GGC Medicines


Adult Therapeutics Handbook

COVID-19 (Coronavirus) Infection

Management of COVID-19 (Coronavirus) Infection

Introduction

COVID-19 (coronavirus) is the illness caused by a new strain of coronavirus (SARS-CoV-2). It can cause a cough and/or a fever/high temperature and serious complications in some patients. In older adults, COVID-19 can have an atypical presentation.

Information in this guideline has either been directly endorsed by NHSGGC or originates from a reputable source, such as NHS Inform. It is intended to be updated as and when guidance changes.

Brief guidance has been provided below, but further information is available on NHSGGC StaffNet / Clinical Info / COVID-19 Clinical Guideline Page (link available if accessing via a NHS computer). 

Assessment / monitoring

The main clinical features of COVID-19 are:

  • Fever and/or high temperature (defined as ≥37.8°C)
  • Continuous cough, which is defined as:
    • a new cough that has lasted more than 1 hour
    • where a patient has had 3 or more coughing episodes in 24 hours
    • where a patient may be coughing more than usual.
  • Loss of, or change in sense of smell (anosmia) or taste.

In addition to these, patients who are presenting to hospital with COVID, or who have been diagnosed with COVID during admission, may also be showing the following clinical features:

  • Dyspnoea
  • Fatigue/myalgia
  • Confusion
  • Viral illness with possible pneumonitis
  • Patients also may present at the immunological clinical stage, where most patients recover, but where there can be Acute Respiratory Distress Syndrome (ARDS) and/or cardiovascular collapse.

COVID-19 in the older adults

This patient group is more likely to have an atypical presentation of COVID-19 and are less likely to present with cough, dyspnoea or raised temperature. Atypical presentation may include:

  • Delirium
  • Anorexia / fatigue / malaise
  • Falls / syncope
  • Gastrointestinal symptoms
  • Deterioration in function
  • Day to day variability

Symptoms may be unreliable so consider early testing and if index of suspicion is high then repeat swabs.  

Testing

The Coronavirus Information Hub on NHSGGC StaffNet has detailed advice about how to collect a sample and arrange suitable transportation to labs.

Investigations

  • CRP - may be raised or normal and does not reflect presence of bacterial co-infection.
  • U&Es and renal function - in older adults acute kidney injury and hyponatraemia may occur
  • LFTS - transaminitis may occur
  • FBC - lymphopenia is common
  • Oxygen saturations - in older adults hypoxia without breathlessness can occur
  • Assess fluid status - febrile patients have high insensible losses and may need IV fluids. 
  • NT-Pro BNP, Troponin and D-dimer may be elevated and need to be interpreted with caution.
  • CXR - typical initial presentation is bilateral peripheral ground glass opacities. In older adults there may be no changes on the CXR.
  • Chest CT - only if it will change management.

Differential Diagnosis

Always consider other diagnosis or dual pathology, including bacterial infection / sepsis (although bacterial infection is an uncommon dual infection). Consider HIV testing / PCP pneumonia particularly in patients with 'atypical pneumonia' who are COVID negative.  

Management / treatment options

A Treatment Escalation Plan (TEP) is required for all suspected COVID-19 patients. If appropriate involve the palliative care team early and individualise the care. As for all severe viral respiratory illness in pregnant women, delivery may be a "therapeutic option" and so regular discussion with the Obstetric and Neonatal Team is necessary.

Oxygen

  • Suspected COVID pneumonia: target SpO2 90-94%.
  • If chronic obstructive pulmonary disease (COPD) or risk of hypercapnia: target  SpO2 88-92%.
  • Consider proning for ward patients with an oxygen requirement

Seek consultant review and treatment escalation plan if SpO2 is below the target levels stated above.

Non-invasive respiratory support (CPAP, nasal high flow therapy, non-invasive ventilation) is considered on a case-by-case basis for patients with COVID-19 severe respiratory failure. Respiratory support interventions are aerosol generating procedures so are only initiated in selected high dependency - hi-care areas. Please refer to site specific guidance on escalation thresholds and place of care for COVID-19 respiratory support. 

Dexamethasone

Dexamethasone shows reduced mortality in patients with severe and critical COVID-19 as per the RECOVERY trial. Criteria for using dexamethasone includes: COVID-19 (suspected or confirmed) in patients requiring oxygen therapy as per targets, non-invasive ventilation or invasive ventilation, or extracorporeal membrane oxygenation (ECMO). Patients with non-severe COVID (i.e. not requiring oxygen to maintain target saturations) should not be given dexamethasone as there is no evidence that they derive benefit from it and may, instead, derive harm.

Dose of dexamethasone is oral /IV 6mg once daily for 10 days (stop prior to hospital discharge if within 10 days). Use tablets (or oral solution), unless swallow is an issue or there are significant concerns with regards to enteral absorption. 

N.B. If dexamethasone 3.3mg/ml IV 1ml ampoule is used, then dosage required is 1.8ml (5.94mg) once daily for 10 days.

In pregnant or breastfeeding women, prednisolone oral 40mg daily (or hydrocortisone IV 80mg twice daily) for 10 days should be used, instead of dexamethasone. Use tablets (or oral dispersible tablets), unless swallow is an issue or there are significant concerns with regards to enteral absorption, in which case use IV hydrocortisone. Stop treatment if discharged from hospital within 10 days. 

A proton pump inhibitor should be considered in patients on dexamethasone who are at high risk of gastrointestinal bleeding or dyspepsia:

  • Omeprazole oral 20mg once daily or
  • Lansoprazole oral 15mg-30mg once daily.

Dexamethasone and blood glucose monitoring

Dexamethasone and COVID-19 can independently cause severe insulin resistance and impaired glucose metabolism. Combined, there is therefore a risk to people with and without known diabetes of significant hyperglycaemia and possible Hyperosmolar Hyperglycaemic State (HHS) or Diabetic Ketoacidosis (DKA). Therefore all patients with COVID-19 on dexamethasone (or alternative high dose steroid as above) will require capillary blood glucose (CBG) checked once a day (at 4pm) upon commencement if not diabetic, and four times a day in those with diabetes.

For non-diabetic patients who have a CBG>12mmol/L, and for all those with diabetes, please follow the guideline here for ongoing monitoring and management.  

Drug interaction

Co-administration of dexamethasone with remdesivir has not been studied, but based on metabolism, clearance and course duration; a clinically significant interaction is unlikely as:

  • Remdesivir has a rapid clearance and a moderate-high hepatic extraction ratio
  • Dexamethasone is used for a short duration in the treatment of COVID-19.

Thromboprophylaxis

Patients with COVID-19 are at high-risk of venous thromboembolism (VTE) and thromboprophylaxis should be prescribed in all patients admitted to hospital with suspected or confirmed COVID-19 infection unless contraindicated. See the thromboprophylaxis in COVID-19 patients guideline for further information.

Antibiotics

Bacterial co-infection with SARS-CoV-2 is unusual, occurring in approximately 3-4% of patients. CRP is usually raised in COVID-19 and does not predict bacterial infection. The majority of patients with COVID-19 outside of the intensive care setting therefore do not require antibiotics. If there is clinical uncertainty, prescribe antibiotics as per current NHSGGC guidance (amoxicillin or doxycycline unless severe bacterial pneumonia is suspected) but review the ongoing need for an antibiotic when the SARS-CoV-2 result is available. In suspected bacterial pneumonia or infective exacerbation of COPD, limit the duration of antibiotics to 5 days irrespective of severity. 

Remdesivir

Remdesivir does not improve mortality, but there may be some benefit in recovery. Please note, due to worldwide demand, availability is currently restricted. It should be considered for use in severe cases only and must fulfil a series of critera which include: for the treatment of adults and adolescent patients aged ≥12 years and weighing ≥40kg hospitalised with coronavirus disease 2019 (COVID-19) who require supplemental oxygen. Remdesivir should only be used in patients with eGFR >30ml/minute and ALT <5x upper limit of normal.

Initiation of treatment with remdesivir

The decision to treat with remdesivir is not an emergency and should be made judiciously after assessment and in a timely manner during office hours. Do not call out the on-call pharmacist to obtain supply. Complex cases can be discussed with the infectious diseases or respiratory consultant during office hours.

Remdesivir should not be initiated in patients who present to hospital more than 10 days after symptom onset or present to hospital and are unlikely to survive (determined by clinical judgment). In complex cases, multidisciplinary discussion should be sought and infectious disease or respiratory specialist can be contacted via the on-call consultant during office hours.

After initiation of remdesivir, patients require daily clinical review, U&Es and LFTs. It should be stopped prior to completion of the 5 day course if:

  • Improvement and no oxygen requirement after 72 hours
  • Deterioration after 48 hours ventilation
  • Patient assessed to be at end of life
  • Discharged from hospital even if <5 days of treatment course
  • eGFR <30ml/minute or LFT >5x upper limit of normal.

See remdesivir flowchart for brief dosing and monitoring information. For further information, see the manufacturer's summary of product characteristics via www.medicines.org.uk

Tocilizumab

Tocilizumab is an immune modulating drug that may have some benefit in eligible patients in the ITU setting only. Administration would be initiated only by intensive care consultant usually in the context of a therapeutic drug trial.

NHSGGC continues to support a number of COVID therapeutic drug trials which continue to contribute to this fast moving field.

Patients receiving systemic anti-cancer treatment (SACT)

Some cancer patients including, but not limited to, those receiving SACT are at very high risk of severe illness from COVID-19 and may be on the national shielding list. It is important to withhold all oral anti-cancer medicines, including chemotherapy and biological modifiers, in hospitalised patients and notify the on-call haemato-oncology or oncology team. There are particular risks associated with the use of Granulocyte Colony Stimulating Factor (GCSF) e.g. filgrastim / pegfilgrastim in patients with COVID-19. GCSF must be withheld in patients with suspected COVID-19 and discussed with the on-call haemato-oncology or oncology team. For more information see the West of Scotland Cancer Network guideline on the WoSCAN intranet site (NHS network access required).

Useful Links 

 

Guideline reviewed and clinical content updated 7th December 2020

Page updated 11th January 2021