COVID treatment: Centre issues revised guidelines on use of drugs and therapies

There is no evidence of injectable steroids benefitting COVID patients not requiring oxygen supplementation or in continuation after discharge, according to the revised ‘Clinical Guidance for Management of Adult COVID-19 Patients.’ The revised guidelines issued by AIIMS, ICMR-COVID-19 National Task Force and Joint Monitoring Group (DGHS) under the union health ministry also stated that anti-inflammatory or immunomodulatory therapy, such as steroids, can have the risk of secondary infection like invasive mucormycosis, when used too early, at higher dose or for longer than required.

Injection methylprednisolone 0.5 to 1 mg/kg in two divided doses, or an equivalent dose of dexamethasone, can be given usually for a duration of five to 10 days in moderate cases, the guidelines stated. The same drug in two divided doses of 1 to 2 mg/kg can be given for the same duration in severe cases.

“Inhalational budesonide (given via metered dose inhaler/dry powder inhaler) at a dose of 800 mcg BD for five days can be given in mild cases if symptoms (fever and/or cough) are persistent beyond five days of disease onset,” it was stated in the guidelines.

If cough persists for more than two-three weeks, one should opt for investigation for tuberculosis and other conditions, they stated.

The revised guidelines continue to recommend Emergency Use Authorisation (EUA) or off-label use of Remdesivir in patients with moderate-to-severe disease and those with no renal or hepatic dysfunction within 10 days of the onset of any symptom.

It warned against use of the drug for patients who are not on oxygen support or in home settings.

According to the guidelines, EUA or off-label use of the Tocilizumab drug may be considered for use in the presence of severe disease, preferably within 24 to 48 hours of onset of severe disease or Intensive Care Unit (ICU) admission.

Tocilizumab may be considered for patients with significantly raised inflammatory markers, and not improving despite use of steroids with there being no active bacterial, fungal or tubercular infection, they stated. Coronavirus patients have been classified into those affected by mild, moderate and severe disease, the guidelines stated.

According to the guidance note, upper respiratory tract symptoms without shortness of breath or hypoxia has been categorised as mild disease and have been advised home isolation and care.” Those suffering from mild COVID should seek medical attention if they have difficulty in breathing, high-grade fever, or severe cough lasting for more than five days.

Those having breathlessness with SpO2 fluctuating between 90-93 per cent, can get admitted to a ward, and they will be considered moderate cases. Such patients should be given oxygen support and awake proning should be encouraged in all patients requiring supplemental oxygen therapy, in sequential position changes every two hours, the guidelines stated.

Respiratory rate over 30 per minute, breathlessness or SpO2 lower than 90 per cent on room air should be considered as severe disease and such patients have to be admitted to an ICU as they will need respiratory support, they stated.

Such patients should be put on respiratory support. Non-invasive ventilation (NIV) — helmet or face mask interface depending on availability — may be considered in those with increasing oxygen requirements if work of breathing is low.

High-flow nasal cannula should be considered in patients with increasing oxygen requirements. Intubation should be prioritised in patients with high work of breathing if NIV is not tolerated and institutional protocol for ventilatory management should be used when required, the new guidelines stated.

Those aged above 60 years, or those having cardiovascular disease, hypertension and coronary artery disease diabetes mellitus and other immunocompromised states, such as HIV, active tuberculosis, chronic lung, kidney or liver disease, cerebrovascular disease or obesity are at high risk for severe disease and mortality, the guidelines stated.