Other considerations for Patients Hospitalized due to COVID-19

 

- Clinical progression to more severe disease usually begins between 5-7 days after symptom onset.  Risk factors for disease progression include older age and presence of underlying medical conditions (e.g. hypertension, obesity, diabetes, chronic lung diseases, and immunocompromised state). However, younger, previously healthy individuals can develop severe illness.

 

Avoid nebulized medications and do not do bronchoscopy for obtaining specimens alone (ET aspirate preferred) to reduce aerosolization risk.

 

-  If oxygen demand is increasing, consider early referral for appropriate respiratory supports depending on access and infrastructure, as patient outcomes may be superior and planned intubations are at a lower risk for infection transmission than emergent ones.

 

- There is no evidence that ACE Inhibitors and Angiotensin Receptor Blockers need to be stopped.  There is a theoretic concern about ACE inhibition and increased risk of adverse outcomes in hospitalized COVID-19 patients, but there are no clinical data supporting risk.  Major cardiovascular societies (Statement on COVID-19) recommend that suspect and confirmed COVID-19 patients on ACE inhibition should be maintained on their therapy if it is otherwise indicated to avoid decompensation of cardiac disease.

 

- There is no specific contraindication to NSAIDs:  There is current anecdotal concern about the antecedent use of NSAIDs in patients with severe disease, but no clinical data are yet available.  As other symptomatic therapy can be substituted (acetaminophen, appropriately dosed) pending further information, it may be reasonable to prefer acetaminophen to NSAIDs for COVID-19 symptoms, but patients with inflammatory conditions on stable doses of NSAIDs should remain on them.

 

 

-  Other investigational therapies that are NOT currently recommended:

  • High dose steroid therapy – may cause harm; worse outcomes in SARS and influenza
  • IVIG - not expected to have neutralizing antibody and may worsen ARDS
  • Ribavirin as an adjunct to lopinavir/ritonavir - high dose has toxicity concerns, and must be used in combination
  • Anti-IL6 inhibitors (tocilizumab) and other immune modulating therapies for cytokine release syndrome (anakinra, other) – At this time in AHS, immune modulating therapies for COVID-19 can only be pursued in the context of clinical trials or compassionate use.