Important Read: COVID Home care, Isolation and Treatment
For Information and Understanding of COVID-19 read:
COVID treatment and medical care has the following important objectives-
- providing symptomatic relief and improving general health
- preventing complications and death
- reducing viral shedding and transmission
LEVELS OF MEDICAL CARE
To prevent the overwhelming and overloading of healthcare workers and facilities, multi-level isolation and COVID treatment systems have come into play in some countries like India.
Mild cases are those with symptoms, but blood oxygen saturation maintained at >94% and no breathlessness. Their HR-CT if done usually shows <50% lung damage (score <13/25). Such patients are isolated and managed at home (if an independent room and toilet are available) or in COVID-Healthcare Centers (self-care/basic care repurposed isolation centers like hotels, hostels, lodges, stadia, guest houses, etc.). The same also applies to asymptomatic COVID-positive people. These patients should self-assess temperature, and oxygen saturation by a digital pulse oximeter, every 4-6 hours, and inform the over-seeing healthcare professional. For people who have other medical risk factors or pre-existing comorbidities, a more detailed evaluation would be needed to decide on home management or hospitalization.
Moderate cases are those having a blood oxygen saturation consistently of 90-93%, and breathlessness with respiratory rate >24 breaths/min. Their HR-CT score is usually >13/25. They are treated in COVID isolation wards in dedicated COVID Hospitals or hospital blocks with oxygen administering facilities. Sometimes people initially in the mild category can progress to moderate-severe disease, and may also need hospitalization in case of persistent/worsening symptoms (like high fever >101 deg F, cough with congestion/phlegm), developing shortness of breath, reduction in oxygen saturation, and high or rapidly rising levels of inflammatory markers like CRP, D-dimer, ferritin, LDH, IL6, etc. after 5-7 days of home care. Those feeling very sick, weak, or unable to eat and take medicines orally should also be given hospital care.
Severe cases are those with oxygen saturation consistently <90%, and a respiratory rate> 30 breaths/min. They commonly have HR-CT scores >18/25 and can develop severe breathlessness (ARDS -acute respiratory distress syndrome), and/or other complications. They are cared for in COVID Hospital ICUs with the availability of mechanical ventilators and life support systems.
There is currently no specific drug or medicine available for COVID-19. All symptomatic, as well as asymptomatic RT-PCR-positive people, should be placed in strict isolation.
Maintaining hydration (adequate water/fluid intake), having a nutritious diet, and clinical monitoring of symptom severity with 4 hourly temperature and oxygen saturation (by pulse oximetry), are central to managing the infection. Antiseptic gargling may also be beneficial, along with breathing exercises. Steam is not required routinely but may be taken once or twicw daily if nose or throat congestion is present.
Medicines for general health and symptomatic relief
Nutritional supplements including vitamin C, D, and B complex are often prescribed to improve general nutrition and immunity, without any specific role in treating COVID.
Mild cases recover with symptomatic treatment alone (paracetamol and naproxen/mefenamic acid) for fever and body ache. Sometimes additional drugs for improving cough-cold symptoms may be given like antihistamines, montelukast, or mucolytics like ambroxol.
It is important to take all medicines and supplements regularly as prescribed by the doctor and complete the full course. One should not stop, skip or start any medicine on one’s own, and always be in touch with the treating doctor. The entire duration of a minimum 14-day isolation period should be completed before stepping out in public, even if symptoms are absent or gone.
Lying on one’s belly (prone position) is helpful as it can improve lung ventilation and blood supply, and thereby oxygen saturation. It can be done for half to 1-hour, twice or thrice a day, and combined with taking 5-10 deep breaths every 5-10 minutes. Proning should be avoided for 1-hour post meals and by pregnant women, very obese, and those with spine, joint, or heart problems.
This may be required in moderate-severe COVID treatment when blood oxygen saturation on pulse oximetry is seen to fall, or there is associated breathlessness. Oxygen can be given at home or in COVID healthcare/isolation centers through oxygen cylinders or oxygen concentrators with the use of a nasal cannula or face mask.
An oxygen concentrator extracts oxygen from the air itself giving an unlimited supply, unlike an oxygen cylinder which would need periodic refilling. The oxygen concentrator can deliver a higher oxygen flow rate (around 5-10L/min) and concentration (FiO2 up to 90% or more) compared to a cylinder (1-5 L/min and up to 40% FiO2). It is important to note that the concentration of oxygen delivered can fall significantly with increasing flow rates in some lightweight oxygen concentrators, so the appropriate one delivering adequate oxygen should be selected. Simple (low flow) nasal cannulas can deliver around 1-6L/min, (up to 45% oxygen) and face mask around 6-10L/min (up to 60% oxygen). Oxygen therapy at home can help manage small dips in oxygen saturation or buy some time in case hospital beds are not immediately available. It is not a substitute for hospitalization, as people with significantly dropping oxygen saturation require high flow therapy, injection of medicines to control inflammation, and higher-level care.
Oxygen in hospitals is usually delivered at high concentration (90-100%) through central oxygen lines, with NRBM (non-rebreather mask can deliver 10-15L/min of 80-100% oxygen), or high flow nasal cannulas (HFNC for higher flow rates up to 40-60L/min). Non-invasive ventilation (NIV) is a method of ventilating the airway and lungs where oxygen is given under pressure to help improve blood saturation and reduce breathing effort (continuous or bilevel positive airway pressure: CPAP or BiPAP). As mentioned, the patient is also made to lie prone (on his belly) to facilitate better oxygen delivery to the lungs and removal of phlegm/congestion.
Serious cases may require mechanical ventilation and life support in hospital/mobile ICUs. A mechanical ventilator puts air directly into the lungs with the help of a tube placed in the airway (intubation) by the ICU doctor.
Repurposed medicines for COVID
Some drugs which were specifically developed and approved in the past for other infections are being researched and tried as COVID treatment in certain patients and are therefore called repurposed medicines. More studies and research are required and ongoing to confirm the effectiveness of many of the drugs mentioned below, for various parameters of COVID treatment. These drugs can have side effects that need to be clinically monitored, especially when given in combination, and to patients with pre-existing medical conditions. Therefore these medicines should be used appropriately as part of COVID treatment, depending on patient type, disease severity, and presence of associated co-morbidities. Most importantly, none of these drugs should ever be taken without the prescription and monitoring of a qualified physician.
DRUGS USED FOR TREATING COVID
Remdesivir (originally developed for the Ebola virus) and favipiravir (an anti-flu drug) have shown some effectiveness in reducing the recovery time and duration of illness in COVID patients.
Remdesivir given by intravenous injection has been approved for treating all hospitalized COVID patients. The large SOLIDARITY trial by WHO showed no significant effect of remdesivir on reducing overall mortality, initiation of ventilation, and duration of stay in hospitalized patients. However, the smaller ACTT1 trial (based on which USFDA approval was given) has shown an overall reduction in recovery time, and a mortality reduction in the subgroup of patients on oxygen therapy. Remdesivir is mainly useful for patients hospitalized for breathlessness, decreasing oxygen saturation levels needing oxygen therapy, and severe lung involvement/pneumonia. It should be initiated within 10 days of symptom onset.
Favipiravir is given orally and has been approved for mild-moderate COVID patients, especially those in home care or health centers. In clinical studies, favipiravir has shown a shortening of recovery time and faster symptomatic relief, along with more rapid viral clearance and reduced shedding. More scientific data is still needed as to how much favipiravir changes the clinical course, and whether it helps decrease hospitalization risk or complications, need for oxygen therapy, or transmission in the family/community. It works best when given within 5 days after a positive RT-PCR test.
Anti-HIV drugs like lopinavir-ritonavir had been tried initially with some success in certain countries where the above drugs were not yet available. They may be useful in patients in whom lymphocyte count is extremely low. However, this combination has not shown benefit in hospitalized COVID patients according to the WHO SOLIDARITY drug trial. Other anti-HIV drugs like zidovudine are still under evaluation for COVID and studies are awaited. As of now, anti-HIV drugs are not part of COVID treatment recommendations.
2-deoxy-D-glucose (2-DG) is a drug, recently developed and approved in India post a small phase 3 clinical trial showing a reduction in oxygen requirement or dependence, and a faster recovery time. This drug is in a powder sachet form to be taken orally after dissolving in water. It acts by specifically accumulating in the virus-infected cells, preventing viral growth and energy production, and maybe a useful adjunct in moderate-severe COVID patients hospitalized for low oxygen saturation. However, more data is needed from larger and randomized control studies.
Interferons are signaling antiviral proteins part of our immune system. PEG Interferon alpha-2b injection has recently been approved in countries like India for treating moderate COVID to reduce viral load and improve recovery. Some preliminary evidence has come in about Interferon-beta treatment in an inhalational form to prevent severe disease and lung damage in COVID patients.
Nitric Oxide Nasal Spray (NONS) is another agent which has recently shown effectivity in significantly reducing viral loads and COVID severity in phase 2 trials. More data on efficacy is awaited.
Anti-parasitic and Antibiotic medicines
Ivermectin (anti-parasitic drug) is being prescribed (sometimes along with the antibiotic doxycycline), in mild-moderate non-hospitalized COVID cases. Ivermectin is known to have antiviral properties and in some clinical studies, it has shown shorter recovery time, along with better symptomatic relief and clinical course. Ivermectin also showed effectiveness as a prophylaxis drug for people with documented exposure to COVID in a recent study. Data from large clinical trials are yet to confirm the definite place of ivermectin in managing COVID. However, ivermectin is very economical and is part of treatment protocols advocated by medical associations in some countries like India. There is no proven role or clinical recommendation for using doxycycline. Another anti-parasitic drug nitazoxanide is also being studied and more data is awaited.
Hydroxychloroquine, an oral anti-malaria, and anti-rheumatoid arthritis (RA) drug, is being used in some countries. It has been also studied and sometimes given along with the antibiotic azithromycin. Results were initially encouraging in some clinical studies which showed a reduction in viral shedding, hospitalization rate, ICU admission, and mortality when given early in the course of mild-moderate non-hospitalized COVID patients. However other subsequent clinical studies have refuted the same. Hydroxychloroquine has not shown benefit in severe cases or hospitalized patients according to the WHO SOLIDARITY and other recent trials. Caution and monitoring with ECG (for QT interval prolongation or heart rhythm abnormalities) are advised, especially in elderly COVID patients with other co-morbid health conditions. Hydroxychloroquine is still part of COVID treatment regimens in mild non-hospitalized cases, in some countries due to it being economical. Hydroxychloroquine has also been approved in a few countries like India to prevent symptomatic or severe COVID in exposed or infected health care workers and close/household contacts, however definite supportive scientific evidence is lacking for this. Azithromycin though not recommended as such, is still prescribed in mild-moderate COVID patients with sore throat and cough.
Corticosteroids that include dexamethasone, prednisolone or methylprednisolone (oral/injectable), have shown effectiveness in clinical studies in reducing inflammatory lung damage and mortality in moderate-severe hospitalized COVID patients especially those on ventilators or requiring oxygen therapy. So far, only corticosteroids have been proven effective for severe or critical hospitalized COVID-19 patients. Corticosteroids should not be given in mild non-hospitalized COVID patients in the first week of illness especially if their oxygen saturation is adequately maintained and their inflammatory markers are normal. They may be introduced in the second week in case fever or cough is persistent or comes back, inflammatory markers like CRP are significantly raised or rising, and oxygen saturation is showing a tendency to fall below 94%. In such cases, they are given orally as low dose tablets, or as inhalers (budesonide). Giving steroids to recovering patients with mild symptoms and maintained oxygen saturation can do more harm than good, therefore the appropriate usage and timing of these medicines is crucial. Prolonged and high-dose steroids are associated with suppression of immunity, rise in blood sugar, and risk of Mucormycosis.
Baricitinib, an oral anti-arthritic drug is also used as an effective anti-inflammatory agent (usually along with remdesivir) for hospital-based COVID treatment especially in those people non-responsive to or who can’t be given corticosteroids or have very low lymphocyte count.
Tocilizumab, an injectable anti-RA drug (anti-IL-6 cytokine), is indicated in hospitalized patients for reducing severe lung damage and symptoms caused by a ‘cytokine storm’ (a damaging hyper-immune reaction with massive inflammation, and rapidly rising inflammatory markers). Sarilumab, another anti-RA anti-IL-6 drug is also available for this indication. Patients admitted to ICU and not showing improvement in the next 24-48 hours despite corticosteroids and high flow nasal oxygen, may be suitable candidates for such drugs. Itolizumab, an injectable anti-psoriasis drug, has also been approved for limited emergency use in such COVID cases. Due to the shortage of these drugs, some hospitals are also using other substitutes like bevacizumab, etc. but both regulatory approval or clinical evidence are absent. Any active infection should be ruled out before using these drugs, and being strong immunosuppressants there should be close monitoring for adverse effects. Cytokine absorption filters (cytosorb) are available as kits for hospital use during cytokine storms. This helps remove inflammatory mediators from the pumped-out patient’s blood after which the blood is recirculated back to the patient.
Ulinastatin is an injectable anti-inflammatory (protease inhibitor) drug used for sepsis and pancreatitis, that reduces inflammatory markers and cytokines. It may be used, often with corticosteroids in hospitalized COVID patients with progressing lung damage, ARDS, or during a cytokine storm, to decrease complications, need for mechanical ventilation and risk of mortality. Methylene blue (through a nebulizer, as sublingual tablet or injection) has also shown some anecdotal benefit in temporarily improving oxygen saturation and reducing inflammatory markers involved in a cytokine storm, but large-scale studies are still needed to verify its use, place in treatment, and benefit.
Colchicine, an oral anti-inflammatory anti-RA drug, has shown some evidence of reducing mortality, hospitalization, and the need for ventilation when given early after COVID diagnosis in non-hospitalized RT-PCR positive patients. (recent COLCORONA study). It may be a useful option instead of corticosteroids in mild-moderate home care COVID patients who have additional risk factors like diabetes, high BP, heart disease, obesity, or known respiratory disease especially if they have high fever (>101 def F) and low lymphocyte counts. However, more research is still needed to ascertain a definitive role. Colchicine has not shown benefit in hospitalized COVID patients.
There is also some case-based and anecdotal evidence to show that high doses of vitamin C, due to its anti-oxidant property, given as injections can help suppress massive inflammation in the body especially during a ‘cytokine storm’ in hospitalized COVID patients.
Aspirin (used early in low dose in mild-moderate cases) can have protective effects on the endothelium by its anti-inflammatory and anti-platelet (anti-thrombotic) action and should be continued in patients with cardiovascular disease and risk, who are already taking it. Low molecular weight Heparins (LMWH like enoxaparin injected subcutaneously) are anticoagulants, used in hospitalized patients with an increased risk of thrombosis. Alternately directly acting oral anticoagulants like apixaban and rivaroxaban are used in those discharged from hospital or rarely in non-hospitalized patients with high D-dimer suggesting thrombosis risk. Another investigational drug, nafamostat, also an anticoagulant, is under clinical trial for its anti-viral properties of inhibiting entry and activation of SARS-CoV-2 in human cells.
The statin group of cholesterol-lowering drugs (like atorvastatin) also have anti-inflammatory and antithrombotic properties that help protect blood vessels and thereby reduce endothelial damage and dysfunction. As of now, these drugs should be continued in patients already on them for cholesterol control and cardiovascular disease. These drugs are being further evaluated for their likely benefits as an adjunct therapy in COVID patients.
In November 2020, biological monoclonal antibody drugs casirivimab-imdevimab and bamlanivimab-etesevimab (as combinations) have been approved by the US FDA for treating mild-moderate COVID patients 12 years or older at high risk for progressing to severe COVID, complications, and hospitalization. This includes those who are 65 years of age or older, or who have certain associated comorbid medical conditions like diabetes, hypertension, heart/kidney/respiratory conditions, high obesity (BMI of 35 or more), and immunosuppressive diseases/therapy. These agents are given together as a single intravenous infusion and act specifically against the spike protein of the coronavirus to prevent its entry into human cells. These agents work best if given within 72 hours of symptom onset (maximum within a week). They are not to be used in already hospitalized patients and those requiring oxygen therapy or ventilation.
Convalescent Plasma is the non-cellular component of the blood from recovered patients which contains antibodies to the COVID virus. It is being used to treat certain severe and non-responsive hospitalized cases and has helped in the recovery of some patients. However, clinical studies currently have not been able to confirm its efficacy or benefits, and more research is needed before it can be recommended. Plasma therapy mainly has value if antibody titers are high, and it is given early in the disease course. Its large-scale feasibility and effectiveness are still inconclusive.
IVIg (Intravenous Immunoglobulin) is also used in severe patients non-responsive to other drugs and therapies, in some COVID hospitals. Though some studies have shown improvement in clinical outcomes and reduction in mortality, more data is needed on the timing and group of patients who would actually benefit. It may be useful to manage post-COVID multisystem inflammatory syndrome (MIS). Preformed concentrated COVID antibodies (hyper-immune globulin) have also been developed for treatment and short-term prophylaxis, but more large-scale data is still awaited on the use of these therapies.
Post COVID rehabilitation
A lot needs to be studied and understood over time about the long-term impact of COVID on lung function, general health, and work capacity. Post-COVID symptoms can be present for up to 3 months and sometimes longer (long COVID). These include weakness, chronic fatigue, body ache, headache, indigestion, low appetite, feeling feverish or breathless, anxiety-depression, brain fog (feeling less sharp mentally), palpitations, and subnormal taste/smell.
Chest physiotherapy, diet and nutrition management, graded physical activities and breathing exercises, as well as counseling for mental well-being, will play important roles. Medicines like nintedanib and pirfenidone are being studied and used in some patients to manage post-COVID lung fibrosis and restricted function.
Research labs and companies in some countries have genetically studied and sequenced the COVID virus and have been able to fast-track potential vaccines, for which clinical trials have been conducted. The types of COVID vaccines already approved for emergency use include inactivated (killed) virus, vector (adenoviral-CoV spike protein), and genetic (mRNA) vaccines from various companies around the world. Public immunization has begun in several countries in Jan-Feb 2021. Currently, vaccination is the most promising way of preventing severe COVID and achieving long-term control on the pandemic control with herd immunity.
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