For Information and Understanding of COVID-19 read:
COVID treatment and medical care has the following important objectives-
- providing symptomatic relief and improving general health
- preventing complications and death
- reducing viral shedding and transmission
LEVELS OF CARE
To prevent the overwhelming and overloading of healthcare workers and facilities, multi-level isolation and COVID treatment system patients have come into play in some countries like India.
Mild cases are those with symptoms but no breathlessness, blood oxygen saturation of 95% or more, HR-CT mild score <8/25, and without other risk factors or pre-existing medical illness. Such patients are isolated at home (if an independent room and toilet are available) or in COVID-Healthcare Centers (self-care/basic care repurposed stay centers like hotels, hostels, lodges, stadia, guest houses, etc.). The same also applies to asymptomatic COVID-positive people. These patients should self-assess temperature, and oxygen saturation by a digital pulse oximeter, at-least every 4 hours, and inform the over-seeing health-care professional.
Moderate cases (having breathlessness, blood oxygen saturation <95%, HR-CT moderate score 8-17/25, or respiratory rate >24 breaths/min) or patients with comorbidities, are treated in COVID isolation wards in dedicated COVID Hospitals or hospital blocks with oxygen administering facilities.
Severe cases (oxygen saturation <90%, respiratory rate> 30 breaths/min or HR-CT severe score of 18/25 or more), are cared for in COVID Hospital ICUs with the availability of life support systems like ventilators.
There is currently no specific drug or medicine available for COVID-19. All active cases (RTPCR positive) should be placed in strict isolation. Maintaining hydration, a nutritious diet, and clinical monitoring of symptom severity, and oxygen saturation by pulse oximetry are central to managing all patients.
Medicines for general health and symptomatic relief
Nutritional supplements including vitamin C, D, and zinc are often prescribed to improve general nutrition and immunity, without any specific role in treating COVID. Steam inhalation may also be beneficial.
Mild cases recover with symptomatic treatment alone (paracetamol and naproxen/mefenamic acid) for fever and body ache. Sometimes additional drugs for improving cough-cold symptoms may be given like antihistamines, montelukast, or mucolytics like ambroxol.
Repurposed Medicines for COVID
Some drugs which were specifically developed and approved in the past for other infections are being researched and tried as COVID treatment in certain patients and are therefore called repurposed medicines. More studies and research data are required and ongoing to confirm the effectiveness of many of the drugs mentioned below, for various parameters of COVID treatment. These drugs can have side effects that need to be clinically monitored, especially when given in combination, and to patients with pre-existing medical conditions. Therefore these medicines should be used appropriately depending on patient type, disease severity, and presence of associated co-morbidities. Most importantly, none of these drugs should ever be taken without the prescription and monitoring of a qualified physician.
This may be required in moderate-severe cases when blood oxygen saturation on pulse oximetry is seen to fall, or there is associated breathlessness. This can be given at home, or in healthcare centers/hospitals. Sometimes the oxygen may be given with pressure for better blood saturation (continuous or bilevel positive airway pressure: CPAP or BiPAP). The patient is also made to lie prone (on his stomach) to facilitate better oxygen delivery to the lungs. Serious cases may require ventilator and life support.
DRUGS USED FOR TREATING COVID
Remdesivir(originally developed for the Ebola virus) and favipiravir (an anti Flu drug) have shown effectiveness in reducing the recovery time and duration of illness in COVID patients.
Remdesivir given by intravenous injection has been approved for treating all hospitalized COVID patients. The recent SOLIDARITY trial by WHO showed no significant effect of remdesivir on reducing overall mortality, initiation of ventilation, and duration of stay in hospitalized patients. However, the ACTT1 trial (based on which USFDA approval was given) has shown an overall reduction in recovery time, and a mortality reduction in the subgroup of patients on oxygen therapy.
Favipiravir is given orally and has been approved for mild-moderate COVID patients. In clinical studies, favipiravir has shown a shortening of recovery time and faster symptomatic relief, along with more rapid viral clearance and reduced shedding. This can help decrease hospitalization risk, need for oxygen therapy, and complications, as well as reduce transmission in the family/community, when given early post-diagnosis (RTPCR positive test) in mild-moderate or asymptomatic COVID cases. Currently, favipiravir is being increasingly prescribed in mild-moderate COVID patients in home-care and isolation.
Anti-HIV drugs like lopinavir-ritonavir had been tried initially with some success in certain countries where the above drugs were not yet available. They may be useful in patients in whom lymphocyte count is extremely low. However, this combination has not shown benefit in hospitalized COVID patients according to the WHO SOLIDARITY drug trial. Other anti-HIV drugs like zidovudine are still under evaluation for COVID and studies are awaited.
Nitric Oxide Nasal Spray (NONS) has recent shown effectivity in significantly reducing viral loads and COVID severity in phase 2 trials.
Anti-parasitic and Antibiotic medicines
Hydroxychloroquine, an oral anti-Malaria, and anti-rheumatoid arthritis (RA) drug, is being used in many countries, sometimes with azithromycin (antibiotic). Results have been encouraging in some clinical studies which showed a reduction in viral shedding, hospitalization rate, ICU admission, and mortality when given early in the course of mild-moderate COVID patients, as recommended in some countries. However other clinical studies have refuted the same. Hydroxychloroquine has not shown benefit in severe cases or hospitalized patients according to the WHO SOLIDARITY and other recent trials. Caution and monitoring with ECG (for QT interval prolongation or heart rhythm abnormalities) are advised, especially in elderly COVID patients with other co-morbid health conditions. Hydroxychloroquine has also been approved in a few countries to prevent symptomatic or severe COVID in exposed or infected health care workers and close/household contacts, however definite supportive scientific evidence is still lacking for this.
Ivermectin and nitazoxanide (anti-parasitic drugs) are also being given in certain centers (sometimes with doxycycline), in some COVID cases. Ivermectin has antiviral properties and its use has shown shorter recovery time, better symptomatic relief and also a reduction in mortality. Ivermectin in a recent study also showed effectiveness as a prophylaxis drug for people with documented exposure to COVID. Data from large clinical studies are yet to confirm the definite place of these medicines in managing COVID, before their inclusion in standard treatment protocols advocated by countries or medical organizations.
Corticosteroids: Dexamethasone or prednisolone/methylprednisolone (oral/injectable), have shown effectiveness in clinical studies in reducing inflammatory lung damage and mortality in moderate-severe COVID patients especially those on ventilators or requiring oxygen therapy. So far, only corticosteroids have been proven effective for severe or critical hospitalized COVID-19 patients. Sometimes corticosteroids may also be given via nebulizers with or without added bronchodilators.
Tocilizumab, an injectable anti-RA drug (anti-IL-6 cytokine), is being used in certain moderate-severe hospitalized patients for reducing severe lung disease and symptoms caused by a ‘cytokine storm’ (which is a damaging hyper-immune reaction with massive inflammation). However, recent trial data has not been conclusive of its benefits. Itolizumab, an injectable anti-psoriasis drug, has also been approved for limited emergency use in moderate-severe COVID cases.
Ulinastatin is an injectable anti-inflammatory (protease inhibitor) drug used for sepsis and pancreatitis. It reduces inflammatory markers and cytokines, and may be used, often with corticosteroids in hospitalized COVID patients with progressing lung damage, ARDS or during a cytokine storm to decrease complications, need for mechanical ventilation and mortality. Methylene blue has also shown some anecdotal benefit in such situations.
Colchicine, an oral anti-inflammatory anti-RA drug, has shown evidence in reducing mortality, hospitalization, and the need for ventilation in COVID patients in the recent COLCORONA study.
Recently some preliminary evidence has come in about Interferon-beta treatment in an inhalational form to prevent severe disease and lung damage in COVID patients. There is also some case-based and anecdotal evidence to show that high doses of vitamin C, due to its anti-oxidant property, given as injections can help to suppress massive inflammation in the body especially during a ‘cytokine storm’ in hospitalized COVID patients.
Aspirin (used early in low dose in mild-moderate cases) can have protective effects on the endothelium by its anti-inflammatory and anti-platelet (anti-thrombotic) action. Low molecular weight Heparins (LMWH like enoxaparin injected subcutaneously) are anticoagulants, used in hospitalized patients with an increased risk of thrombosis. Alternately directly acting oral anticoagulants like apixaban and rivaroxaban are also used especially in discharged or out-patients at thrombosis risk. Another investigational drug, nafamostat, also an anticoagulant, is being studied for its anti-viral properties of inhibiting entry and activation of SARS-CoV-2 in human cells.
The statin group of cholesterol-lowering drugs (like atorvastatin) also have anti-inflammatory and antithrombotic properties that help protect blood vessels and thereby reduce endothelial damage and dysfunction. These drugs are also being further evaluated for their likely benefits as an adjunct therapy in COVID patients.
In November 2020, biological monoclonal antibody drugs bamlanivimab-etesevimab and casirivimab-imdevimab (as combinations) have been approved by the US FDA for treating mild-moderate COVID patients12 years or older at high risk for progressing to severe COVID, complications, and/or hospitalization. This includes those who are 65 years of age or older, or who have certain associated chronic medical conditions like diabetes, hypertension, heart/kidney/respiratory conditions, high obesity (BMI of 35 or more), and immunosuppressive diseases. These agents are given as a single intravenous injection and act specifically against the spike protein of the coronavirus to prevent its entry into human cells. These agents are not to be used in already hospitalized patients or those requiring oxygen therapy/ventilation.
Convalescent Plasma is the non-cellular component of the blood from recovered patients which contains antibodies to the COVID virus. It is being used to treat certain severe and non-responsive cases and has helped in the recovery of some patients. However, clinical studies currently have not been able to confirm its efficacy or benefits, and more research is needed, while its large-scale feasibility and effectiveness are still being ascertained.
Preformed concentrated COVID antibodies (hyper-immune globulin) have also been developed for treatment and short-term prophylaxis.
Post COVID rehabilitation
A lot needs to be studied and understood over time about the long-term impact of COVID on lung function, general health, and work capacity. Chest physiotherapy, diet and nutrition management, graded physical exercises and activities, as well as counseling for mental well-being, will play important roles.
Research labs and companies in some countries have genetically studied and sequenced the COVID virus and have been able to fast-track potential vaccines, for which clinical trials have been conducted. The types of COVID vaccines already approved for emergency use include Inactivated (killed) virus, vector (adenoviral-CoV spike protein), and genetic (mRNA) vaccines from various companies around the world. Public immunization has begun in several countries in Jan-Feb 2021.
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