Patient Treatment Guidelines

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Management of Patients with Suspected SARS-CoV-2 (COVID-19)

Last update: July 21, 2021

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The backbone of the treatment strategy for COVID-19 is good quality supportive care as in any viral pneumonia. Certain therapies have shown benefit for COVID-19 and are included in the recommendations below, including inpatient and outpatient treatments. This page will be updated continually as new evidence emerges and based on the availability of treatment regimens.

Management of Hospitalized Patients with COVID-19

Patient Admitted on Nasal Cannula

Disposition: Consider admission to intensive care unit if older than 65 years of age with a new oxygen requirement, D-dimer > 1,000 ng/L, or RR > 22 breaths/min

Fluids

Conservative fluid management strategy

Medications

Evaluate for enrollment in clinical trials

 

AntimicrobialsConsider empiric antibiotics for bacterial pneumonia while COVID-19 results are pending

Corticosteroids

Initiate dexamethasone for patients requiring O2; do not continue on discharge

Bronchodilators

If needed, use metered dose inhalers and avoid nebulized therapies.

Coagulopathy

Evaluate hematologic abnormalities and treat as appropriate. See Anticoagulation Dosing Recommendations for COVID-19 Patients.

O2 Supplement

Target SpO2 >90%. If oxygen requirement increases to 5 L, call primary team and ICU for evaluation.

Consider high-flow nasal cannula at 15 – 30 LPM with surgical mask over patient’s face.

Patient Admitted to Intensive Care Unit

Fluids

Conservative fluid management strategy such as daily net neutral fluid balance in patients without evidence of shock

Medications

Evaluate for enrollment in clinical trials

 

AntimicrobialsConsider empiric antibiotics for bacterial pneumonia while COVID-19 results are pending

 

CorticosteroidsInitiate dexamethasone for patients requiring O2 or mechanical ventilation

Coagulopathy

Evaluate hematologic abnormalities and treat as appropriate. See Anticoagulation Dosing Recommendations for COVID-19 Patients.

O2 /Mechanical Ventilation

Target SpO2 >92%. Consider HFNC at 15-30LPM with surgical mask over patients face.

Once intubated, maintain plateau pressures < 30cm H20. Low Vt and high PEEP strategies are controversial.

If PaO2/FiO2 < 150, consider early proning and use of paralytics.

If PaO2/FiO2 remains < 150 after proning and paralysis, consider cautious use of inhaled vasodilators and ECMO consult.

Clinical trials

Information about ongoing or potential clinical trials at UMMC can be found in our Clinical Trials database.

Additional comments

  • Early intubation for hypoxemic respiratory failure is no longer required.

Agents not recommended for COVID-19 treatment

The agents listed below have no evidence supporting the use for treatment of COVID-19 but can be used for alternative diagnoses or in the context of clinical trials. * = drugs with low supply (recent shortage or currently on allocation) – contact Pharmacy with questions.

  • HIV protease inhibitors (more on lopinavir/ritonavir below): darunavir, atazanavir
  • H2-receptor blockers: famotidine*, cimetidine
  • Supplements: zinc*, ascorbic acid*, vitamin D
  • Miscellaneous: hydroxychloroquine, IVIG*, interferon, azithromycin, cetirizine, ivermectin 

Inpatient Treatment Algorithm (PDF)

Treatment Information

Approved Therapies

DrugDose and DurationComments

Remdesivir (Veklury)

  • Direct acting antiviral
  • Allocation decisions made on an individual basis

Adult

  • 200 mg IV x 1 followed by 100 mg IV q24h

Pediatric

  • <40 kg: 5 mg/kg IV load followed by 2.5 mg/kg IV q24h
  • ≥40kg: Refer to adult dosing

Duration: 5 days or until no longer hypoxic

FDA approved for patients >12 years old weighing >40 kg. Available through emergency use authorization for pediatric patients <12 years old and/or <40 kg.

Criteria:

  • Requires O2 sat ≤94% or oxygen supplementation 
    • Low-flow nasal cannula
    • High-flow nasal cannula within 24 hours of being placed on oxygen
    • No benefit seen in patients who are already mechanically ventilated
  • Requires baseline eGFR and ALT
  • Contraindicated with ALT > 10x UNL
A/E: Increased ALT/AST.

Corticosteroids
Dexamethasone

  • Initiate in patients requiring mechanical ventilation or oxygen
  • Do not start in patients not requiring oxygen

Adult

Preferred: Dexamethasone 6-10 mg IV/PO* daily

Duration: 10 days or until no longer hypoxic 

Decreased mortality shown in the RECOVERY trial

Not recommended for the treatment of non-hospitalized or non-hypoxic patients

Additional assessment

  • Monitor blood sugar
  • Elevations in WBC can occur with corticosteroid use

Investigational Therapies

Convalescent Plasma

Only available through clinical trials

  • COVID-19 Convalescent Plasma trial (Contact: Amy Wigglesworth, ajwigglesworth@umc.edu)
  • PassItOn trial (Contact: Rebekah Peacock, rpeacock@umc.edu)

Tocilizumab (Actemra)

  • Adjunctive agent that targets IL-6
  • Patients who inclusion criteria will undergo a secondary review for eligibility, and it does not guarantee receiving tocilizumab. Given the limited supply of bamlanivimab, tocilizumab allocation will be determined based on disease severity, risk factors, and overall clinical status.

Adult

8 mg/kg IV x1 dose 


  • Use total body weight for dosing
  • Doses will be rounded to the nearest available full vial (80 mg, 200 mg, 400 mg vials)
  • Max dose = 800 mg
Duration: 1 dose

Mortality benefit shown in certain patient populations REMAP-CAP and RECOVERY trials

Inclusion Criteria:

  1. Symptoms <10 days
  2. Hospitalized <48 hours
  3. Patients who are rapidly progressing and are requiring >4L nasal cannula
  4. CRP ≥7.5
Exclusion Criteria:
  1. Current bacterial or fungal co-infection
  2. Unlikely to survive >48 hours
  3. Mechanical ventilation 

Risk/benefit discussion for pregnant women.

A/E: Increased ALT/AST, infusion related reactions, hematologic dyscrasias, increased LDL, secondary infections

Information on drug interactions and administration for patients who cannot swallow can be found at: http://www.covid19-druginteractions.org/


Management of Non-Hospitalized Patients with Mild-Moderate COVID-19

At this time, no therapies have shown a favorable risk/benefit profile for outpatient treatment of COVID-19, including corticosteroids, azithromycin, and ivermectin. The FDA has approved the REGEN-COV™ (casirivimab/imdevimab) monoclonal antibodies for the use in outpatients who are at high risk of disease progression.

The criteria defined by the EUA for both monoclonal antibodies are below and can easily be accessed using the SmartPhrase “.COVIDABINFSCREENING”:

  •  Within 10 days from symptom-onset
  • ≥12 years of age
  • Weighs ≥40kgs /88lbs.

Patient must meet the 3 criteria above PLUS 1 of the following risk factors for disease progression:

  • ≥65 years of age

12-64 years of age AND have

  • Body mass index (BMI) ≥35 or BMI ≥85th percentile for their age and gender based on CDC growth charts, https://www.cdc.gov/growthcharts/clinical_charts.html
  • Chronic kidney disease or
  • Diabetes or
  • Cardiovascular disease/hypertension (including congenital heart disease) or
  • Chronic lung disease (COPD, mod-severe asthma, interstitial lung disease, cystitic fibrosis, pulmonary HTN) or
  • Immunosuppressive disease* or
  • Currently receiving immunosuppressive treatment (chemotherapy, transplant immunosuppressants, immune modulators such as Rituximab, etc.)
  • Sickle cell disease or
  • Neurodevelopmental disorders or other conditions that confer medical complexity or
  • Medical-related technological dependence (tracheostomy, gastrostomy, or PPV not related to COVID-19) or
  • Pregnant

*AIDS or CD4 count < 200, Complement deficiency, Grafts-Vs-Host disease (GVHD), HIV infection, Immunoglobulin deficiency/ Immunodeficiency, Immunosuppressive therapy (within the last 12 months), Leukemia, Lymphoma (Hodgkin’s/ Non-Hodgkin’s (NHL)), Metastatic cancer, Multiple Myeloma, Solid organ malignancy, Steroid therapy (within past 2 weeks), Bone marrow transplant (BMT) or peripheral stem cell transplant (PSCT), Solid organ transplant

The monoclonal antibodies should not be used for patients who are hospitalized with COVID-19, require oxygen therapy for COVID-19, or have an increase in baseline oxygen flow rate due to COVID-19.

Currently UMMC only has access to REGEN-COV. If you are a UMMC provider and have a patient who you think may qualify for the monoclonal antibodies, please fill out the screening form (.COVIDABINFSCREENING) in Epic and send it to “P COVID-19 MONOCLONAL ANTIBODIES REQUEST”. Prior to sending the requests, please ensure the positive COVID-19 test is available to review in the chart.

Disclaimer

These documents and content on this website are guidelines during the COVID-19 pandemic. Because new information is released rapidly, these documents can be updated or changed at any time. These documents are in no way to be considered as a standard of care and the content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. The information in these documents is provided with no guarantees, accuracy, or timeliness. All content in these documents and website are for informational purposes only and do not constitute the providing of medical advice.