Management of COVID-19 & Mucormycosis patients: DGHS’ advisory on treatment, medicines

KEY STORY

• In its revised Covid-19 management guidelines, the Union health ministry’s Directorate General of Health Services (DGHS) has dropped all medicines, except antipyretic (fever) and antitussive (cold), for asymptomatic and mild coronavirus cases.

• In a May 27 order, the DGHS said that Remdesivir should be used only in select moderate/ severe hospitalised COVID-19 patients on supplemental oxygen within 10 days of onset of disease. It is not indicated in mild coronavirus patients.

• Tocilizumab is an immunosuppressant drug medicine that should be used in severe and critically ill patients of COVID-19 meeting the following conditions:

• If the patient shows no signs of improvement in terms of oxygen requirement even after 24-48 hours of administration of steroids.

• The patient has significantly raised inflammatory markers (C-Reactive Protein≥75 mg/L).

• However, it must be ensured that the patient is free of any bacterial/ fungal/ tuberculous infection at the time of administration of Tocilizumab.

• Single dose of 8 mg/kg body weight (not more than 800 mg) in 100 ml normal saline over one hour.

When to administer steroids to COVID patients

On the usage of steroids, the DGHS said that steroids are not indicated and are harmful in asymptomatic and mild cases of COVID-19 and are indicated in only hospitalised moderately severe and critically ill cases.

Dexamethasone 6mg IV once daily or per oral for initially for 10 days or till the time of discharge whichever is earlier, based on clinical judgement on daily basis.

Equivalent glucocorticoid dose may be substituted (if dexamethasone is unavailable) by methylprednisolone 32 mg orally or 40 mg I/V or 50 mg hydrocortisone intravenously every 8 hours or Prednisone 40 mg (per oral).

Anti-coagulants usage:

Moderate cases:

Prophylactic doses to be used in moderate cases of COVID-19 with un-fractionated heparin or low molecular weight heparin (weight based e.g., Enoxaparin 0.5 mg/kg per day SC OD).

There should be no contraindication or high risk of bleeding.

Severe cases:

Prophylactic doses to be used in severe cases of COVID-19 with un-fractionated heparin or low molecular weight heparin (weight based e.g.,

Enoxaparin 0.5 mg/kg per day SC OD), therapeutic dose to be used only if there is evidence of thromboembolism.

There should be no contraindication or high risk of bleeding.

Mucormycosis/black fungus management

The Directorate General of Health Services said that the treatment of Mucormycosis/black fungus involves combination of surgical debridement and antifungal therapy.

“Liposomal Amphotericin B in initial dose of 5mg/kg body weight (10 mg/kg body wt in case of CNS involvement) is the treatment of choice. It should be diluted in 5% dextrose, it is incompatible with normal saline/ Ringer Lactate.It should be given over 2-3 hours and should be started with full dose from day 1. Monitoring for kidney function tests and serum elecrolytes is recommended. It has to be continued till a favourable response is achieved and disease is stabilized which may take 3-6 weeks following which step down to oral Posaconazole (300 mg delayed release tablets twice a day for 1 day followed by 300 mg daily) or Isavuconazole (200 mg 1 tablet 3 times daily for 2 days followed by 200 mg daily) shall have to be taken for prolonged period as per advice of the physician,” the order stated.

The therapy has to be continued until clinical resolution of signs and symptoms of infection as well as resolution of radiological signs of active disease and elimination of predisposing risk factors such as hyperglycemia, immunosuppression etc. It may have to be given for quite long periods of time, the order said.

Conventional Amphotericin B (deoxy cholate) in the dose 1-1.5mg/kg may be used if liposomal form is not available.

Kidney functions must be monitored during the entire management period.