137 CMAAO CORONA FACTS and MYTH BUSTER Treatment Protocols
Dr K Aggarwal
President CMAAO
959: Minutes
of Virtual Meeting of CMAAO NMAs on “Covid-19 treatment experiences in CMAAO
countries”
27th
June, 2020, Saturday; 9.30am-10.30am
Participants
Member
NMAs
Dr
KK Aggarwal, President CMAAO
Dr
Yeh Woei Chong, Singapore Chair CMAAO
Dr
Ravi Naidu, Past President CMAAO, Malaysia
Dr
Marthanda Pillai, Member World Medical Council
Dr
Marie Uzawa Urabe, Japan
Dr
Md Jamaluddin Chowdhary, Bangladesh
Dr
Sajjad Qaisar, Pakistan
Dr
Deborah Cavalcanti, Brazil
Dr
Prakash, Nepal
Invitees
Dr
Russell D’Souza, UNESCO Chair in Bioethics, Australia
Dr
Sanchita Sharma, Editor IJCP Group
·
If the patient comes after 9 days of symptoms
or 9 days of Covid positive test, he/she is presenting with Covid sequelae and
not Covid per se. Treatment of post-Covid sequelae is as per their standard
treatment guidelines or protocols.
·
The virus becomes non-replicating
from 9th day onwards in mild cases; RTPCR test may remain positive for up
to 48 days. In non-hospitalized patients, isolation may be stopped after 9th
day, followed by 4 days of quarantine and then monitoring (with precautions
like masking).
·
Loss (partial) of smell and taste usually
means mild illness; it may be intermittent and may last up to 3 months. Bitter
and sour tastes and sour (lime) smell are retained. In women, it may be
associated with single episode of diarrhea or skin rash.
·
If the patient has fever (<100.40F),
evidence of hyper immune inflammatory response (high ESR, CRP or ferritin),
treat with hydoxychloroquine (HCQ) and colchicines.
·
If patient comes within first 4 days of
symptoms, give antibiotics with anti-viral response (doxycycline or
azithromycin x 5 days). Antibiotics may have no role if patient presents after 9
days.
·
Anti-parasitic drug ivermectin 12 mg single
dose as prophylaxis to whole family
·
If patient develops exertional hypoxia or
pneumonia (very high d-dimer and ferritin levels) (day 4-7), give IL-6
pathway inhibitor (tocilizumab IV 8 mg/kg as a single dose or IV
remdesivir or methyl prednisolone alone or in combination.
·
In high risk case (HT, DM), give Favipiravir x
7 days (in India, given for 14 days) in the first three days of onset of
symptoms; it probably has no action after 72 hours. Remdesivir acts best when
given at the time of hypoxia. Tocilizumab is given when CRP is >100.
·
If cytokine response is very high, the two
options are tocilizumab and prednisolone.
·
In all high risk patients, if they develop
hypoxia (day 4), give LMWH.
·
Give prednisolone 1 mg per kg stat in case of
sudden development of hypoxia (exertional or rest), as an alternative to
remdesivir or tocilizumab.
·
Advise patients to sleep prone; oxygen
concentrator at home or in hospital @ 5 liters/min
·
Give elemental zinc 75 mg daily; vitamin D
60,000 units x 3 days and then 2000 units per day; vitamin C 1000 mg x 3 days
and then 500 mg daily
·
Ranitidine 150 mg twice daily to reduce
acidity; mefenamic acid, naproxen, indomethacin for fever
·
Regularly monitor SpO2 and pulse, especially
between days 4 and 7.
·
Inform if temperature >1030F or lasts
>14 days or breathlessness, SpO2 falls by >4 after six minutes walking,
persistent chest pain
·
Sudden loss of smell and taste is not a
serious sign, may persist for some time, may come and go, may come before fever
·
Conjunctivitis may occur in one eye and is
not a serious sign
·
Rash may occur on any part of body (more in
women) and is not a serious sign
·
Pus cells may be present in urine, indicating
viral cystitis and not secondary infection (low TLC)
·
High monocytes indicate high viral response;
if CRP > 100, this means very high inflammatory response
·
If diarrhea (more common in women), this
means a superspreader; it may be intermittent.
·
Povidone iodine gargles twice daily
·
Do CBC with ESR, CRP, LDH on day 1 and day 5
onwards every 3rd day.
·
If lymphocyte count is < 1000, give ritonavir
+ lopinovir combination
Treatment experience
in CMAAO countries
·
Singapore: The
pandemic is slowing down; there are very few patients in ICU.
·
Pakistan: Antiviral
drugs are being used; tocilizumab and dexamethasone are also being used.
·
Bangladesh:
Stopped
using HCQ as not recommended by WHO. Favipiravir and remdesivir are being used.
Ivermectin is not officially recommended though it is being used by some; there
is a difference of opinion about this drug.
·
Nepal: Antiviral
and/or HCQ are not used; if critical patients, then physicians can use
·
Malaysia: Cases are
now in single digits; infection is mostly coming from overseas and migrant
workers. All Covid patients are referred to designated government hospitals and
not treated in private sector.
·
Japan: Around
100 people diagnosed positive a day, mostly young and no serious cases. 3000
patients have been given favipiravir; but no RCT because of lack of number.
·
Brazil: Cases are
increasing, more than one million diagnosed cases; ivermectin is being used as
prophylaxis
·
Australia:
Melbourne
has some amount of community transmission; 6 suburbs have been identified as
hotspots and everyone will be tested.
·
Kerala,
India: The
number of cases is decreasing. Less than 6% need ICU care; mortality is around
1%. Azithromycin is preferred; treatment covers monsoon fevers like dengue. HCQ
is not used as patients have lot of comorbidities and renal and liver functions
have to be strictly monitored. Strict titration of medication and monitoring of
patients has to be done. Also, selective use of medicine has helped to reduce
mortality.
