It takes your breath away
Join Dr. Nathan Erdmann (@NerdmannID, University of Alabama Birmingham) as he walks us through inpatient covid management from antivirals, immune modulators and anticoagulation.
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COVID 19 has been defined by NIH Guidelines on a spectrum of mild to severe disease with mild disease typically being managed in the ambulatory setting and severe requiring hospitalization.
Mild: Signs and symptoms of covid 19 will be present but do not include respiratory symptoms (i.e. shortness of breath, dyspnea on exertion, or abnormal lung imaging).
Moderate: Presence of lower respiratory symptoms on exam or imaging, with an SpO2 >/= 94% on room air.
Severe: Presence of lower respiratory symptoms on exam with an SpO2 < 94%, RR > 30, or lung infiltrates on imaging.
Critical: presence of respiratory failure, shock, or multiorgan failure.
There is no clearly defined laboratory panel to use to measure risk of decompensation. Dr. Erdmann mentions that each institution may have different inflammatory markers that they use, but he finds cycle time (CT) values on the PCR especially helpful in the immunosuppressed population. He also uses CRP & ferritin as markers of inflammation. He recommends against q24-48 hour trending, and to use these markers for clinical change to try to guide management. Additionally, d-dimer will be elevated in the inflammatory state, therefore it may be more useful if it is markedly elevated or if it uptrends significantly. These may help to determine thrombosis risk (expert opinion).
In terms of imaging, knowing when to order a CT PE can be a challenge, but Dr. Erdmann suggests that especially in the patient who is decompensating, that it is reasonable to get the imaging to assess for pulmonary embolism.
For patients with mild disease who can be managed as an outpatient. With the caveat that different variants may be more or less susceptible to these treatments, so check the guidelines frequently. include: monoclonal antibodies, oral antiviral agents, convalescent plasma, and a 3-day course of remdesivir (Gottlieb 2022). The logistical barriers of remdesivir being IV only and requiring a support staff to administer, largely makes it impractical for many institutions to do this in the outpatient setting.
Dr. Erdmann suggests considering how the patient appears clinically, the support system they have, and barriers for them to return if needed.
Although prior studies did not support a large benefit of convalescent plasma, a newer study using high-titer convalescent plasma suggests a potential role in treating outpatients.(Sullivan 2022).
Dr. Erdmann breaks this down into two components: 1) antiviral response and 2) immunomodulator response. He explains that the antiviral response targets symptoms such as fevers, myalgias, malaise which may be earlier symptoms; and, immunomodulators target respiratory symptoms and inflammation caused by the virus.
Remdesivir is the mainstay of antiviral treatment. Length of treatment depends upon severity of disease and immunocompromised state.
ACTT-1 initially reported on remdesivir for a 10 day course (Beigel, 2020). However, shortly after this, Goldman et al released an RCT showing no difference with a 5 day course vs a 10 day course of remdesivir (Goldman 2020). Dr. Erdmann explained that most institutions have favored a 5 day course, but he will still use a 10 day course in immunocompromised patients (expert opinion).
Steroids are the mainstay of immunomodulating therapy. The RECOVERY Collaborative group showed mortality benefit in those patients requiring supplemental oxygen who received dexamethasone (Horby, 2020). Dr. Erdmann notes that the benefit of steroids were driven by those who were intubated, and the arm who received steroids without oxygen requirement had suggestion of harm. Therefore, it is important that only patients with new oxygen requirements receive steroids.
JAK Inhibitors, such as baricitinib (Kalil, 2021), or IL-6 inhibitors, such as tocilizumab (Abani, 2021), are additional immunomodulators which can be used if a patient has worsening oxygen requirements despite steroids (NIH Guidelines).
Therapeutic anticoagulation is recommended in the hypoxic floor patient with high D-dimer levels and no contraindications, but in the event the patient requires higher level of care in the ICU, the recommendation is to step down to prophylactic dosing (Goligher, 2021). This recommendation is based on the end point of greater organ support-free days in hypoxic floor patients who received therapeutic anticoagulation; however, no benefit was seen in critically ill patients.
The rate of concomitant bacterial infection is very low with Covid-19 (Langford, 2020), and so Dr. Erdmann strongly recommends against the routine use of antibiotics in known Covid 19 viral syndrome (expert opinion).
There is no script for the phase immediately post
-hospitalization, so depending on the patient, they may need close pulmonology follow-up, especially if discharged on oxygen. If your community has a long covid clinic, it may be an appropriate referral to make for patients with persistent symptoms.
Vaccines should be recommended to all patients if they have not had one yet, or if they are due for booster vaccine. The timing is not clearly defined, but Dr. Erdmann recommends waiting about a month after the acute illness to stimulate an immune response similar to the vaccine series (i.e. illness would act as first antigen exposure and vaccine a month later would act as 2nd antigen exposure).
Listeners will develop a framework to navigate an approach to inpatient management of covid 19.
After listening to this episode, listeners will…
Dr. Erdmann has two financial disclosures that are unrelated to this episode–Platform Corp and Bristol Meyers Squib. The Curbsiders report no relevant financial disclosures.
Amin, M, Trubitt, M. Erdmann, NB, Williams PN, Watto MF. “332 Inpatient Covid Management”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list May 2, 2022
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