Patient Treatment Guidelines

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

Last update: December 9, 2020

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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 document 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, colchicine, cetirizine

Inpatient Treatment Algorithm (PDF)

Approved Therapies

DrugDose and DurationComments

Remdesivir (Veklury)

  • Direct acting antiviral
  • FDA approved emergency use authorization
  • Supply limited

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.

Additional assessment

  • Requires O2 sat < 95% or oxygen supplementation
  • 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 at this time

Additional assessment

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

Not Recommended

Azithromycin

  • No intrinsic activity for SARS-COV-2
  • No benefit demonstrated for COVID-19

Adult

  • 500 mg IV/PO on day 1, followed by 250 mg IV/PO daily x 4 days + HCQ

Pediatric - >3 months

  • 10 mg/kg IV/PO on day 1 (max 500 mg), followed by 5 mg/kg IV/PO daily x 4 days (max 250 mg)

Additional assessment

  • Assess for serious drug-drug interactions (DDI)
  • Assess baseline QTc and Mg2+ with follow-up QTc in 24-48 hours
Contraindications
  • QTc >500

Hydroxychloroquine (HCQ)

No benefit in multiple RCT for COVID-19

Adult

400 mg PO BID x2 doses followed by 200 mg PO BID x4 days

Pediatric

6.5 mg/kg (max: 400 mg/dose) q12h PO x2 doses followed by 3.5 mg/kg (max: 200 mg/dose) PO q12h x 4 days

 Additional assessment

  • Assess QTc prior to initiation
  • Assess for serious drug-drug interactions (DDI)

Contraindications

  • QTc >500 (see QTc monitoring table on page 2)

A/E: retinopathy, rash, nausea, glucose fluctuations

Lopinavir-Ritonavir (Kaletra®)

  • No benefit in RCT for COVID-19

Adult

  • 400mg-100mg PO BID

Pediatric

  • 14 days to 6 months:
    • 16 mg/kg PO BID (lopinavir component) 
  • 6 months to 18 years:
    • 15-25 kg: 200 mg-50 mg PO BID
    • 26-35 kg: 300 mg-75 mg PO BID
    • >35 kg: 400 mg-100 mg PO BID

Additional assessment

  • Check HIV antigen/antibody prior to first dose
  • Assess for serious DDI (CYP3A4 substrate/inhibitor)

A/E: hepatotoxicity, pancreatitis, QTc prolongation, diarrhea 

Combination with ribavirin has been suggested based on synergistic action with lopinavir/ritonavir. Additional studies are needed before recommending this combination.  

Tocilizumab (Actemra)

  • Adjunctive agent that targets IL-6
  • No benefit in RCT (COVACTA) for COVID-19

Adult

  • 400 mg IV x1 dose

Pediatric – 2 years of age and older

  • <30 kg: 12 mg/g IV x1 dose (max 400 mg)
  • ≥30kg: 8 mg/kg IV x1 dose (max 400 mg)

Duration: 1 dose

Additional assessment

  • Consider checking inflammatory markers (CRP, ferritin, LDH, fibrinogen, D-dimer)
A/E: Increased ALT/AST, infusion related reactions, hematologic dyscrasias, increased LDL

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

The FDA has approved two monoclonal antibodies for the use in outpatients who are at high risk of disease progression:

  1. Bamlanivimab (Eli Lilly)
  2. Casirivimab/imdevimab (Regeneron)

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
  • Chronic kidney disease or
  • Diabetes or
  • Immunosuppressive disease* or
  • Currently receiving immunosuppressive treatment (chemotherapy, transplant immunosuppressants, immune modulators such as Rituximab, etc.)

≥55 years of age AND have

  • Cardiovascular disease, OR
  • Hypertension, OR
  • Chronic obstructive pulmonary disease/other chronic respiratory disease.

12-17 years of age AND have

  • BMI ≥85th percentile for their age and gender based on CDC growth charts,  https://www.cdc.gov/growthcharts/clinical_charts.htm, OR
  • Sickle cell disease, OR
  • Congenital or acquired heart disease, OR
  • Neurodevelopmental disorders, for example, cerebral palsy, OR
  • Medical-related technological dependence, for example, tracheostomy, gastrostomy, or positive pressure ventilation (not related to COVID-19), OR
  • Asthma, reactive airway or other chronic respiratory disease that requires daily medication for control.

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 bamlanivimab. If you are a UMMC provider and have a patient who you think may qualify for bamlanivimab, 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.