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) first identified in Wuhan city, China. It can cause a cough and/or a fever/high temperature and serious complications in some patients.

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.

In older adults, COVID-19 can have an atypical presentation. 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 well documented:

  • 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

Patients are likely to have co-morbidities. Always consider other diagnoses or dual pathology, including bacterial infection / sepsis. 

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.

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.

  • Do not use high-flow nasal oxygen or non-invasive ventilation (NIV) outwith designated locations and without respiratory consultant review or critical care recommendation.

Antibiotics

  • Most patients do not require antibiotics. If they do, see table 1 below.

Table 1: Infection management

Presentation Choice of antibiotic:
Infective exacerbation of COPD with purulent sputum

Doxycycline oral 200mg as a one-off dose followed by 100mg daily

or

Amoxicillin oral 500mg 8 hourly 

Total course duration: 5 days.

Suspected bacterial pneumonia

Follow community acquired pneumonia guidelines available within the Lower Respiratory Tract Infections guidelines however, do not add clarithromycin unless on the advice of microbiology, Infectious Diseases team or respiratory specialist.

Doxycycline oral 200mg as a one-off dose followed by 100mg daily (5 days) may be used for atypical cover if required.

Suspected hospital acquired pneumonia - Non-severe

Doxycycline oral 100mg 12 hourly 

or 

Co-trimoxazole oral 960mg 12 hourly

Total course duration: 5 days.

Suspected hospital acquired pneumonia - Severe

Co-amoxiclav IV 1.2g 8 hourly +/- gentamicin IV (dosing info here, gentamicin max 3-4 days) 

or if penicillin allergy: 

Levofloxacin (monotherapy) oral 500mg 12 hourly (use the same dose IV if oral route compromised)

Total course duration: Review (usually 5 days).

  • Remember QTc prolongation with macrolides (such as clarithromycin) or levofloxacin, and drug interactions (doxycycline, macrolides, levofloxacin). See BNF for details of drug interactions.
  • If IV antibiotics are used, consider IVOST when patient is improving.

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.

Dexamethasone

Dexamethasone has been shown to have benefit in some patients with severe 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).

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) checks four times a day upon commencement. 

  • If CBG ≥12mmol/L, consider corrections with subcutaneous insulin or use of the variable rate insulin infusion (VRIII) protocol as clinically appropriate and refer to the inpatient diabetes team. Check venous blood gas and blood / urine ketones if unwell and discuss with a senior. VRIII protocol can be found by searching 'Variable Rate Intravenous Insulin Infusion' on NHSGGC StaffNet / Clinical Info / Clinical Guidelines Directory (link is only active if accessing via NHS computer). 
  • If CBG all <10mmol/L for 48 hours, reduce monitoring to once daily at teatime. 
  • Check HbA1c. 

Note that insulin, rather than the commencement or titration of sulphonylureas and other non-insulin hypoglycaemics, is recommended for the management of hyperglycaemia and glycaemic emergencies with COVID-19 infection and the use of high dose steroids. This is because COVID-19 may be cause pancreatic beta-cell dysfunction. 

For further detailed guidance see the ABCD COVID: Diabetes document on dexamethasone therapy on http://abcd.care/coronavirus.  

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.

Remdesivir

This antiviral agent was previously available under the Early Access to Medicines Scheme (EAMS) for suspected or proven COVID-19 and is now a licensed product. It should be considered for use in severe cases only and must fulfil a series of criteria, which include:

  • For the treatment of adults and adolescent patients aged ≥12 years and weighing ≥40kg hospitalised with coronavirus disease 2019 (COVID-19), requiring supplemental oxygen.
  • In the absence of a confirmed virological diagnosis, remdesivir should only be used when a multidisciplinary team have a high level of confidence that the clinical and radiological features suggest that COVID-19 is the most likely diagnosis.  

At the time of decision to treat with remdesivir, the patient should not be receiving ongoing mechanical ventilation or ECMO. Patients who present with an initial rapid deterioration can, however, be considered for treatment with remdesivir, but multidisciplinary team assessment should determine if patients not suitable for escalation would benefit from initiation of treatment with remdesivir. If patients on remdesivir require escalation, continuation of the drug should be considered by multidisciplinary team assessment. 

Dose of remdesivir IV is 200mg on day 1, followed by 100mg daily for 4 days (can be extended for a further 5 days after multidisciplinary assessment). For information on remdesivir, including monitoring, side effects, cautions and contraindications, see the the manufacturer's summary of product characteristics via www.medicines.org.uk. To obtain supply, or for further information, contact pharmacy (see Appendix 6 for contact details).

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).

Other considerations

  • ACE-Inhibitors (ACEI) and Angiotensin II receptor Blockers (ARB) 
    • There is no current evidence that taking these drugs, or stopping them, alters COVID-19 outcomes. 
    • Do not stop these drugs unless:
      • Haemodynamic upset (e.g. if SBP reduced by more than 20mmHg than usual measurement).
      • Acute Kidney Injury (serum creatinine >30% higher than 'baseline').

Useful Links 

 

Content updated 10th August 2020