Standards of care for COVID-19 patients
Significant progress has been made on how to care for COVID-19 patients, and treatment recommendations continue to evolve.
In this video we present the current guidelines and recommendations from the United States National Institute of Health, or NIH, COVID-19 Treatment Guidelines Panel as of January 2021.
An individual’s treatment heavily depends on the patient’s health condition as well as the resources available to the health care team, so health care professionals should follow local policies and use their clinical judgement on a case-by-case basis.Patients with mild symptoms from COVID-19 should be advised to treat the disease like any other bad cold.
Patients should rest, drink fluids, and can take over the counter medications to manage symptoms like fever and congestion.
Healthcare providers should encourage patients to isolate themselves, including isolating within a specific part of their home to avoid contact with other household residents.In November 2020, the United States Food and Drug Administration or FDA, issued Emergency Use Authorization to allow bamlanivimab or casirivimab plus imdevimab to be given to outpatients who are at high-risk for serious infection, such as people with cancer, type 2 diabetes, and pre-existing heart conditions like heart failure.
Bamlanivimab and casirivimab plus imdevimab are laboratory manufactured monoclonal antibodies designed to fight COVID-19 by preventing the virus from entering the host cells.
To date, the NIH panel does not have enough information to make a recommendation for or against using these drugs for COVID-19 patients with mild symptoms, and these drugs can only be given through emergency use authorization or as part of a clinical trial.
Drug supply may also be limited depending on a provider’s location and administration should be prioritized for those with the highest risk.
Bamlanivimab and casirivimab plus imdevimab are not recommended for patients who are hospitalized as studies have suggested this could cause harm.Patients who require hospitalization for COVID-19 infection, but do not require supplemental oxygen should primarily be given supportive treatment, focusing on reducing symptoms and promoting comfort.
Healthcare providers should also consider seeking permission to enroll patients into clinical trials as soon as a COVID-19 diagnosis is confirmed.
Patients who are at high-risk of developing severe COVID-19 symptoms may receive Remdesivir. Remdesivir is an IV antiviral drug that inhibits viruses from replicating in the body, by interfering with a critical enzyme during RNA replication.
Clinical trials with hospitalized patients showed remdesivir treatment reduced the median recovery time from 15 days to 10 days, and reduced the number of individuals requiring mechanical ventilation.
Initial clinical trials also suggest remdesivir is safe for use in people who are pregnant, and has been given Emergency Use Authorization from the United States Food and Drug Administration, for use in children 12 years of age and younger as long as they are over 3.5 kilograms.Patients who are unable to maintain appropriate oxygen saturations should receive supplemental oxygen.
Patients who need minimal oxygen, such as with low-flow nasal prongs, are good candidates to receive remdesivir as its benefits are greatest for patients on supplemental oxygen.
Remdesivir reduced recovery times as well as mortality rates for patients on supplemental oxygen.Patients on supplemental oxygen with high-flow non-invasive devices may also benefit from the corticosteroid dexamethasone.
The immune response of the body in patients with severe COVID-19 symptoms can cause lung injury and significant damage to other organs.
Corticosteroids help reduce the intensity of the immune response. One clinical trial with patients with severe COVID-19 symptoms showed that corticosteroids reduced mortality from 40% to 32%.
Other clinical trials showed similar mortality rate reductions and reduced need for invasive mechanical ventilation in severe COVID-19 cases.
The NIH panel recommends patients in need of high-flow oxygen or non-invasive mechanical ventilation receive dexamethasone or other similar corticosteroids, such as prednisone, preferably in combination with remdesivir.
If remdesivir is unavailable, dexamethasone alone may also be used in this patient population. Dexamethasone is safe for use with people who are pregnant, however little information exists on its use in children, and should be used on a case by case basis.The FDA also has given Emergency Use Authorization for baricitinib to be used in combination with remdesivir.
Baricitinib inhibits the Janus kinase 1 and 2, which limits the immune system’s reaction to COVID-19. To date, the NIH panel does not have enough information to make a recommendation for or against the use of the drug, however, it recommends using baricitinib when corticosteroids cannot be used, and it must always be used in conjunction with remdesivir.For patients requiring invasive mechanical ventilation, or extracorporeal membrane oxygenation, dexamethasone is the only recommended medication for COVID-19.
Remdesivir is not recommended for patients of this clinical severity, as clinical trials have not shown significant benefit with this patient group.There have been a number of other proposed treatments such as the use of injecting the convalescent plasma from people who’ve recovered from COVID-19 and likely have antibodies against the virus into patients who are seriously ill with the disease.
While the FDA has issued Emergency Use Authorization for convalescent plasma, the National Institute of Health panel indicates there hasn’t been sufficient evidence in clinical trials to show this treatment helps or harms patients, and they do not recommend its routine use.Another proposed treatment is the use of interleukin-6 inhibitors, such as sarilumab, tocilizumab, and siltuximab.
While interleukin-6 inhibitors are FDA approved, the NIH panel recommends against using them for the treatment of COVID-19 as there’s been insufficient data on their effect.
In the spring of 2020, chloroquine and hydroxychloroquine were proposed to be treatment options for severe COVID-19 patients.
In June of 2020, the FDA revoked Emergency Use Authorization of these drugs for COVID-19 due to concerns about drug toxicity [8].
Similarly, the National Institute of Health panel has issued a statement that recommended against using these drugs, as initial trials in COVID-19 patients had either shown no benefit at all, or had led to worse outcomes for patients due to the drugs’ side effects.There are a number of other therapeutic agents that are being investigated for their use in COVID-19 patients, including favipiravir, lopinavir-ritonavir, interferons, azithromycin, ivermectin, vitamin D, and zinc.
First, prior to influenza season, health care providers should encourage patients to receive the influenza vaccine. Direct encouragement either in person during patient appointments or over the phone are ideal.
If a patient has influenza like symptoms, begin COVID-19 precautions.Influenza and COVID-19 have nearly identical symptoms, and the only definitive way to differentiate the two is diagnostic testing.Second, some observational studies have suggested NSAIDS may lead to worse outcomes for patients with COVID-19, however the NIH specifically indicates NSAID use should continue as normal.
Similarly, ACE inhibitors and statin drugs should continue to be used for chronic illnesses in COVID-19 patients.Third, COVID-19 patients who are already on immunosuppressant drugs like prednisone for other underlying conditions should be assessed on a case-by-case basis whether to discontinue use during COVID-19 infection in order to prevent serious COVID-19 symptoms from developing.Fourth, encourage patients and family to wear face masks, regularly wash their hands or use hand sanitizer, continue to follow social distancing requirements, and get vaccinated when the vaccine becomes available to them.
on a case-by-case basis whether to discontinue use during covid-19 infection in order to prevent serious covid-19 symptoms from developing.
Fourth encourage patients and family to wear facemasks regularly wash their hands or use hand sanitizer continue to follow social distancing requirements and get vaccinated in the back seat becomes
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