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.
Video at https://www.youtube.com/watch?v=2rQKMD_5po0
Part of the "Hypoxemia in the Ward Patient with COVID-19" talks in Frederick Southwick's Coursera MOOC on COVID-19, "COVID-19 - A clinical update".
"Dr. Ben Geisler, Hospitalist at Massachusetts General Hospital and Harvard Medical School faculty member reviews the current treatments for COVID-19. He first discusses the management of fluid replacement and diuretics, as well as the indications for bronchodilators and antibiotics. He emphasizes the importance of DVT anticoagulation prophylaxis. He next reviews the potential role of statins, evidence with regards angiotensin converting enzyme inhibitors, and NSAIDS. He next reviews the current indications for the agents of proven efficacy: Remdesivir and Dexamethasone. Finally he discusses the dilemma of equipoise and the best resources for staying up to date with this ever changing topic."
In this iteration, we have added baricitinib and tocilizumab/IL-6 inhibitors.
Pre-ASCO Seminar: (Re)Defining Value in Cancer Care: Priorities for Patients, Providers, and Health Systems
Panel: International Experience with Health Technology Assessment (HTA) & Lessons for the United States,
A primer on available evidence and management of Covid -19 infection, with system wise pathophysiology and therapeutic strategies.
Perspective of intensive care, with specific information and tips on intubation and ventilatory management of these patients.
Focus on severe infections, and various manifestations.
Serious symptoms:
difficulty breathing or shortness of breath
chest pain or pressure
loss of speech or movement
Seek immediate medical attention if you have serious symptoms. Always call before visiting your doctor or health facility.
Webinar Series on COVID-19: Jointly organized by Malaysian Society of Infection Control and Infectious Diseases (MyICID) & Institute for Clinical Research, NIH
Speaker: Dr Yasmin Gani, ID Physician, Hospital Sungai Buloh, MOH Malaysia.
More info about the speaker and this webinar available here: https://clinupcovid.mailerpage.com/resources/g7e5g8-medical-management-of-covid-19-an
Video at https://www.youtube.com/watch?v=2rQKMD_5po0
Part of the "Hypoxemia in the Ward Patient with COVID-19" talks in Frederick Southwick's Coursera MOOC on COVID-19, "COVID-19 - A clinical update".
"Dr. Ben Geisler, Hospitalist at Massachusetts General Hospital and Harvard Medical School faculty member reviews the current treatments for COVID-19. He first discusses the management of fluid replacement and diuretics, as well as the indications for bronchodilators and antibiotics. He emphasizes the importance of DVT anticoagulation prophylaxis. He next reviews the potential role of statins, evidence with regards angiotensin converting enzyme inhibitors, and NSAIDS. He next reviews the current indications for the agents of proven efficacy: Remdesivir and Dexamethasone. Finally he discusses the dilemma of equipoise and the best resources for staying up to date with this ever changing topic."
In this iteration, we have added baricitinib and tocilizumab/IL-6 inhibitors.
Pre-ASCO Seminar: (Re)Defining Value in Cancer Care: Priorities for Patients, Providers, and Health Systems
Panel: International Experience with Health Technology Assessment (HTA) & Lessons for the United States,
A primer on available evidence and management of Covid -19 infection, with system wise pathophysiology and therapeutic strategies.
Perspective of intensive care, with specific information and tips on intubation and ventilatory management of these patients.
Focus on severe infections, and various manifestations.
Serious symptoms:
difficulty breathing or shortness of breath
chest pain or pressure
loss of speech or movement
Seek immediate medical attention if you have serious symptoms. Always call before visiting your doctor or health facility.
Webinar Series on COVID-19: Jointly organized by Malaysian Society of Infection Control and Infectious Diseases (MyICID) & Institute for Clinical Research, NIH
Speaker: Dr Yasmin Gani, ID Physician, Hospital Sungai Buloh, MOH Malaysia.
More info about the speaker and this webinar available here: https://clinupcovid.mailerpage.com/resources/g7e5g8-medical-management-of-covid-19-an
Presentación utilizada por el Dr. Domingo Pascual Figal en el directo online ‘Lo mejor en Insuficiencia Cardiaca de ESC Múnich 2018’, realizado el 19 de septiembre de 2018 en la Casa del Corazón
Yasser's covid 19 discrepancy phenomenon-dr. yasser mohammed hassanain elsayedYasserMohammedHassan1
Yasser’s COVID-19 Discrepancy phenomenon is a novel descriptive phenomenon that is always seen in all COVID-19 pneumonia. Initial dramatic improvement of the clinical status of COVID-19 pneumonic patient, not a simultaneously after the management, not a coincide with laboratory, radiological, and electrocardiographic workup. Further larger studies for the study medical regimen with considering of “Yasser’s COVID-19 Discrepancy phenomenon” is recommended.
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.
Presentación utilizada por el Dr. Domingo Pascual Figal en el directo online ‘Lo mejor en Insuficiencia Cardiaca de ESC Múnich 2018’, realizado el 19 de septiembre de 2018 en la Casa del Corazón
Yasser's covid 19 discrepancy phenomenon-dr. yasser mohammed hassanain elsayedYasserMohammedHassan1
Yasser’s COVID-19 Discrepancy phenomenon is a novel descriptive phenomenon that is always seen in all COVID-19 pneumonia. Initial dramatic improvement of the clinical status of COVID-19 pneumonic patient, not a simultaneously after the management, not a coincide with laboratory, radiological, and electrocardiographic workup. Further larger studies for the study medical regimen with considering of “Yasser’s COVID-19 Discrepancy phenomenon” is recommended.
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 Mgh COVID-19 Treatment Guidance March 17, 2020 (20)
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Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
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TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
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The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
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Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
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ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?
Mgh COVID-19 Treatment Guidance March 17, 2020
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
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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
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•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