Clinical Management Updates On COVID-19

CLINICAL MANAGEMENT
UPDATES ON COVID-19
Dr Yasmin Gani
ID physician
Hospital Sungai Buloh
For healthcare professionals use only. The organizer of this CME will share the slides after the
session. Participants should not take or reproduce this slide in any form without permission.

Disclaimers
● This slide was prepared for the Webinar Series on COVID-19
session on 3rd Feb 2021, by Dr. Yasmin Gani, Infectious
Disease Physician from Hospital Sungai Buloh.
● This is intended to share within healthcare professionals, not
for public.
● Kindly acknowledge “Clinical Updates in COVID-19
http://www.nih.gov.my/covid-19/” should you plan to share
the information obtained from this slide with your
colleagues.
For healthcare professionals use only.

SP02
1 min sit and
stand test
THINK PCP LIKE ILLNESS WITHOUT
MUCH CYANOSIS

Clinical management

Watch out for Warning Signs

Monitoring guidelines
Symptomatic
without
pneumonia
Vitals signs monitoring
8-12hrly
Doctors review bd
● FBC, RP, LFT, CRP/LDH, RBS (or capillary
blood sugar) at baseline
● Repeat FBC, CRP/LDH if patient has any
warning signs
● Rest, repeat as indicated
● CXR at first presentation
● Repeat CXR if patient develops warning
signs
● Baseline ECG for those with risk factors,
repeat as necessary

Common questions on cat 3
⬩Who requires antiviral
⬩How often to monitor blood parameters and
CXR
⬩Who are more likely to deteriorate
⬩When to discharge

CASE 1
41 YEAR OLD MALE
No known medical illness
Fever for 5 days and urti
No sob
Blood test:
• Wcc 6, plt 200, alc 2.3
• CRP 6🡪 4🡪 4
• Rest normal
• BP 120/77, Pr 70
• Spo2 : 100 on room air
• Never needed O2
Let's study these 2 patients

CASE 2
44 YEAR OLD female
Dyslipidaemia / obese
No sob
Blood test:
• Wcc 5, plt 280, alc 2.5
• CRP 32 baseline
• BP 140/57, Pr 70
• Spo2 OA : 98%
X-ray OA

Generally, no treatment required
•Close observation of vital signs and
oxygen saturation as stated in
monitoring guidelines
•Treat with Favipiravir as category 4 if
patient has any of the following risk
factors:
•Age> 50 with comorbid
•ESRF (consult ID physician on the choice
of treatment
•In the presence of any warning signs
(see below)

Antiviral
Favipiravir
•Use in category 4 and 5
•Used in category 3 if high risk
for deterioration
•> 50 with comorbid
•End stage renal failures
•Those with more than one
warning signs
What does our guidelines say

Evidence of favipiravir?
● Clinical deterioration less significant in
the FVP
○ OR 0.59, (95% CI 0.30 to 1.14)
participants = 376; studies = 3
● Oxygen support requirements and
non-invasive mechanical ventilation
not significantly different
○ OR 0.76, (95% CI 0.42 to 1.39);
participants = 255; studies = 2
No serious adverse effects
Hyperuricemia
GI disturbances
Shrestha DB, Budhathoki P, Khadka S, Shah PB,
Pokharel N, Rashmi P. Favipiravir versus other antiviral
or standard of care for COVID-19 treatment: a rapid
systematic review and meta-analysis. Virol J [Internet].
2020 Sep 24

Favipiravir
Common side eﬀects:
● Hyperuricemia
● Diarrhoea
● Elevated transaminase
● Neutropenia
Drug interactions:
• Paracetamol – maximum 3gm per
day
• Theophylline – increases
Favipiravir levels
• Pyrazinamide – both cause
hyperuricemia
Teratogenic eﬀect:
● Favipiravir is contraindicated
for women of childbearing
potential and men whose
partner is of childbearing
potential.
● In this group, if Favipiravir is
used, they should be advised
to use contraception for 7 days
after the last dose of
Favipiravir
● Avoid if GFR <30ml/min
Not registered drug. Requires patient consent to administer

%
deterioration
<40 yrs NO Comorbid 0.48
<40 yrs + Comorbid 4.15
40-60 yrs NO Comorbid 4.95
40-60 yrs + Comorbid 9.36
>60 yrs + NO Comorbid 6.21
>60 yrs + Comorbid 16.19

Co-morbidities Univariate Multivariate
OR(95% CI) p-value OR(95% CI) p-value
History of chronic cardiac diseases 6.96 (5.05 - 9.50) <0.001 1.38 (0.56 - 3.26) 0.470
History of hypertension 6.36 (5.22 - 7.75) <0.001 0.99 (0.52 - 1.84) 0.972
History of chronic kidney disease 17.49 (11.46 - 26.91) <0.001 3.21 (1.09 - 9.25) 0.032
History of diabetes mellitus 8.18 (6.61 - 10.10) <0.001 1.06 (0.54 - 2.03) 0.862
Obese 3.20 (1.89 - 5.19) <0.001 4.16 (0.31 - 44.58) 0.289
Sim BLH, Chidambaram SK, Wong XC, Pathmanathan MD, Peariasamy KM, Hor CP, et al. Clinical
characteristics and risk factors for severe COVID-19 infections in Malaysia: A nationwide observational
study. The Lancet Regional Health – Western Paciﬁc [Internet]. 2020 Nov
ANY comorbidities stand out?

Identification of
Warning Signs In
patients Progressing
to Severe Disease in
COVID-19 illness
● Looked at 228 patients who were admitted at day
with mild illness and looked at their risk factors of
deterioration
● Median day of deterioration is 10 days ( IQR 8-12)
● Univariate analysis : presence of fever, High MEWS
score , Increased zone of CXR involvement , CRP >
50 and NLR >3.13 was associated with deterioration
Multivariate analysis
➢ Higher Mews score ( HR 5.20 95CI 2.58-10.50; p <001)
➢ Presence of 2 or more comorbids ( HR 4.35 95CI
1.79-10.5; p 0.001)
➢ CRP>50 (HR 3.23CI1.45-7.3; p 0.004)

Pneumonia
not requiring
oxygen
Standard Vital signs monitoring TDS
However, in the presence of Risk
Factors vital signs monitoring 6-8hrly
If further clinical deterioration,
increase frequency of monitoring
Doctors review TDS
Include exertional desaturation test
at every review
FBC, RP, LFT, CRP/LDH, RBS (or
capillary blood sugar) CXR at
baseline
• If any warning signs – repeat daily
(FBC, CRP/LDH)
• If no WS repeat FBC/CRP and a
CXR at day 9/10 of disease
• Other blood test, repeat as indicated
*Baseline ECG for those with risk factors.
Repeat as necessary
*Repeat CXR if patient develops warning signs

Day 5 ( baseline) Day 6 Day 9 Day 11 Day 12
ALC 2.5 1.9 1.0 0.6 0.5
CRP 30 34 40 70 50
ferritin 897
Ddimer 1020
Oxygenation
(NP/FM) RA RA RA NP
Exertional desat test
3% to 93%
NP 3lo2
Treatment
( dexa/toci/MPS
/antibiotics) Favipiravir Favipiravir Favipiravir
Started dexa 12mg
dly
Dexa 12mg dly
favipiravir
Others
44 YEAR OLD female
Dyslipidaemia / obese
No sob

Day 10
Day 5

Discharge criteria for Cat 3

Dexamethasone – Recovery study,
UK NHS
•Dose used 6 mg daily for 10 days

Lesson 1
SOME SWITCH OFF
WITH A SHORT
COURSE OF
DEXAMETHASONE
day 4 Day 8 Day 11 Day 12 Day 12
ALC 1,9 1.9 1.0 0.6 Patient was
discharged at
day 14 after 48
hrs
Dexa given
total 10 days
CRP 12 36🡪6.0 70
ferritin 2765 897
Ddimer 1300 600
Oxygenation
(NP/FM) RA NP 4 L
Desaturated
Np 2LO2
Room air
Treatment
( dexa/toci/MPS
/antibiotics)
Favipiravir Favipiravir
completed
Started dexa
8mg dly
Dexa 8mg dly Dexa 8mg dly
Others febrile afebrile afebrile

Day 8 Day 12

Sometimes we need
to titrate up the
dexamethasone
dose depending on
severity of
inﬂammation
Lesson 2

DAY10/d11 DAY 12 Day 13 Day 14-15
CRP 24🡪48 123 88 44🡪22 Weaned off
o2 at day 5 of
dexa and
tapered off
and stopped
dexa at day 8.
ALC 0.5 0.6 0.5 0.3
Ferritin 611 568 988 783
D dimer 199
O2
requirement
NP 3L 02
STATIC
NP 3L 02
( RR 22)
NP 3L 02 NP 3L 02
(Total dose
of dexa for
the day)
CLEXANE
ADDED DEXA
24HRS LATER
8MG STAT
THEN 4MG BD
(total 12 mg
dexa given)
Increased dexa
dose 6mg bd
Total 12mg Total 12mg

There may be
some patients
who are
dexamethasone
failures
57 year old diabetic lady
Left Breast cancer, mastectomy, chemotherapy +
radiotherapy – 2015
Presented on D7 of illness as COVID +
Required Nasal prong 3L on admission
Clinical category 4
Given Dexamethasone IV 8mg on D1 admission
Favipiravir
Clexane
Desaturates further requiring face mask 5L/min within
24h
Lesson 3

Date
Day of
illness
5/11
Day7
6/11
Day8
7/11
Day9
8/11
Day10
9/11 10/11 11/11 12/11 13/11
O2 NP 3L FM 5L FM 5L FM 5L NP 3L Room
air
Room
air
Room
air
Room
air
CRP
mg/L
118 122 75 32 16 8 <4 <4 <4
D-dimer 819 474
PCT 0.13
Meds Dexa
8mg
Dexa
8mg dly
MTP
150mg
MTP
150mg
Dexa
12mg
Dexa
12mg
Dexa
8mg
Dexa
4mg
Dexa
4mg

6 Nov

•

Pulmonary Embolism
Consider Pulmonary Embolism and treat with full dose of
anticoagulation in patients with:
• Marked increase/rising D dimer
AND
• Acute worsening of hypoxaemia, blood pressure, tachycardia with imaging ﬁndings
NOT consistent with worsening COVID-19 pneumonia
OR
• Evidence of acute, otherwise unexplained right heart strain, or intra-cardiac
thrombus
OR
• Clotting of vascular devices (eg venous, arterial and dialysis catheters/ tubing)
• If unable to perform CT Pulmonary Angiography (CTPA), Ultrasound or
Echocardiogram and clinical suspicion for PE remains high,
full dose anticoagulation (unless contraindicated) is recommended.

Lesson 5:
⬩ 48 yr old , DM : Day 6 of illness
⬩ Last 2 days prior to admission, worsening
cough and SOB
⬩ On arrival complained of chest tightness :
Developed SOB and cough and
desaturated to 92%
⬩ CRP : 13→ 23
⬩ Ferritin 182
⬩ Ddimer 582
⬩ Wcc: lymphocyte percentage increasing(
from 29 % to 35%)
Don’t start dexa too early

⬩ Started On Favipiravir
and given 1 dose of
Interferon
⬩ No steroids were
started
⬩ Patient was
discharged well on the
19th
11/12 12/12 13/12 15-16/
12
17/12 18/12
crp 28 20 34 38-32 24 10
ferritin 128
NLR 2.0 1.4 2.2 1.84 2.7 2.91
L% 28% 35% 34% 43% 31% 39%
O2 RA Np np np ra ra

Lesson 5 :
DAY4-7 DAY 8 Day 10 Day 10
CRP 24→10 15 88 44→22
Neutrophil% 45 50 73
Lymph % 44% 39% 25 0.3
Ferritin 125 160 988 783
D dimer 199
O2 requirement NP 3L 02
STATIC
NP 3L 02
( RR 22)
fM 5L 02 HFM 10 L /transfer
to ICU
(Total dose of dexa
for the day)
CLEXANE
Added dexa and
favipiravir
Clexane ‘
Favipiravir
Dexa 8mg dly
Methylpred 2mg/kg
Clexane
Methyl pred 500mg

❖ Statins
❖ Aspirin
❖ Ivermectin
❖ Tocilizumab
REMAP-CAP trial
• Reduced mortality by 8.5%
• Relative reduction in mortality 24%
• Given early when pt required
ventilation/ NIV

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