COVID-19 Treatment in MOH Facilities

COVID-19HealthPharmacy
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By Sally Ng

A pharmacist by profession, an explorer by nature

Health director-general, Dr Noor Hisham Abdullah during press conference on current situation of COVID-19 in our country.

Wondering what medicines are being used in our MOH facilities in treating COVID-19 patients despite no specific approved treatment and vaccines for this disease?

Recently, our Ministry of Health published a guideline on management of COVID-19 (updated 19th October 2020). This write-up aims to provide a quick summary on treatment plan for hospitalised COVID-19 patients.

First and foremost, treatment approaches for COVID-19 is evolving rapidly as we learn more about the disease and this write-up may or may not be applicable in the near future. Thus, it is vital as a healthcare professional to keep ourselves updated on the current approaches practiced, specifically in our country.

For starters, positive COVID-19 patients are categorised based on their symptoms and management plans are tailored according to their clinical stage as below;

Clinical stage
Condition of
COVID-19 Patients
Management Plan
MILD 1 Asymptomatic
  • No treatment required
2 Symptomatic,
No Pneumonia
  • No treatment required
  • Close monitoring of vital signs & oxygen saturation
  • Look out for warning signs & if present, treat as category 4
3 Symptomatic,
Pneumonia
  • No treatment required
  • Close monitoring of vital signs & oxygen saturation
  • Treat as category 4 if
    • Age ≥ 50 years
    • ESRF
    • Present with any warning signs
Clinical stage
Condition of
COVID-19 Patients
Management Plan
SEVERE 4 Symptomatic,
Pneumonia,
Requiring supplemental oxygen
  • Antiviral
    • Favipiravir
    • S/C Interferon Beta
  • Immuno-modulatory
    • Dexamethasone (preferred)
    • Methylprednisolone
    • Others: IV Tocilizumab or Convalescent plasma
  • Thrombo-embolism
    • Prophylactic LMWH Enoxaparin
5 Symptomatic,
No Pneumonia
  • Place patient in negative pressure isolation room with ante room OR single room with closed doors OR ICU
  • Non- ventilatory support
    • Simple face mask or non-breathing mask if SpO2<92%
    • Mild ARDS : use High flow nasal cannula
  • Ventilatory support
  • Haemodynamic support
  • Sedation – aim for light sedation 
    • Fentanyl or morphine
    • If additional sedatives required, Propofol or dexmedetomidine
  • Nutritional therapy – enteral nutrition
  • Venous thromboprophylaxis – prophylactic LMWH or unfractionated heparin
  • Stress ulcer prophylaxis in risk factors – medical ventilation > 48 hours, coagulopathy, RRT, acute liver failure, high dose steroids
    • No previous GI ulcer: IV Ranitidine
    • Previous GI ulcer or on PPI: IV Pantoprazole, Omeprazole or Esomeprazole
  • Glycemic control – maintain BG 8-10mmol/L using insulin
  • Antivirals and/or Immunomodulating agents
Warning signs predicting deterioration
Clinical
  • Persistent or new onset of fever
  • Persistent lethargy/ anorexia/ cough
  • Exertional dyspnea, RR>25, SpO2 room air <95%
Laboratory
  • Rising CRP value OR CRP ≥ 5mg/dL
Radiological
  • Multi-lobular involvement OR rapidly worsening chest
    X-ray
Favipiravir (Haifukang) – one of the medicines in treating COVID-19

The following table lists the therapeutics currently in use to treat stage 4 & 5 COVID-19 patients in MOH facilities.

Drug
Recommended Dose
Notes
Favipiravir 200mg Tablet
(HAIFUKANG)		 1800mg BD for
1 day,
then 800mg BDOR1600mg BD for
1 day
then 600mg BDDuration:
5-10days,
up to 14days
  • Start treatment promptly on onset of influenza-like symptoms
  •  Administer on empty stomach
  • Teratogen, contraindicated in women suspected or known to be pregnant. Confirm negative pregnancy test before starting treatment in women with child-bearing potential.
  • Advise contraception during and 7 days after end of treatment for women of childbearing age & men with partner of childbearing age
  • Contraindicated in severe renal (GFR<30ml/min) and liver impairment, pregnancy, breastfeeding
  •  A/E: hyperuricemia, diarrhea, decreased neutrophil count, increased AST, ALT
  • Drug interactions: Live/Attenuated Influenza Virus Vaccine, Pyrazinamide, Repaglinide, Theophylline, Famciclovir, Sulindac
Interferon Beta-1A 44mcg Pre-filled Syringe (REBIF)

OR

Interferon Beta-1B 250mcg/ml Powder & solvent for solution for injection (BETAFERON)

 S/C Interferon Beta-1A :
44mcg stat then EODORS/C Interferon Beta-1B:
250mcg stat then EOD
  • Total : 3-5 doses
  • No dosage adjustment necessary for renal and liver impairment
  • Use in the first week of illness as viral activity may predominate. It may not be useful if started in the second week of illness.
  • Contraindications: hypersensitivity to interferon beta, human albumin or any formulation component, decompensated liver disease, pregnancy (Betaferon only)
  • A/E: local injection site reaction, headache, flu-like symptoms
  • However, NIH guidelines recommend against the use of interferon unless in severe or critically ill COVID-19 patients in clinical trial settings
Dexamethasone Oral/ IV 6mg OD for 5-7 days
  • Recommended in all patients needing supplemental oxygen > 7 day of illness
  • Dexamethasone is preferred as limited data supporting the use of other glucocorticoids
  • A/E: hyperglycemia, increased risk of infections
Methyl-prednisolone 0.5 – 1 mg/kg for 5-7 days
Tocilizumab 20mg/ml Solution for infusion (ACTEMRA) IVI 4-8mg/kg single dose over 1 hour (max: 800 mg/dose)

Dilute solution for injection to 100ml of 0.9%NS, not infused simultaneously with other drugs via same IV line
  • No dose adjustment in CrCl≥30ml/min, no dose adjustment provided in CrCl≤30ml/min & liver impairment
  • A/E: local injection site reactions, increased serum cholesterol, ALT, AST
  • Storage: Vial store at 2-8 °C, protect from light, Prepared infusion solution at 2-8 °C for 24 hours
  • However, NIH guidelines recommend against the use of tocilizumab unless in clinical trial settings
Anticoagulants
Prophylaxis (for all Stage 4 & 5 patients)  

  • All patients in Stage 4 & 5 should receive standard prophylactic anticoagulation with LMWH unless contraindicated.
  • Contraindication: active bleeding, serious bleeding 24-48 hours prior, platelet count <25000, heparin-induced thrombocytopenia
  • Use alternative agent (fondaparinux) or mechanical prophylaxis in patient with contraindication

 
CrCl >30ml/min CrCl <30ml/min
Standard Risk patients Enoxaparin 0.5mg/kg daily SC UFH
5000u BD
High Risk Patient (ICU) Enoxaparin 0.5mg/kg BD UFH is preferred
OR
Enoxaparin 20mg daily / 40mg EOD
Treatment of DVT & PE
(including suspected cases)
Start full dose of anticoagulants
(eg. Enoxaparin 1mg/kg BD)

General care for all COVID-19 patients includes;

General Care for all COVID-19 patients
  • Symptomatic treatment: antipyretic, nutritional support, maintain fluid & electrolytes balance
  • Close monitoring of vital signs
  • Regular blood investigations & imaging
  • No nebulizer, use MDI with spacer bronchodilator
  • No routine antibiotics prescribed
  • No longer using hydroxychloroquine, lopinavir+ritonavir (Kaletra), ribavirin as treatment

To date, the aforementioned therapeutics are only used as off-label for COVID-19 treatment. While we are waiting for more results from clinical trials, let’s continue to abide to the SOPs – physical distancing, wearing face mask & frequent hand washing. #staysafe

Credits: Alexsandro Palombo/Instagram
References:

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