#332 Inpatient Covid Management with Dr. Nathan Erdmann.

May 2, 2022 | By Matthew Watto, MD

Video

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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Credits

• Producer: Monee Amin, MD
• Writers: Monee Amin, MD and Meredith Trubitt, MD
• Show Notes: Meredith Trubitt, MD
• Infographic and Cover Art: Monee Amin, MD
• Hosts: Monee Amin, MD; Matthew Watto MD, FACP; Paul Williams MD, FACP   
• Reviewer: Rahul Ganatra, MD
• Showrunner: Matthew Watto MD, FACP
• Production Team: PodPaste
• Guest: Nathan Erdmann, MD

Sponsor: Panacea Financial
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Show Segments

• Intro, disclaimer, guest bio
• Guest one-liner, Picks of the Week*
• Case from Kashlak; Definitions
• Outpatient vs ER therapeutic options
• Considerations for labs to risk stratify 
• Antivirals
• Immunomodulators
• Anticoagulation
• Empiric Antibiotics
• Transitions of Care
• Take Home Points
• Outro

Inpatient Covid 19 Management Pearls

1. There are two phases to covid 19: viral phase vs immune mediated phase
2. These two phases should guide the best approach to treatment. For example, if there is no evidence of an inflammatory phase, then the patient does not warrant immunomodulators.
3. Immunocompromised patients can present unique challenges with regards to diagnosis as they can present in a multitude of ways, often in vastly differents ways than immunocompetent patients. At times they can have high inflammatory response without the classic signs/symptoms.
4. Steroids are first line for immunomodulators whereas JAK and IL-6 inhibitors are reserved for patients who are worsening despite adequate steroid therapy. 
5. The rate of bacterial coinfection is low, so reserve empiric antibiotics for when there is evidence of bacterial infection. 
6. Therapeutic anticoagulation is recommended for floor patients with hypoxemia and elevated D-dimer,but if a patient requires a higher level of care in ICU, the current recommendation is to step down to prophylactic dosing. 

Inpatient Covid Management Show Notes

Definitions

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.

Labs and Imaging

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. 

Outpatient Treatment Options

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). 

Inpatient Treatment Options

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.

Antiviral Agent

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). 

Immunomodulators 

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). 

Anticoagulation

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.  

Empiric Antibiotics

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). 

Transitions of Care Considerations

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).

Links

1. Peaky Blinders (Netflix)
2. MLB
3. It’s Tricky by Run DMC
4. Monee’s Mashup on YouTube
5. Call Me Maybe by Carly Rae Jepsen
6. The Middle by Zedd and Maren Morris 
7. Since U Been Gone by Kelly Clarkson
8. The Batman

Goal

Listeners will develop a framework to navigate an approach to inpatient management of covid 19. 

Learning objectives

After listening to this episode, listeners will…  

1. Identify evolving severity thresholds and how they impact treatment decisions
2. Differentiate antiviral, immunomodulators, and anticoagulation as multifaceted treatment approach
3. Learn how to provide anticipatory care counseling for patients with COVID 19 pneumonia. 
4. Discern how immunocompromised status changes treatment approach 

Disclosures

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.

Citation

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