Acute Covid-19: Guidance for prescribing in primary and community care

See KCCG latest SOP (v01) here

See NICE guidance here

Contents:
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Current Knowledge

Patients who become significantly unwell with COVID have several days ~ 6-11 where their condition follows a non-specific pathway followed by sudden and occasionally catastrophic deterioration

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Silent hypoxia is a recognised feature of the presentation of patients to hospital with severe COVID

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There are a range of therapies which if given to patients with severe COVID-19 seem to reduce the severity of the disease

  • Oxygen

  • Steroids

  • Remdesivir

 

We also know that compared to other countries the UK thresholds for Oxygen initiation were amongst the lowest and that this had a negative association with national case fatality rates.

 

Many others are being studied including convalescent plasma and azithromycin.

Mild Covid

  • 1st consider home isolation

  • plus monitoring (refer to Covid Oximetry at Home if meets criteria)

  • plus symptom management and supportive care

  • https://www.nice.org.uk/guidance/ng191

  • Consider antipyretic/analgesic

  • Fever and pain: paracetamol or ibuprofen are recommended. There is no evidence at present of severe adverse events in COVID-19 patients taking non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, Ibuprofen should only be taken at the lowest effective dose for the shortest period needed to control symptoms.

Moderate Covid

  • 1st consider home isolation or hospital admission

  • plus monitoring (refer to Covid Oximetry at Home if meets criteria)

  • plus symptom management and supportive care

  • consider antibiotics (see below)

  • consider antipyretic/analgesic

Antibiotics

https://www.nice.org.uk/guidance/ng191

Consider the following tests to help inform decision making about using antibiotics:

 

  • sputum sample

  • chest imaging (X‑ray, CT or ultrasound via acute GP)

  • full blood count

  • Be aware that high C‑reactive protein levels do not necessarily indicate that the pneumonia is due to bacteria rather than COVID‑19. If there is confidence that the clinical features are typical for COVID‑19, it is reasonable not to start empirical antibiotics.

 

Empirical antibiotics should be started if there is clinical suspicion of bacterial infection, including characteristic symptoms and localised chest findings.


Antibiotic choice – use local microguide app for latest guidance  KCCG Antibiotic Guideline  and Primary Care Antibiotic Guideline. (Always check allergies)

NB. MHRA recent advice that Doxycyline is ineffective in Covid-19 pneumonia

Severe Covid

Defined by any of:

  • oxygen saturation < 90% on room air.

  • respiratory rate > 30 breaths per minute in adults and children > 5 years old;

    • ≥ 60 in children less than 2 months 

    • ≥ 50 in children 2–11 months

    • ≥ 40 in children 1–5 years old

  • signs of severe respiratory distress (i.e. accessory muscle use, inability to complete full sentences, central cyanosis;

    • in children, very severe chest wall indrawing, grunting, or presence of any other general danger signs).

  • Treatments to consider:

    • oxygen,

    • steroids,

    • anticoagulants

Oxygen Therapy

Start oxygen if:

  • Patients with SpO2 ≤92% on air with normal oxygen levels.

  • Patients with SpO2 ≥4% lower than their baseline oxygen levels (e.g. ≤84% if baseline is 88%).

Adjust litres according to PMH.

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IF COMMUNITY OXYGEN SUPPLY  NEEDED <4 HRS CALL AIR LIQUIDE HCP LINE

Air Liquide prescriber support team 24 hour helpline 0808 202 2099

 

Air Liquide patient 24 hour helpline (for care homes for patients on HOS) 0808 143 9999

Obtaining Home oxygen in the community

See the Home Oxygen page to order

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VTE Prophylaxis in Covid - Community setting

https://www.nice.org.uk/guidance/ng191

Patients with COVID 19 Pneumonia managed in Community Settings

VTE Prophylaxis in Covid - Hospital setting

https://www.nice.org.uk/guidance/ng191

Patients with COVID 19 Pneumonia managed in Community Settings

  • Assess risk of VTE and bleeding.

  • Consider prophylaxis if VTE risks outweigh bleeding risk.

  • Offer a standard prophylactic dose (for acutely ill medical patients) of low molecular weight heparin (LMWH).

  • Start VTE prophylaxis as soon as possible and within 14 hours of admission and continue for the duration of the hospital stay or 7 days, whichever is longer.

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For patients who are already having anticoagulation treatment for another condition when admitted to hospital:

  • continue their current therapeutic dose of anticoagulation unless contraindicated by a change in clinical circumstances

  • consider switching to LMWH if their current anticoagulation is not LMWH and their clinical condition is deteriorating.

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If a patient's clinical condition changes, assess the risk of VTE, reassess bleeding risk and review VTE prophylaxis.

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Please note: Intermediate  (double standard prophylactic  dose) dosing of LMWH is indicated for  patients on advanced respiratory support (eg BiPAP, CPAP) as per NICE guidance see link above.

Corticosteroids in Covid

NICE -covid19-prescribing-briefing-corticosteroideroids

Offer dexamethasone or hydrocortisone to people with severe or critical COVID-19 (in line with updated WHO guidance); that is, people with any of the following:

• signs of severe respiratory distress

• oxygen saturation <90% (or deteriorating) on room air

• increased respiratory rate (>30 breaths per minute in adults and children over 5 years).

• acute respiratory distress syndrome (ARDS)

• sepsis or septic shock.

 

Corticosteroids should not normally be used in people with COVID-19 that is not severe or critical, because there is the possibility of harm to such people.

Dosages

The recommended dosage and duration of treatment for adults is:

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For dexamethasone:

6 mg once a day orally for 7 to 10 days (three 2 mg tablets or 15 ml of 2 mg/5 ml oral solution)

-- or --

6 mg once a day intravenously for 7 to 10 days (1.8 ml of 3.3  mg/ml ampoules [5.94 mg])

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For hydrocortisone

50 mg every 8 hours intravenously (0.5 ml of 100 mg/ml solution, powder for solution for injection/infusion is also available). This may be continued for up to 28 days for patients with septic shock.

 

Treatment should stop if the person is discharged from hospital before the 10 day course is completed.

Remdesivir

Remdesivir is an adenosine nucleotide prodrug that is metabolised intracellularly to form the pharmacologically active substrate remdesivir triphosphate. Remdesivir triphosphate inhibits SARS-CoV-2 RNA polymerase which prevents viral replication.  Clinical Trials  have been running to establish effectiveness in COVID 19.

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Update November 2020

WHO has issued a conditional recommendation against the use of remdesivir in hospitalized patients, regardless of disease severity, as there is currently no evidence that remdesivir improves survival and other outcomes in these patients.

https://www.who.int/news-room/feature-stories/detail/who-recommends-against-the-use-of-remdesivir-in-covid-19-patients

 

Remdesivir was unlikely to be available to be prescribed  in community hospitals or by GPs in the community as there is a severely limited supply ,which is only available as part of a clinical trial.

EOL/palliation advice

See the EoL guidance page

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Managing anxiety, delirium and agitation

Address reversible causes of anxiety, delirium and agitation first by:

  • exploring the patient's concerns and anxieties

  • ensuring effective communication and orientation (for example explaining where the patient is, who they are, and what your role is)

  • ensuring adequate lighting

  • explaining to those providing care how they can help.

 

Treat reversible causes of anxiety or delirium, with or without agitation, for example hypoxia, urinary retention and constipation.

Consider trying a benzodiazepine to manage anxiety or agitation

https://www.nice.org.uk/guidance/ng191