Protocol Of Treatment Of Confirmed COVID19 Infection

This is just trials done by the CDC MICC team, thought you might want it shared:

Treatment of COVID19 upper respiratory tract infection (fever, runny nose, cough without lung infiltrate + positive PCR)

MED

ROUTE

DOSE

Chloroquine Phosphate

Oral

500MG BID for 5 Days

Oseltamivir

Oral

150MG BID for 5 Days

Treatment of COVID19 Pneumonia

MED

ROUTE

DOSE

Chloroquine Phosphate

Oral

500MG BID for 5 days

Darunavir / cobicistat

Oral

Darunavir 800MG + Cobicistat 150MG daily for 2 weeks

Or

Atazanavir

Oral

400MG once daily for 2 weeks

Oseltamivir

Oral

150MG BID for 5 Days

Corticosteroids 

Intravenous

Methylprednisolone 40MG bid for 5 days


SUPPORTIVE CARE AND ANTIVIRAL TREATMENT OF SUSPECTED OR CONFIRMED COVID-19 INFECTION

Last Updated on 

Disclaimer: This is a personal guidance that is subject to change as more data rise. It will be updated regularly whenever needed. The following data should be used to assist healthcare practitioners against COVID-19 infection and is not intended to replace clinical judgment but rather enhanced.

Common orders and procedures: CBC, Urea/Electrolytes, Creatinine, CRP, LFTs, Chest X-Ray, COVID-19 PCR tests.

Ambulatory Care Settings

Guidance for Pharmacies

Guidance for Dental Settings

COVID-19 Antiviral Options with Dosages

G6PD screening if Hydroxychloroquine or chloroquine will be used

Hydroxychloroquine:
Adults: 200 mg 3 times daily for 10 days (Gautret 2020) or 400 mg twice daily on day 1 followed by 200 mg twice daily for 4 days (CDC 2020; Yao 2020) or 400 mg twice daily on day 1 followed by 400 mg once daily for 5 days or 600 mg twice daily on day 1 followed by 400 mg once daily for 4 days (CDC 2020).
Children and Adolescents: 6.5 mg/kg/dose hydroxychloroquine sulfate twice daily on day 1; maximum day 1 dose: 400 mg/dose; followed by 3.25 mg/kg/dose hydroxychloroquine sulfate twice daily on days 2 through 5; maximum dose: 200 mg/dose (ASTCT 2020).

Chloroquine: 
Adults: 1 g (600 mg base) once on day 1 followed by 500 mg (300 mg base) once daily for a total treatment duration of 4 to 7 days (FDA 2020).
Infants, Children, and Adolescents: 8.3 mg/kg/dose chloroquine phosphate every 12 hours for 10 days; maximum dose: 500 mg/dose (ASTCT 2020)

Hydroxychloroquine/Chloroquine toxicity: QT interval at baseline: Follow-up ECG monitoring and adjustments in medical management are dependent on clinical scenario (eg, baseline risk, concomitant medications, overall clinical status)

Lopinavir 400 mg/ritonavir 100 mg twice daily.
can be taken as once daily dose of 800/200 but not with pregnant women.
Once-daily dosing is not recommended in those receiving efavirenz, fosamprenavir, nevirapine, nelfinavir, carbamazepine, phenobarbital, or phenytoin.

Remdesivir (CHECK FOR ELIGIBILITY CRITERIA)
Adults: IV: 200 mg as a single dose on day 1, followed by 100 mg once daily for a total duration of 5 to 10 days. (GILEAD 2020)
Children and Adolescents ≤17 years: 
<40 kg: IV: 5 mg/kg/dose as a single dose on day 1, followed by 2.5 mg/kg/dose once daily.
≥40 kg: IV: 200 mg as a single dose on day 1, followed by 100 mg once daily.

COVID-19

1.

Patient is suspected to have COVID19 but with no shortness of breath, admission is only recommended if emergency situation at hand. We should treat symptoms as they arise and there is no antiviral treatment recommended at this stage. We can use Paracetamol to treat pain and fever, and try to avoid NSAIDS

Common orders and procedures to be followed (medications, radiology and labs).

2.

Patient is suspected to have COVID19 with high risk comorbidities  but with shortness of breath, admission is only recommended if emergency situation at hand. We should treat symptoms as they arise, admit to an isolation room with negative pressure and there is adequate evidence to start empirical antiviral treatment at this stage till the lab results is obtained. We can use Paracetamol to treat pain and fever, and try to avoid NSAIDS

Common orders and procedures to be followed (medications, radiology and labs).

3.

Patient is confirmed to have COVID19 with no symptoms, admission is only recommended if emergency situation at hand. We should treat symptoms as they arise, admit to an isolation room with negative pressure if undergoing any aerosol generating procedure and there is no need to start empirical antiviral treatment at this stage . We can use Paracetamol to treat pain and fever, and try to avoid NSAIDS

Common orders and procedures to be followed (medications, radiology and labs).

4.

Patient is confirmed to have COVID19 with mild symptoms without pneumonia or ventilation, admission is recommended. We should treat symptoms as they arise, admit to an isolation room with negative pressure and start empirical antiviral treatment promptly. Consider antifungals and antibiotics to treat secondary infections. We can use Paracetamol to treat pain and fever, and try to avoid NSAIDS

Common orders and procedures to be followed (medications, radiology and labs).

5.

Patient is confirmed to have COVID19 with severe symptoms: 

  • Respiratory rate 30/min(adults); 40/min (children)
  • Blood oxygen saturation 93%
  • PaO2/FiO2 ratio <300
  • Lung infiltrates >50% if the lung field within 24 to 48 hours

admission to ICU to an isolation room with negative pressure. We should treat symptoms as they arise, admit and start empirical antiviral treatment promptly. Consider antifungals and antibiotics to treate secondary infections. We can use Paracetamol to treat pain and fever, and try to avoid NSAIDS

Common orders and procedures to be followed (medications, radiology and labs).

6.

Patient is confirmed to have COVID19 with critical symptoms:

  • Acute respiratory distress syndrome
  • Sepsis
  • Altered consciousness
  • Multi-Organ failure

admission to ICU to an isolation room with negative pressure. We should treat symptoms as they arise, admit and start empirical antiviral treatment promptly. Consider antifungals and antibiotics to treate secondary infections. We can use Paracetamol to treat pain and fever, and try to avoid NSAIDS

Common orders and procedures to be followed (medications, radiology and labs).

COVID-19 TESTING

CATEGORY

SUPPORTIVE CARE

ANTIVIRAL THERAPY

PRECAUTIONS

Suspicious cases 


Mild to moderate:
Symptoms with no shortness of breath

  • Treat symptoms
  • If no hospital admission required, need to follow instructions and recommendations posted by CDC

NOT REQUIRED

  • Use acetaminophen
  • Avoid ibuprofen
  • Labs and work-up: CBC, Urea/Electrolytes, Creatinine, CRP, LFTs, Chest X-Ray, COVID-19 PCR tests.

Mild to moderate:
Symptoms with shortness of breath in high risk patients

  • Treat symptoms
  • If no hospital admission required, need to follow instructions and recommendations posted by CDC
  • Consult infectious disease specialist

Case needs to be discussed with infectious disease specialist, to initiate an empirical antiviral therapy, based on the potential delay to obtain results.

  • Admission to negative pressure room
  • Labs and work-up: CBC, Urea/Electrolytes, Creatinine, CRP, LFTs, Chest X-Ray, COVID-19 PCR tests.

Mild to moderate:
Symptoms with no shortness of breath in high risk patients

Confirmed cases

Asymptomatic

Follow instructions and recommendations posted by CDC

NOT REQUIRED

  • Use acetaminophen
  • Avoid ibuprofen
  • Labs and work-up: CBC, Urea/Electrolytes, Creatinine, CRP, LFTs, Chest X-Ray, COVID-19 PCR tests.

Mild to moderate:
Symptoms (no O2 requirement and no evidence of pneumonia)

  • Treat symptoms
  • Consult infectious disease specialist

- consider starting Hydroxychloroquine 400mg BID for 1 day, followed by 200mg BID up to 5 days

- If Hydroxychloroquine is not available, consider Chloroquine 600mg (10mg/kg) at diagnosis and 300mg(5mg/kg) 12 hours later, followed by 300mg (5mg/kg) BID up to day 5, or Chloroquinephosphate 1000mg at diagnosis and 500mg 12 hours later, followed by 300mg BIDup to day 5

Hydroxychloroquine and Chloroquine:

- Labs and work-upL Same as above with additional G6PD screening if chloroquine will be used

- Perform ECG daily if initial QTc 450 -  500msec, and biochemistry according to underlying disease

Sever:

Symptoms as 1 of the following:

- Respiratory rate 30/min(adults); 40/min (children)

- Blood oxygen saturation 93%

- PaO2/FiO2 ration <300

- Lung infiltrates >50% if the lung field within 24 to 48 hours

  • Treat symptoms
  • ICU admission, decision by ICU treating team
  • Consult infectious disease specialist
  • consider antibiotics or antifungals according to local antibiogram and institutional pneumonia management guidelines.

- consider starting Hydroxychloroquine 400mg BID for 1 day, followed by 200mg BID up to 5 days

- If Hydroxychloroquine is not available, consider Chloroquine 600mg (10mg/kg) at diagnosis and 300mg(5mg/kg) 12 hours later, followed by 300mg (5mg/kg) BID up to day 5, or Chloroquine phosphate 1000mg at diagnosis and 500mg 12 hours later, followed by 300mg BIDup to day 5

- consider combination therapy (Lopinavir/Ritonavir) 400/100mg (2 tabs of 200/50mg) BID and (Hydroxy)chloroquine up to 10 days

Lopinavir/Ritonavir:

- Labs and work-upL Same as above with additional G6PD screening if chloroquine will be used

- Perform ECG daily if initial QTc 450 -  500msec, and biochemistry according to underlying disease

- Avoid coadministration with drugs that are highly dependent on CYP3A fod clearance or with potent CYO3A inducers

- precautions with patient with renal or liver impairments 

Critical:

Symptoms as 1 of the following:

- Acute respiratory distress syndrome

- Sepsis

- Altered consciousness

- Multi-Organ failure

  • Treat symptoms
  • ICU admission, decision by ICU treating team
  • Mechanical ventilation
  • Consult infectious disease specialist
  • Specific prevention and treatment of ARDS
  • Secondary bacterial and opportunistic (Aspergillus) infection according to local antibiogram and institutional pneumonia management guidelines
  • - Prevention of subsequent lung fibrosis

- consider combination therapy (Lopinavir/Ritonavir) 400/100mg (2 tabs of 200/50mg) BID and (Hydroxy)chloroquine up to 10 days, crushed in NGT and the same dosage and monitoring as above

- Remdesivir (compassionate use, once available) 200mg loading dose (IV, within 30 min), followed by 100mg once daily for 2 to 10 days

- however, since the clinical efficacy of (Hydroxy)chloroquine isn't demonstrated, caution is required in case of kidney / liver / cardiac failure and abstention in such situations is preferred

Remdesivir:

- Inclusion criteria for the use of Remdesivir: ICU + confirmation of SARS-cov-2 by PCR + mechanical ventilation

- Exclusion criteria for the use of Remdesivir:

Evidence of multi-organ failure, need of inotropic, creatinine clearance < 30ml/min, dialysis/hemofiltration, transaminases > 5 x  ULN of concomitant use of Lopinavir/Ritonavir

- This means that most(if not all) patient in ICU will not be eligible


update 26-03-2020:  Role of Pharmaceutical companies against COVID-19

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Update 31-03-2020:

Concluding Remarks ...

  • COVID 19 has caused the worst pandemic since the Spanish influenza
  • The virus spreads rapidly and efficiently
  • Droplet and contact precautions are recommended by WHO except for aerosol generating procedures where airborne isolation is necessary
  • In countries where rigorous measures were taken such as Hong Kong and Singapore containment was achieved (banned gathering, work from home, social distancing. HCWS practices)
  • Vaccine trials are underway
  • Treatment options include chloroquine/hydroxychloroquine +/- azithromycin; need to be verified in randomized controlled trials 
  • Lopinavir/Ritonavir to be considered early in the treatment course but needs to be studied further
  • Antiviral medications (remdesivir, favipiravir) are not currently available in the Middle East but for compassionate use 
  • IL-6 antagonists to be considered for severe cases with cytokine storm
Few COVID-19Facts
AO

Pharmacist interested in improving the health outcome for every single case he meets.

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