Post By: Dr. Abdul Khaliq

Pathophysiology:

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Pathogenesis:

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Drugs: Mechanism of action

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Categorization of Patients:

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Management According to Groups:

Colchicine 0.5 mg up to even thrice daily for 5 days is the maximum. Maintenance can be 0.5 mg BD up to another 5 days.

Dexamethasone6 mg is equivalent to 40 mg of prednisolone, 32 mg of methyl prednisolone and160 mg of hydrocortisone.

Caution of medications:

Colchicine:

Be aware of interaction with Statins if patient is already on particularly in elderly with renal dysfunction. It may cause myalgia’s and myolysis.

Avoid concomitant use with azithromycin- QT interval changes

Be cautious if renal dysfunction and cirrhosis

Avoid in pregnancy and lactation.

Diarrhea, muscle pain, nausea vomiting and abdominal pain can occur.

 

Aspirin:

Gastritis, UGI Bleed, worsening renal function

 

Baricitinib:

Avoid in pregnancy and lactation

Cytopenia scan occur

Add antibiotic cover as it reduces immune response

 

Q & A:

When should the patient get tested and what tests?

If symptoms persist for more than 2 days go ahead and get the RT PCR done. The reason for early testing is if early diagnosis is made then early treatment and better prognosis is anticipated. More or less because of increasing cases sometimes getting report is not possible on the same day in multiple places. So the dictum is early the testing done the better for management.




Can the patient get Rapid antigen test?

Rapid antigen testing can be done but if the report is available immediately. Once a rapid antigen test is negative, RT PCR has to be tested again. If getting report is delayed better to go ahead with the standard of the testing that is RT PCR.




What should the patient do when waiting for the reports?

1. Isolate
2. Betadine gargles
3. Steam inhalation



How to use Betadine Gargles?

Betadine gargles protocol 15 ml twice a day for 1 minute 1% povidine iodine. Dilute 10% Betadine 2 ml with 20 ml of water. Rinse through both nostrils and gargle through mouth for at least 1minute twice a day. For 5 days to 7 days. (Oral This. 2020.10.1111/odi.13526d).




How to use steam inhalation?

Steam inhalation protocol: Each session of 4 minutes - total 5 sessions (that is 20minutes of total exposure) with in 1-hour period. Heat denatures the virus mainly in the paranasal sinuses. For 5 days to 7 days (doi.org/10.1016/j.lfs.2020.118801).




What to do if Clinical symptoms are like COVID-19 but RT PCR is negative?

In such a case it is better to go ahead with HR CT chest after at least 3 days of symptom onset. It is more likely to help in diagnosing with presence of classical radiological findings.




If HR CT is noncontributory in RT PCR Negative case then what?

Then look for other causes depending upon the symptoms. If clinical suspicion is high wait for 2 days more and get RT PCR again.




What are the medications to start with if in Group A?

1. Most of the patients in group A will improve with good outcome. Baseline supportive medications and symptomatic medications are required.
2. Supportive medications : Famotidine, aspirin, statin, colchicine, zincovit, vitamin D sachet
3. Symptomatic medications: paracetamol, ascoril, cetirizine, etc.



When are tests required in Group A?

1. At baseline and repeat at 3-5 days if severe symptoms persisting (fever/myalgia/fatigue/cough/sob) or when labs are abnormal as described.
2. At baseline and repeat at 5-7 days if mild symptoms persisting and mild derangement in labs
3. At baseline and need not repeat if symptomatic improvement and all lab parameters within normal.



How to identify Group B from amongst Group A?

(Baseline good characteristics but outcome will be poor if unattended early)

1. Severe symptoms (High grade fever>101F, Myalgia’s, undue fatigue, persistent cough, dyspnea) persisting more than 5 days
2. Lab parameters as described in table (at least 1 lab parameter abnormal). High reliance is given to CRP, NLR and D-dimer.



When to start antivirals in Group B and which antivirals?

1. Once identified as Group B give antivirals
2. Favipiravir if mild elevations in labs /symptoms persisting
3. Remdesivir if significant elevation in lab as in group C / CT > 50% involvement



If started on Favipiravir of group B then when to shift to remdesivir?

Though no enough data but Remdesivir is perceived to be better. So in spite of Favipiravir if repeat markers are showing worsening in the labs done after 2-3 days better to change to Remdesivir




Can Remdesivir be started in Group B right at the onset of inflammatory cascade?

Yes, Remdesivir can be started right at the beginning subject to availability and given under healthcare observation.




What medications to start in group C?

1. Group C are either age more than 45,obesity, co-morbidities then
2. Betadine, steam inhalations
3. Famotidine, aspirin+ statin, colchicine, multivitamins, Vitamin-D
4. LM WH right at onset 40- 60 mg depending upon age
5. Remdesivir under medical supervision.



When to retest for labs in group C/ group B?

All labs or preferably CBP, CRP to be repeated after 3 days.




What if labs are worsening along with clinical status co or worsening in Group C/ B in spite of Rem, LM WH?

1. If D-dimer is increasing consider optimizing LM WH to therapeutic dose or twice a day 60 mg
2. If CRP/ Ferritin / NLR is worsened along with clinical worsening consider optimizing colchicine or add on Baricitinib if within 1 week and no hypoxemia on 6-min walk test.
3. If still CRP/ Ferritin/NLR is worsening along with clinical worsening in spite of adding colchicine and Baricitinib -consider getting HR CT for lung involvement- if it is > 40% involved consider adding steroids in spite of no hypoxemia.