This document provides guidance from Massachusetts General Hospital on potential treatment options for COVID-19, including both approved and experimental therapies. It recommends supportive care for mild cases but considers investigational antivirals like remdesivir for moderate or severe cases. It also outlines monitoring and treatment guidance for special populations, potential side effects of therapies, and criteria for considering treatments targeting cytokine release syndrome. The guidance is intended to be updated frequently as new data emerges on COVID-19 treatment.
Chair, Jamie E. Chaft, MD, and Jonathan D. Spicer, MD, PhD, FRCSC, prepared useful Practice Aids pertaining to NSCLC for this CME/MOC/CC/NCPD activity titled “Marking New Milestones With Immunotherapy in Locally Advanced and Early Lung Cancer: Latest Data Informing Best Practices for Multimodal Management of Stage I-III NSCLC.” For the full presentation, downloadable Practice Aids and complete CME/MOC/CC/NCPD information, and to apply for credit, please visit us at https://bit.ly/3fcc3qs. CME/MOC/CC/NCPD credit will be available until July 11, 2022.
A brief overview of the potential for biomarkers to impact on sepsis diagnosis and management, looking at recent meta-analysis data on procalcitonin and exploring future options for prognostic and diagnosis markers including metabolomics.
PERIOPERATIVE MANAGEMENT OF COVID 19 SUSPECT/ CONFIRMED PATIENTBhagwatiPrasad18
These recommendations are based on recent guidelines and protocols followed in major hospitals in India and also from recent articles published online. This cannot be taken as final. Guidelines will be updated from time to time.
Watch this presentation in laptop/ pc as slideshow for beautiful animations.
Chair, Jamie E. Chaft, MD, and Jonathan D. Spicer, MD, PhD, FRCSC, prepared useful Practice Aids pertaining to NSCLC for this CME/MOC/CC/NCPD activity titled “Marking New Milestones With Immunotherapy in Locally Advanced and Early Lung Cancer: Latest Data Informing Best Practices for Multimodal Management of Stage I-III NSCLC.” For the full presentation, downloadable Practice Aids and complete CME/MOC/CC/NCPD information, and to apply for credit, please visit us at https://bit.ly/3fcc3qs. CME/MOC/CC/NCPD credit will be available until July 11, 2022.
A brief overview of the potential for biomarkers to impact on sepsis diagnosis and management, looking at recent meta-analysis data on procalcitonin and exploring future options for prognostic and diagnosis markers including metabolomics.
PERIOPERATIVE MANAGEMENT OF COVID 19 SUSPECT/ CONFIRMED PATIENTBhagwatiPrasad18
These recommendations are based on recent guidelines and protocols followed in major hospitals in India and also from recent articles published online. This cannot be taken as final. Guidelines will be updated from time to time.
Watch this presentation in laptop/ pc as slideshow for beautiful animations.
The aim of this lecture is to provide
an overview of the management of various toxic exposures.
emergency medical services that should be immediately contact to provide advanced life support for patient with unstable vital signs resulting from a poisoning exposure.
The recent definition, concept and terminologies of septic shock, surviving sepsis campaign, management techniques, SOFA score. Also includes antibiotics and supportive modalities.
This presentation deals with important pathophysiological steps involved with HIV infection, the various classes of drugs used in treatment of this condition, along with WHO-guidelines for treatment regimen(depending on various ages & conditions).
Newer drugs have also been mentioned and emphasized upon.
The aim of this lecture is to provide
an overview of the management of various toxic exposures.
emergency medical services that should be immediately contact to provide advanced life support for patient with unstable vital signs resulting from a poisoning exposure.
The recent definition, concept and terminologies of septic shock, surviving sepsis campaign, management techniques, SOFA score. Also includes antibiotics and supportive modalities.
This presentation deals with important pathophysiological steps involved with HIV infection, the various classes of drugs used in treatment of this condition, along with WHO-guidelines for treatment regimen(depending on various ages & conditions).
Newer drugs have also been mentioned and emphasized upon.
Paul E. Sax, MD prepared useful Practice Aids pertaining to COVID-19 for this CME/MOC/CNE/CPE activity titled "Coronavirus Disease 2019 (COVID-19): Need-to-Know Information and Practical Guidance for Healthcare Professionals on the Front Lines of Patient Care." For the full presentation, monograph, complete CME/MOC/CNE/CPE information, and to apply for credit, please visit us at https://bit.ly/3gBvfOw. CME/MOC/CNE/CPE credit will be available until July 23, 2021.
Chair and Moderator, Petros Grivas, MD, PhD, Shilpa Gupta, MD, and Gary D. Steinberg, MD, prepared useful Practice Aids pertaining to bladder cancer for this CME/MOC activity titled “Breaking Down the Evidence in Bladder Cancer: Expert Perspectives and Practical Strategies on Immune, Targeted, and Antibody-Based Therapies.” For the full presentation, downloadable Practice Aids, and complete CME/MOC information, and to apply for credit, please visit us at https://bit.ly/2WcJp3n. CME/MOC credit will be available until December 31, 2022.
This Presentation contains an international directory of guidelines collection from many international sources and best practice recommendations documents for the care and management of COVID-19 .
Contents
1-anticoagulation in COVID-19.
2-Antivirals in COVID-19.
3-immunomodulators in COVID-19.
4-antifibrotic therapy in COVID-19.
5-Antibiotic in COVID-19.
6-Nebulization in COVID-19.
7-Systemic steroids in COVID-19.
8- supplement in COVID-19.
9-radiation therapy in COVID-19.
10-Convalescent plasma in COVID-19.
11- COVID-19 in Pregnancy
12-Acute Kidney Injury in COVID-19.
13- Cardiology in COVID -19.
14-Critical Care in COVID-19.
15-Nutrition in ICU Patients in COVID-19.
16 Hypoxemia Management in COVID-19.
17-Mechanical Ventilation in COVID-19.
Challenging Cases in HIV Management.2014 Hivlife Info
Challenging Cases in HIV Management,including poorly adherent patients,individuals with cryptococcal meningitis,HBV coinfection, and diabetes and hypertension.2014
This Protocol is adapted from the World Health Organization recommendations and reflects the current expert opinion of staff from Montefiore’s Antimicrobial Stewardship Program, Infectious Diseases Division, and Pharmacy. Clinical efficacies of these agents are still under investigation at this time. Treatments of COVID-19 are evolving as we gain more clinical experiences along with more published data. Supportive care remains the mainstay of treatment. The availability of certain agents may be limited due to supply chain disruptions and backorders. For suspected or confirmed cases requiring treatments listed below, please consult Infectious Diseases and notify Infection Prevention and Control Departments immediately.
Similar to Covid19 mgh treatment_guidance_031820 Dr. Freddy Flores Malpartida (20)
Antibiotic Stewardship by Anushri Srivastava.pptxAnushriSrivastav
Stewardship is the act of taking good care of something.
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
ACCORDING TO pewtrusts.org,
Antibiotic stewardship refers to efforts in doctors’ offices, hospitals, long term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate
According to WHO,
Antimicrobial stewardship is a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials
In 1996, John McGowan and Dale Gerding first applied the term antimicrobial stewardship, where they suggested a causal association between antimicrobial agent use and resistance. They also focused on the urgency of large-scale controlled trials of antimicrobial-use regulation employing sophisticated epidemiologic methods, molecular typing, and precise resistance mechanism analysis.
Antimicrobial Stewardship(AMS) refers to the optimal selection, dosing, and duration of antimicrobial treatment resulting in the best clinical outcome with minimal side effects to the patients and minimal impact on subsequent resistance.
According to the 2019 report, in the US, more than 2.8 million antibiotic-resistant infections occur each year, and more than 35000 people die. In addition to this, it also mentioned that 223,900 cases of Clostridoides difficile occurred in 2017, of which 12800 people died. The report did not include viruses or parasites
VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
India Clinical Trials Market: Industry Size and Growth Trends [2030] Analyzed...Kumar Satyam
According to TechSci Research report, "India Clinical Trials Market- By Region, Competition, Forecast & Opportunities, 2030F," the India Clinical Trials Market was valued at USD 2.05 billion in 2024 and is projected to grow at a compound annual growth rate (CAGR) of 8.64% through 2030. The market is driven by a variety of factors, making India an attractive destination for pharmaceutical companies and researchers. India's vast and diverse patient population, cost-effective operational environment, and a large pool of skilled medical professionals contribute significantly to the market's growth. Additionally, increasing government support in streamlining regulations and the growing prevalence of lifestyle diseases further propel the clinical trials market.
Growing Prevalence of Lifestyle Diseases
The rising incidence of lifestyle diseases such as diabetes, cardiovascular diseases, and cancer is a major trend driving the clinical trials market in India. These conditions necessitate the development and testing of new treatment methods, creating a robust demand for clinical trials. The increasing burden of these diseases highlights the need for innovative therapies and underscores the importance of India as a key player in global clinical research.
QA Paediatric dentistry department, Hospital Melaka 2020Azreen Aj
QA study - To improve the 6th monthly recall rate post-comprehensive dental treatment under general anaesthesia in paediatric dentistry department, Hospital Melaka
Defecation
Normal defecation begins with movement in the left colon, moving stool toward the anus. When stool reaches the rectum, the distention causes relaxation of the internal sphincter and an awareness of the need to defecate. At the time of defecation, the external sphincter relaxes, and abdominal muscles contract, increasing intrarectal pressure and forcing the stool out
The Valsalva maneuver exerts pressure to expel faeces through a voluntary contraction of the abdominal muscles while maintaining forced expiration against a closed airway. Patients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound are at greater risk for cardiac dysrhythmias and elevated blood pressure with the Valsalva maneuver and need to avoid straining to pass the stool.
Normal defecation is painless, resulting in passage of soft, formed stool
CONSTIPATION
Constipation is a symptom, not a disease. Improper diet, reduced fluid intake, lack of exercise, and certain medications can cause constipation. For example, patients receiving opiates for pain after surgery often require a stool softener or laxative to prevent constipation. The signs of constipation include infrequent bowel movements (less than every 3 days), difficulty passing stools, excessive straining, inability to defecate at will, and hard feaces
IMPACTION
Fecal impaction results from unrelieved constipation. It is a collection of hardened feces wedged in the rectum that a person cannot expel. In cases of severe impaction the mass extends up into the sigmoid colon.
DIARRHEA
Diarrhea is an increase in the number of stools and the passage of liquid, unformed feces. It is associated with disorders affecting digestion, absorption, and secretion in the GI tract. Intestinal contents pass through the small and large intestine too quickly to allow for the usual absorption of fluid and nutrients. Irritation within the colon results in increased mucus secretion. As a result, feces become watery, and the patient is unable to control the urge to defecate. Normally an anal bag is safe and effective in long-term treatment of patients with fecal incontinence at home, in hospice, or in the hospital. Fecal incontinence is expensive and a potentially dangerous condition in terms of contamination and risk of skin ulceration
HEMORRHOIDS
Hemorrhoids are dilated, engorged veins in the lining of the rectum. They are either external or internal.
FLATULENCE
As gas accumulates in the lumen of the intestines, the bowel wall stretches and distends (flatulence). It is a common cause of abdominal fullness, pain, and cramping. Normally intestinal gas escapes through the mouth (belching) or the anus (passing of flatus)
FECAL INCONTINENCE
Fecal incontinence is the inability to control passage of feces and gas from the anus. Incontinence harms a patient’s body image
PREPARATION AND GIVING OF LAXATIVESACCORDING TO POTTER AND PERRY,
An enema is the instillation of a solution into the rectum and sig
Struggling with intense fears that disrupt your life? At Renew Life Hypnosis, we offer specialized hypnosis to overcome fear. Phobias are exaggerated fears, often stemming from past traumas or learned behaviors. Hypnotherapy addresses these deep-seated fears by accessing the subconscious mind, helping you change your reactions to phobic triggers. Our expert therapists guide you into a state of deep relaxation, allowing you to transform your responses and reduce anxiety. Experience increased confidence and freedom from phobias with our personalized approach. Ready to live a fear-free life? Visit us at Renew Life Hypnosis..
The dimensions of healthcare quality refer to various attributes or aspects that define the standard of healthcare services. These dimensions are used to evaluate, measure, and improve the quality of care provided to patients. A comprehensive understanding of these dimensions ensures that healthcare systems can address various aspects of patient care effectively and holistically. Dimensions of Healthcare Quality and Performance of care include the following; Appropriateness, Availability, Competence, Continuity, Effectiveness, Efficiency, Efficacy, Prevention, Respect and Care, Safety as well as Timeliness.
Navigating Challenges: Mental Health, Legislation, and the Prison System in B...Guillermo Rivera
This conference will delve into the intricate intersections between mental health, legal frameworks, and the prison system in Bolivia. It aims to provide a comprehensive overview of the current challenges faced by mental health professionals working within the legislative and correctional landscapes. Topics of discussion will include the prevalence and impact of mental health issues among the incarcerated population, the effectiveness of existing mental health policies and legislation, and potential reforms to enhance the mental health support system within prisons.
Covid19 mgh treatment_guidance_031820 Dr. Freddy Flores Malpartida
1. Version 1.0 3/17/2020 4:00PM
Massachusetts General Hospital
COVID-19 Treatment Guidance
• This document was developed by members of the ID division at MGH in conjunction with
pharmacy, radiology, and other medicine divisions to provide guidance to frontline
clinicians caring for patients with COVID-19.
• This document covers potential off-label and/or experimental use of medications and
immunosuppression management for transplant patients as well as a suggested laboratory
work up. It does NOT cover recommendations for infection control, PPE, management of
hypoxemia or other complications in patients with COVID-19.
• This is a living document that will be updated in real time as more data emerge.
1
For a primer on liver issues related to COVID19 and treatment, please seek link.
2
Viral serologies assist for interpretation of ALT elevations, present in ~25% of presentations. Lopinavir/ritonavir
should not be used as the sole agent if HIV positive. Active viral hepatitis increases risk of hepatotoxicity due to
lopinavir/ritonavir. Note: follow-up molecular testing for HIV/HBV/HCV may have longer turnaround times than usual
3
Elevated troponin (> 2 times upper limit of normal) without hemodynamic compromise, can repeat troponin in 24
hours; echocardiogram not necessary unless otherwise indicated. Up-trending troponin with hemodynamic compromise
or other concerning cardiovascular symptoms /signs should prompt consideration of obtaining an echocardiogram..
4
If starting QTc prolonging drug, can repeat ECG in 24-48 hours to monitor QTc. If baseline QTc > 500, repeat within
24 hours and consider stopping other QTc prolonging drugs.
5
Approval for SARS-CoV-2 may be obtained through the MGH Biothreats Pager, 26876
Table 1: Laboratories for diagnosis, prognosis / risk stratification, and/or safety of agents
Suggested for all hospitalized patients with confirmed or suspected COVID-19
Recommended daily labs:
• CBC with diff (trend total lymphocyte count)
• Complete metabolic panel1
• CPK (creatine kinase)
Viral serologies:2
• HBV serologies (sAb, cAb, and sAg)
• HCV antibody, unless positive in past
• HIV 1/2 Ab/Ag
For risk stratification (may be repeated q2-3
days if abnormal or with clinical deterioration):
• D-dimer
• Ferritin / CRP / ESR
• LDH
• Troponin3
• Baseline ECG4
If clinically indicated:
• Routine blood cultures (2 sets)
• For acute kidney injury (i.e. serum creatinine
>0.3 above baseline), send urinalysis and spot
urine protein:creatinine
• Procalcitonin
• IL-6 See below for criteria
Radiology:
• Portable CXR at admission
• High threshold for PA/lateral in ambulatory
patients, consider only if low suspicion for
COVID-19 and result would change
management or affect PUI status.
Following up-to-date infection control
guidelines and appropriate PPE:
• SARS-CoV-2 test, if not already performed.5
• If available, send influenza A/B and RSV test
2. Version 1.0 3/17/2020 4:00PM
Suggested for immunocompromised patients:
If clinically indicated, consider sending Pneumocystis DFA from sputum (no induced sputum given
risk of aerosolization). If unable to send sputum, consider sending serum beta-d-glucan
If clinically indicated, consider sending fungal/AFB sputum cultures
Therapeutically:
§ If flu unknown or positive, start oseltamivir 75 mg BID in all adult patients with normal
renal function (may stop if flu A/B PCR negative and low suspicion)
o Adjust for pediatric patients and those with renal insufficiency
§ Considerations for empiric treatment for bacterial pneumonia:
o Other centers have reportedly not, to date, seen a lot of bacterial superinfection in
COVID-19 patients; we should monitor for this on a case-by-case basis.
Ceftriaxone 1 g [or cefepime if MDRO risk factors]
+
Azithromycin 500 mg x1, then 250 mg daily x 4 days
+
Vancomycin if risk factors for MRSA
o All for 5 days, or longer guided by clinical status and microbiology
o Note that from studies to date, procalcitonin remains low in the first 7-10 days of
infection and can rise later on, even without bacterial superinfection.
§ Inhaled medications should be given by metered dose inhaler rather than nebulization.
Nebulization risks aerosolization of SARS-CoV-2. If nebulized medications given, use
appropriate PPE.
ACE-Inhibitors (ACEi) / Angiotensin Receptor Blockers (ARBs):
§ Note there is interest in the potential role of ACE-inhibitors (ACEi) / angiotensin receptor
blockers (ARBs) in the pathophysiology of this disease since the SARS-CoV-2 virus binds
to the ACE2 receptor for cellular entry. There are theories these may either help or worsen
COVID-19 disease.
§ Currently there are no data to support either starting or stopping ACEi/ARBs on any patients
with COVID-19. We do not currently routinely recommend stopping these agents for
patients with COVID-19. However, if acute kidney injury, hypotension or other
contraindication develops, we recommend stopping them at that time. After a person is
recovering from their viral syndrome, their home medications can be restarted, and, if
indicated, new ACEi/ARBs can be started if they have a primary indication such as new
persistently reduced ejection fraction.
• Non-contrast CT is of limited utility in
definitively diagnosing COVID-19 and should
only be considered if it is likely to change
management or PUI status
• If available, send respiratory viral panel on all
patients (includes human metapneumovirus
and parainfluenza 1-3)
• As indicated, routine sputum for bacterial
gram stain and culture, Legionella/Strep
pneumo urinary antigen
3. Version 1.0 3/17/2020 4:00PM
COVID-19 Suggested Management:
There are no proven or approved treatments for COVID-19. The following algorithm provides
guidance based on available information to-date regarding possible and investigational treatments.
Caution is advised as there are either no data or limited data for efficacy for COVID-19. As
appropriate, these recommendations will be updated frequently to include new or emerging data.
For clarifications or approval of certain agents, please consult Infectious Diseases.6
Not recommended
§ Systemic steroids should in general be AVOIDED for these patients given potential
harm. Steroids may be considered if indicated for another reason (e.g. refractory septic
shock, or specific to lung transplant guidelines, as delineated below)
Note: Consider discontinuation of inhaled steroids as they may reduce local immunity
and promote viral replication, unless necessary for acute indications
§ At this time, we do not recommend starting ACEi / ARBs or ribavirin for COVID-19
§ There are reports of NSAID use preceding clinical deterioration in some patients
with severe COVID-19 disease. We recommend frontline providers assess and
document recent NSAID use and avoid prescribing NSAIDs while patients are
admitted
Identify High Risk Patients: High risk features may include:
Table 2: Risk Factors for Severe COVID-19 Disease
Epidemiological – Category 1 Vital Signs – Category 2 Labs – Category 3
Age > 55 Respiratory rate > 24
breaths/min
D-dimer > 1000 ng/mL
Pre-existing pulmonary
disease
Heart rate > 125 beats/min CPK > twice upper limit of
normal
Chronic kidney disease SpO2 < 90% on ambient air CRP > 100
Diabetes with A1c > 7.6% LDH > 245 U/L
History of hypertension Elevated troponin
History of cardiovascular
disease
Admission absolute
lymphocyte count < 0.8
Use of biologics Ferritin > 300 ug/L
History of transplant or other
immunosuppression
All patients with HIV
(regardless of CD4 count)
For more information about COVID19 Risk Factors, click here.
6
The infectious disease consult service is actively discussing how to meet the needs of frontline clinicians. More
information to follow.
4. Version 1.0 3/17/2020 4:00PM
Suggested Treatment Algorithm Based on Clinical Severity:
(See figure at end of document for schematic layout of algorithm)
Table 3:
Clinical Situation Recommendation Notes / Considerations
All hospitalized patients Continue statins if already
prescribed. If no contraindication,
and for those who have a
guideline indication for a statin,
consider starting:
atorvastatin 40 mg daily or
rosuvastatin 20 mg daily
When major drug-drug
interactions with atorvastatin or
rosuvastatin are expected,
pitavastatin 2 mg daily (or
pravastatin 80mg daily if
pitavastatin not available) should
be considered 7
Avoid NSAIDs
Note cardiovascular
disease is a major risk
factor for COVID-19
disease severity.
Additionally, statins may
help promote antiviral
innate immune response.
If elevated CPK >/= 500
U/L, consider not starting a
statin
Avoid statins if ALT > 3x
upper limit of normal
For a brief discussion of
statins and immunity, click
here.
For patients with mild disease
with SpO2 >90%, no risk
factors
Supportive care See Table 2 for list of risk
factors
For patients with mild disease
with SpO2 >90% along with
risk factors for severe disease
Supportive care with very close
monitoring and consideration of
application for clinical trial of
remdesivir (see below)
For patients with moderate or
severe disease (patients in ICU
or with progressive disease)
Obtain remdesivir (RDV)
through a clinical trial8
or through
compassionate use.9
Current
dosing of remdesivir is 200 mg IV
For compassionate use,
apply through portal here:
https://rdvcu.gilead.com/
7
If already on a statin, no need to change to these agents
8
Currently open trial: https://clinicaltrials.gov/ct2/show/NCT04280705
9
As of 3/15/2019, compassionate use is for hospitalized patients with confirmed SARS-CoV-2 by PCR and mechanical
ventilation. Exclusions include evidence of multi-organ failure, pressor requirement, ALT>5xULN, CrCl<30/ HD/
CVVH, or use of other investigational agents. Investigational agents do not include off-label approved agents.
5. Version 1.0 3/17/2020 4:00PM
loading dose following by 100 mg
IV daily for up to 10 days.
For patients with moderate or
severe disease (patients with at
least one Category 1 and one
Category 2/3 feature on floor
or any patients in ICU or with
progressive disease)
With guidance from Infectious
Diseases, can consider adding
hydroxychloroquine (400 mg
BID x2 followed by 400 mg daily
while hospitalized, up to 5 days).
Note chloroquine has activity but
limited supply so
hydroxychloroquine preferred
With guidance from Infectious
Diseases can consider:
lopinavir/ritonavir (LPV/r or
Kaletra) 400/100 mg BID for 10
days for certain moderate and
severe presentations
(avoid if candidate for RDV trial)
If LPV/r not available, consider
using darunavir/cobicistat
(DRV/c or Prezcobix) 800/150
mg daily
Check ECG prior to
initiation given risk of QT
prolongation. Risk is
increased in patients on
other QT-prolonging
agents.
Assess for drug-drug
interactions (including with
calcineurin inhibitors)
before starting.
For protease inhibitors,
main side effect is
gastrointestinal intolerance.
Monitor liver function tests
while on therapy.
Discontinue these agents
upon discharge regardless
of duration, unless
previously used as
maintenance medications
for another indication.
For certain refractory or
progressive patients (who are
in ICU)
With ID approval, interferon
beta B1 (Betaseron) can be
considered
Note IFN would need to be
combined with another
antiviral (likely LPV/r). It
can be combined with
HCQ
For patients with evidence of
cytokine release syndrome
(see staging criteria below in
Table 6)
With ID approval, tocilizumab
(Actemra) can be considered
Need to send serum IL6
level prior to giving first
dose of tocilizumab
6. Version 1.0 3/17/2020 4:00PM
Table 4:
Special Populations Recommendation Notes
If IgG <400 Consider IVIG at standard dose of
1 gm/kg daily x 2 doses
Heart/Liver/Kidney Transplant
Recipients
Guided by transplant and
transplant ID teams – please
call/consult
Consider decreasing
tacrolimus/cyclosporine by 50%,
stop mycophenolate
(CellCept/Myfortic) and
Azathioprine in kidney/liver
transplant patients and reduce dose
by 50% in heart transplant patients.
Kidney patients approximate target
tacro level 3-5 ng/ml, cyclosporine
level target 25-50 ng/ml.
In the setting of ground glass
opacities can consider switching
mTor to CNI (tacrolimus) given
possibility of pneumonitis w/
mTor; discuss with heart transplant
before making switch
Critical illness – in liver and
kidney – stop all
immunosuppression except for
prednisone if they are on it at
baseline
For outpatients on belatacept,
consider switching to tacrolimus or
cyclosporine starting 28 days after
last dose, to avoid clinic visit.
Levels will need to be checked and
thus need plan in place to draw
CNI levels without exposing
community.
Screen for drug-drug
interactions with anti-viral
agents, if they are being
used
7. Version 1.0 3/17/2020 4:00PM
For inpatients on belatacept, do not
administer any further belatacept.
28 days after last dose, consider
adding low dose CNI. For CNI
intolerant, consider increasing
daily prednisone dose from 5 mg
to 7.5-10 mg daily.
Continue low dose prednisone (5
mg) in all patients who were on it
before hospitalization.
Request bronchoscopy only if
significant decompensation, versus
lung biopsy as may be lower risk
for aerosolization and exposure to
staff
Lung transplant recipients Guided by transplant and
transplant ID teams -please
call/consult. These are guidelines
only, immunosuppression requires
case-by-case approach.
No change to usual
immunosuppression (avoid high
levels, tailor to patient)
For all those in ICU or with lower
respiratory tract respiratory disease
(most inpatients): pulse
methylprednisolone 125mg IV q
12 hours
Outpatient management:
prednisone taper 60mg x 4 days --
40mg x 4 days – 20mg x 4 days
then back to baseline
8. Version 1.0 3/17/2020 4:00PM
Table 5: Brief Overview of Agents
Agent Classification Target /
Mechanism
Dosing Key
toxicities
atorvastatin
(Lipitor)
Off-label Cardioprotection;
immunomodulatory
40-80 mg
PO daily
pravastatin
(Pravachol)
Off-label Cardioprotection;
immunomodulatory
80 mg PO
daily
remdesivir Investigational RNA dependent
RNA polymerase
inhibitor
200 mg IV
x1, then 100
mg IV daily,
up to 10
days
Nausea,
vomiting,
ALT
elevations
hydroxychloroquine
(Plaquenil)
Off-label Multiple actions;
prevents binding to
ACE2, presents
transport in
endosome, and
possibly others
400 mg BID
x 2 doses,
then 200 mg
BID for 5
days
QT
prolongation
lopinavir/ritonavir
(LPV/r or Kaletra)
Off-label 3CLpro (viral
protease) inhibitor
400/100 mg
BID for up
to 10 days
QT
prolongation,
ALT
elevations
interferon beta-B1
(Betaseron)
Off-label Immunomodulatory;
enhancement of
innate and adaptive
viral immunity
Dosing for
progressive
COVID to
be
determined
Depression,
injection site
reaction, flu
like
syndrome
tocilizumab
(Actemra)
Off-label Monoclonal
antibody to IL6
receptor / treats
cytokine release
syndrome
Dosing for
COVID/CRS
to be
determined
ALT
elevations
Liverpool COVID-19 Drug Interactions: http://www.covid19-druginteractions.org/
Postexposure Prophylaxis for Healthcare Workers:
§ There is currently no role for post exposure prophylaxis for people with a known COVID-19
exposure. They should follow self-quarantine for 14-days and monitor for symptoms.
Healthcare workers should follow instructions from Occupational Health.
9. Version 1.0 3/17/2020 4:00PM
Table 6: Augmenting Host Immunity (tocilizumab, steroids)
Background: Studies indicate advanced stage disease responses to beta-coronaviruses including COVID-19
have a high IL-6 cytokine signature. This response is similar to CAR-T cell based immune side effects where
anti-IL-6 interventions have been of benefit.
Step 1. Establish clinical status to COVID-19 (adopted and based on the Penn CRS criteria)
Grade 1 – mild reaction
Grade 2 – moderate reaction, fever, need for IVF (not hypotension), mild oxygen requirement
Grade 3 – severe, liver test dysfunction, kidney injury, IVF for resuscitation, low dose vasopressor,
supplemental oxygen (high flow, BiPAP, CPAP)
Grade 4 – life threatening, mechanical ventilation, high dose vasopressors
Step 2. Determine treatment intervention
Grade 1 – no treatment
Grade 2 – send for serum IL-6
Grade 3 – send for serum IL-6; consider tocilizumab, if no effect can repeat x 2 more doses Q8H apart; if
no response, consider low dose corticosteroids
Grade 4 – send for serum IL-6; consider tocilizumab as Grade 3; consider corticosteroids
10. Version 1.0 3/17/2020 4:00PM
•If concern for CRS c
,
consider tocilizumab as
below after sending
serum IL6
•Consider statin
•Start hydroxychloroquine
•Consider adding LPV/rd
if
not candidate for clinical
trial
Confirmed Positive
COVID-19
Outpatients Admitted to
Medicine Floor
Admitted to ICU
(consider statin + start HCQ
on all ICU patients if no
contraindication)
•Supportive care
•Close monitoring •Age < 55 or age > 55
with no other risk
factors a
•Age < 55 or age > 55
with additional
Category 1 but no
Category 2/3 features
•Age < 55 or age > 55
with at least one
Category 2/3 risk
factor
•Supportive care
•Close monitoring
•Repeat labs at regular
intervals
•Apply for RDV:
compassionate use if
ventilated or through
trial
•If progression or not
candidate for RDV,
contact ID for
consideration of IFN b
a: See risk factors table (Table 2) in this document
b: Interferon should be added in the presence of
another antiviral (HCQ, LPV/r, RDV – if allowed).
c: See staging criteria related to cytokine release
syndrome and how to use tocilizumab in this setting
d: LPV/r has risk of hepatotoxicity. For HIV+
patients, do not start without other antiretrovirals