Latest key points for treatment of COVID 19 infection for hospitalists

I want to share a few important clinical points useful for adult hospitalists.

By now, we all have seen and treated hundreds if not thousands of patients with COVID infection in hospitals. However, here is a quick recap of some important latest clinical points to refresh your memory.

All patients admitted to the hospital with COVID-19 infection should have a baseline CBC with platelet count, PT, aPTT, fibrinogen, and D-dimer. Apart from regular blood work, CPK can be done for patients who are on Statin.

Patients should be encouraged to cough, take deep breaths apart from moving around in their rooms. Self proning position if they are able.

Some of the unapproved medications are-Vitamin C, Vitamin D, Zinc, Ivermectin, Colchicine, Fluvoxamine, Hydroxychloroquine etc.

Some patients are given Thiamine as cytokine storm can precipitate hypermetabolic state depleting Thiamine stores causing Wernicke Encephalopathy.

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Corticosteroids:

Dose: Dexamethasone 6mg daily for 10 days.

If patients are already on a higher dose of corticosteroid than 6mg Dexamethasone, then that should be continued.

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Remdesivir:

Inhibits RNA-dependent RNA polymerase preventing viral replication.

It is a substrate and inhibitor of CYP3A4. Avoid CYP3A4 inducers like Rifampin or CYP3A4 inhibitors like Voriconazole.

Dose: 200mg IV loading on day 1 followed by 100mg iv daily for 4 days for a total of 5 days or until discharge whichever is earlier if GFR>30ml/min. Therapy can be extended up to 10days if there is no clinical improvement.

No mortality benefit in clinical trials but placebo-controlled trial showed reduced time to clinical recovery in hospitalized patients.

It can be used for hospitalized patients even though they are not on oxygen, if they are at high risk of disease progression.

It is used on patients who are on oxygen for saturation </=94%.

Monitor LFTs daily and discontinue if ALT goes above 10 times upper limit of normal.

For patients who are already on Dexamethasone but have increasing oxygen needs and systemic inflammation, an immunomodulator like Tocilizumab or Baricitinib can be used.

Do we use Remdesivir as monotherapy for patients who are on Mechanical Ventilation or requiring ECMO? -No

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Tocilizumab:

Interleukin-6 Receptor Antagonist.

Dose: A single dose of 8mg/Kg of Actual body weight, up to 800mg.

It is used for patients >/=18yrs within 24hrs of ICU admission or requiring mechanical ventilation or HFNC with FiO2>40% and 30L/min.

It should be avoided in active infections from any pathogens other than COVID19. It should be avoided in Neutropenia, Pregnancy, Thrombocytopenia with PLT <50K, or in those who have elevated ALT/AST >5 times upper limit of normal.

Tocilizumab and Baricitinib cannot be used together. No studies yet showed superiority of one over the other.

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Baricitinib:

Janus Kinase Inhibitor

Dose: 4mg PO Daily for 14 days for GFR more than 60ml/min. Reduce it to 2mg for those with GFR between 30 and 60. Reduce it to 1mg for those with GFR between 15 and 30.

It is used for patients requiring supplemental oxygen, invasive Mechanical ventilation or ECMO.

Patients with history of blood clots or to whom DVT prophylaxis can’t be given, AKI, ESRD, those on immunosuppressants, active TB or any other active serious infections and those who have risk of GI perforation are excluded.

It can be given via PEG tube also.

Monitor for Neutrophil count, ALT/AST, Cr.

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DVT prophylaxis: Hold if PLT <30K.

Per UpToDate, there is “No role for aspirin in inpatients with COVID-19 (November 2021): The RECOVERY trial, which randomly assigned nearly 15,000 individuals hospitalized with COVID-19 to receive standard care with or without Aspirin 150 mg, found no benefit of aspirin in reducing mortality or progression to mechanical ventilation [1]. The aspirin group had a small reduction in thrombosis (4.6 versus 5.3 percent) and a small increase in major bleeding (1.6 versus 1.0 percent).”

-THIN patients:

SQ Lovenox 30mg daily for BMI<40.

-REGULAR patients:

SQ Lovenox 40mg daily for med-surg patients.

SQ Lovenox 30mg BID for ICU patients.

SQ Heparin 5000 units Q 8hrs for those with AKI or GFR <30 or those with ESRD.

OBESITY patients:

SQ Lovenox 40mg BID for BMI>/=40

SQ Lovenox 60mg BID for BMI>/=50

SQ Heparin 7500U Q8hrs

Vaccination:

They should be vaccinated against Flu.

COVID-19 Vaccination upon Discharge from Hospitals, Emergency Departments & Urgent Care Facilities.

COVID-19 ACIP Vaccine Recommendations

These are some of the key points to remember. Please refer to your institution’s guidelines for latest recommendations as the recommendations keep changing.

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