That was a game changer was ketamine. I didn’t even think about it. But I did ketamine on my own because I was desperate. That was the one that actually moved the needle for me from a cognitive perspective. And I feel it works. I mean, it’s a neuro anti- inflammatory. I believe it started to reduce the inflammation. Also, it helped my mood. And it also actually flushed the neurotoxins. I believe. I don’t have any proof of this. But I think that’s what started to be a mover of the needle.

Dr. Mikhail Kogan 45:55
I mean, it’s gonna boost… it’s a decoupler. Right. So it removes the typical thought process and a typical metabolic process in the brain. And you kind of revamp everything quickly. So it’s like a booster. So because I think your your cognitive issues were so predominant, I think that’s why you found it so effective.

Diva Nagula 46:20
100%. And then I started to couple that with photobiomodulation sauna. Infrared sauna. And I was in there three to four times a week. And I really feel over time that got rid of any other toxicity that was in my system, whether I had underlying stuff going on, which was undiagnosed, but it helps things flush out. And I really feel that that was contributory to my overall systemic health and brain health.

Dr. Mikhail Kogan 46:51
Yeah, I’m so glad you brought this up. I think we often underestimate certain tools that we have in our disposal, I think the infrared sauna, or sweating, period, I think is a hugely underappreciated tool. I mean, after all, skin is the largest organ that we don’t utilize for clinical treatment methods as much as we should. And so, yeah, and an infrared seems to be in my mind, a bit more effective than the regular sauna. Although I would say that patients who can’t afford, if you have it at the gym, if you have at your friend’s, if you have, just use it. I mean, the only trick is, I think the patient has to have enough resources to start like either be careful with if somebody is older and more frail. I think you have to be very careful there. That’s actually, when somebody is more older and frail, I think that’s when the homeopathy and ayurvedic, like very gentle methods seem to be the first line. Somebody who’s much younger and stronger. I think what you did really should be the goal, like aggressive detox, aggressive attempt at rescuing mitochondria at every level of the body, not just brain but body too.

Diva Nagula 48:05
I’d love to go into more depth of what you prescribed for homeopathy as well as Ayurvedic.

Dr. Mikhail Kogan 48:12
Yeah, I can say, this is just not my cup of tea. I mean, that’s why I feel like you have to have a

Diva Nagula 48:20
And you do which is fortunate, which is why the integrative medicine model works for this!

Dr. Mikhail Kogan 48:25
The way I always think of think of this is if a particular team member has an expertise in something, that’s what needs to be tapped into aggressively. We can only learn things that our soul is driven to. right? But there’s so many other tools that are great. That’s, I think, one of the most important powers of what we do, we value a whole array of things, even if our reach in our cognitive scope can only grasp this. We open enough to say yeah, but we’re not going to say that that doesn’t work. I mean, we’ve seen enough things to say everything seems to work. It’s more important, the sequence and also like, how did you know how to apply particular resources to a given patient and so the trick is, sequence and also knowing what particular individual is more likely to benefit from and not worrying about, okay, well, I know Ayurveda worked great, but I don’t have an Ayurvedic provider in my practice, because, whatever the reason is, don’t worry about that. Use what you have in your camp and use it in the way that the particular patient is most likely to benefit from. And I think that’s also why we have a lot more agreement than disagreement. Like if you look at the typical western model, I mean, squabble between specialists. It’s just like, oh my god like I’m dealing with this at the university level day in day out and there’s more squabble than there’s alignment on many situations. And I’m like, I don’t want to work like that. We know that the integration of different modalities and whether they’re Western or not, that doesn’t make any difference. I mean, the whole point should be the integration of both processes and expertise. I have a feeling that if the country, this is a my political point, if the country don’t invest into long COVID now it’s going to be a huge problem. It’s like this looming elephant in the room, and nobody wants to talk about it. It’s like, oh, we are just going to keep doing vaccines, which are probably going to contribute positively to an overload of chronic inflammatory response.

Diva Nagula 49:36
Which is very similar to long COVID symptoms, if that develops into a long a long COVID sequela.

Dr. Mikhail Kogan 50:59
Well, exactly. I mean, I’m not denying that they have a role for like, older, frail people who are at the very high risk of complications. Okay, fine, but like giving a 30 year old a vaccine, which can cause out the immune state within 10-30 years. It’s sort of like, you haven’t done any research, like nobody’s done the research, especially the most important thing is this new vaccine, there is zero research, they have not applied this vaccine to humans, it’s only been given to animals. And like we don’t even know, like, we can’t even know whether it’s comparable to the prior one in overall efficacy. It’s just all kinds of assumptions, massive human experiment, everybody has to make their decision, whether they want to participate in and also decide what risk, are they willing to take more? Are they willing to take risk of acute COVID? And if you’re not willing to take that, get your shot, and don’t worry about it. But if you say, I’m willing to take the risk of acute COVID, I’m young and strong enough, I’ll probably have a mild disease, I don’t want to risk long term consequences. You always can come back to us. That’s actually one thing I wanted to bring up. Before we close, it seems like that if you throw on a basic preventive package at the time of onset, we don’t see long COVID after that.

Diva Nagula 52:22 Which is what?

Dr. Mikhail Kogan 52:25
A lot of things you mentioned, the quercetin, right? Well, fatty acids, I don’t think are critical in that moment. But of course, it’s in bromelain, NAD or nicotinamide right beside because you don’t want to let the mitochondria crash, you have to try to rev it up as much as you can. Some kind of a detox molecule. So whether it’s glutathione, or NAC the NAC is very important. If someone has a lot of chest symptoms, cough, productive or non-productive doesn’t matter, if there’s a lot of like congestion, overall, the NAC becomes really important. And I sometimes push NAC to crazy doses, I sometimes push it up to three grams a day depends on what the patient has. But usually it’s like, between one and a half to two grams a day. Zinc, melatonin seems to be a pretty good low, it don’t have to be high.

Diva Nagula 53:16
Great for mitochondrial health too!

Dr. Mikhail Kogan 53:18
Great for mitochondrial health, great antioxidant, 5-10 milligrams, three to six is probably in most of what I give. Some kind of stronger inflammatories. Tumeric. If you know a person’s fatty acid state that their poor, ok great, give them some, but like if I have my own patient, and I know that I’ve tested them before and they’re in a top percentile of fatty acid. I won’t give them more.

Diva Nagula 53:52
What’s the deal? What’s the connection between turmeric and fatty acids? I’m unfamiliar with

Dr. Mikhail Kogan 53:56
They’re all anti-inflamatories. In that context, just trying to throw in a lot of anti inflammatories. I would use paxlovid on some patients, but only on the patients when I know that they’re at risk of the viremia continuing. I’m not going to use it on young patients. I mean, they’ll clear it up no problem whatsoever. What else am I forgetting? I think it’s very useful…

Diva Nagula 54:25
The ivermectin versus chloroquine?

Dr. Mikhail Kogan 54:30
Yeah. I mean, the Chloroquine I don’t like, it’s in the mitochondrial suppressant. I don’t like using it even acutely, I would use it if patient has some kind of an existing autoimmune condition and I know I need a very heavy guns to suppress inflammatory response. Beyond that, for like, even a healthy older person. I wouldn’t use it just because I would worry about mitochondrial damage from Chloroquine. Ivermectin I don’t have a lot of experience but I think it’s a lot safer overall and the doses can be a lot higher. I kind of look at this more from a personal perspective. So if the patient tells me, yeah, I would like that, I have no problem, I’ll just prescribe, like, I don’t argue over it. Definitely vitamin D, even if they’re normal, like because they’re going to overuse the D rapidly, so you can give them probably as much as 50,000 units a day for a couple of days for maybe five to 10 days during the infection, but at least 5000 units, if not 10,000 units per day. Vitamin C and I don’t necessarily care what C they’re gonna get but you want to at least couple of grams that they probably between three to five, depending on what gut can tolerate. If gut cannot tolerate a lot can do sublingual. When I have COVID, I gave myself intravenous, just because I felt like I didn’t want to, like my gut is sensitive so I don’t like to take too much C, I get diarrhea very quickly. Then there’s a whole slew of other things like EGCG is anti-inflammatory, I mentioned bromelain with quercetin but sometimes I had the bosweilia too and I liked this product BCQ, which is a kind of combination of all three. I think that was pretty much more or less the top choice. You know, and ivermectin, if you’re using, I think it needs to be way higher, probably .6 per kilogram. But I also like some of the European drugs that we don’t have. So I do use the European products that are interferon boosters, in patients who are worried about it’s actually a Russian drug that’s approved by there. And it’s heavily available in Europe, there are a couple other interferon boosters, we don’t have them, they are not available in US. So I just import them for, for patients who I’m particularly worried. And they’re general antivirals, like I use them a lot for for EBV. I use them for very cell or for like a chronic very solo lot, there seem to be very effective, because interferon crashes quickly. And we know that that’s, and I’m not aware of any US based treatment protocols for that. And the dosing there, it depends on the individual, I’m not gonna go there, because it also depends on kind of the severity of illness. So sometimes I’d give more than the average. So then if they can afford anything else, you know, intravenous vitamin C would be super, NAD plus IV would be amazing, it’s expensive and long term treatment. But if they can come and get it, that wouldn’t be really useful acupuncture acutely, would be various. So all this same methods that we would use, even for the post COVID. But in acute settings, it seems to dramatically decrease risk of long COVID. Now we know this, but a year ago, year and a half ago, this was all like, I have no idea we’re just trying bunch of stuff, is it gonna do anything? We don’t know. They had no idea.

Diva Nagula 58:19
I’m sure after reviewing this video, I’ll have a lot more questions and I’ll be able to outline things more systemically, and categorically so that I can actually ask more specific questions and see what your thoughts are, this has been a very helpful conversation. Yeah. And I would like to talk to you, even off record or at later point about stem cells, and ketamine therapy and other things that are just I think they’re just so transformative. And very quickly, and obviously it can be expensive. But these are all things that can be a negotiation.

Dr. Mikhail Kogan 58:56
Yeah. So awesome. Well, we’re gonna look for your book, hopefully sooner rather than later, I
think. But I don’t think that this issue is gonna go away.

Diva Nagula 59:06 No, it’s gonna get worse.

Dr. Mikhail Kogan 59:08
I think it’s gonna get a lot worse. I have a prediction that this comes later fall, we’re going to
have another wave.

Diva Nagula 59:14
That’s my thought, too. And then long COVID on the other end next year, yeah.

Dr. Mikhail Kogan 59:20
Most patients are not going to get this acute treatment cocktail, they’re gonna have their 20 whatever percent risk of long COVID. And we only going to keep on going up. But we’re here we’re gonna do our best to serve those patients. We’ll have to have you back when the book is out. Actually, when the book is out. We’ll probably try to get you into GW

Diva Nagula 59:44
And hopefully, you’ll be available for maybe a couple more of these interviews.

Dr. Mikhail Kogan 59:48
Sure. All right. Well, great. Thanks so much. Again, this is Dr. Nagula and Dr. Kogan’s mini-cast is what I call it, everybody have a great day.