From Bleach to Hydroxychloroquine, People are suggesting many things to treat COVID-19. Some ideas are proven wrong and more should have never been suggested. Jay Harold put together this post, “COVID-19 Meds Update,” to provide useful drug information about COVID-19 from the National Institutes of Health (NIH).
Note: Please refer to the article link for additional information inside the updates from NIH.
June 25, 2020, Update1
Based on a preliminary analysis of the data from the Randomised Evaluation of COVID-19 Therapy (RECOVERY) study, the COVID-19 Treatment Guidelines Panel (the Panel) developed recommendations for the use of the corticosteroid dexamethasone in people with COVID-19.
This new guidance from the Panel includes the rationale for these recommendations and additional factors for clinicians to consider before administering dexamethasone to people with COVID-19. For more information, please visit the full announcement.
June 16, 2020, Update: On June 15, The Food and Drug Administration revoked the emergency use authorization (EUA) that permitted the use of chloroquine and hydroxychloroquine donated to the Strategic National Stockpile to treat certain patients with COVID-19. In light of this announcement, the following sections of the COVID-19 Treatment Guidelines have been updated to remove the information regarding the EUA:
- Antiviral Drugs Under Investigation
- Chloroquine or Hydroxychloroquine
Key Updates to the Guidelines
Special Considerations in Children
This section now includes a preliminary description of multisystem inflammatory syndrome in children (MIS-C), a condition that has been associated with COVID-19 in children and young adults. This section will be updated as more data become available.
Potential Antiviral Drugs Under Evaluation for the Treatment of COVID-19
The recommendations for using remdesivir, chloroquine, and hydroxychloroquine to treat COVID-19 have been revised based on data from recently published clinical trials and observational cohort studies. This section and Table 2a now include detailed summaries of the study results. The revised recommendations are listed below, and the rationale for these recommendations is discussed in the text.
Remdesivir2
Recommendation for Hospitalized Patients with Severe COVID-19:
- The COVID-19 Treatment Guidelines Panel (the Panel) recommends the investigational antiviral agent remdesivir for treatment of COVID-19 in hospitalized patients with SpO2 ≤94% on ambient air (at sea level) or those who require supplemental oxygen (AI).
- The Panel recommends remdesivir for treatment of COVID-19 in patients who are on mechanical ventilation or extracorporeal membrane oxygenation (ECMO) (BI).
Recommendation for Duration of Therapy in Patients with Severe COVID-19 Who Are Not Intubated:
- The Panel recommends that hospitalized patients with severe COVID-19 who are not intubated receive 5 days of remdesivir (AI).
Recommendation for Duration of Therapy for Mechanically Ventilated Patients, Patients on ECMO, or Patients Who Have Not Shown Adequate Improvement After 5 Days of Therapy:
- There are insufficient data on the optimal duration of therapy for mechanically ventilated patients, patients on
ECMO, or patients who have not shown adequate improvement after 5 days of therapy. In these groups, some experts extend the total remdesivir treatment duration to up to 10 days (CIII).
Recommendation for Patients with Mild or Moderate COVID-19:
- There are insufficient data for the Panel to recommend for or against remdesivir for the treatment of patients with mild or moderate COVID-19.
Chloroquine or Hydroxychloroquine
- The Panel recommends against the use of chloroquine or hydroxychloroquine for the treatment of COVID-19, except in a clinical trial (AII).
Additional Updates to the Guidelines
Oxygenation and Ventilation
In this section, the Panel added the following recommendations for the use of awake prone positioning in critically ill patients
who are not intubated:
- For patients with persistent hypoxemia despite increasing supplemental oxygen requirements in whom endotracheal intubation is not otherwise indicated, the Panel recommends considering a trial of awake prone positioning to improve oxygenation (CIII).
- The Panel recommends against using awake prone positioning as a rescue therapy for refractory hypoxemia to avoid intubation in patients who otherwise require intubation and mechanical ventilation (AIII).
Interleukin-1 Inhibitors
New clinical data from a single-center case series and a single-center retrospective cohort study that evaluated the use of anakinra to treat of COVID-19 have been added. There is no change to the Panel’s recommendation for interleukin-1 inhibitors.
Interleukin-6 Inhibitors
New clinical data from a prospective, open-label study of tocilizumab have been added. There is no change to the Panel’s recommendation for interleukin-6 inhibitors.
Introduction – Dexamethasone3
Patients with severe COVID-19 develop a systemic inflammatory response that can lead to lung injury and multisystem organ dysfunction. It has been proposed that the potent anti-inflammatory effects of corticosteroids might prevent or mitigate these harmful effects. Small, retrospective cohort studies and case series have yielded conflicting results; both beneficial1-4 and harmful5,6 effects have been reported in studies that have evaluated short courses of corticosteroids in patients with COVID-19.
A preliminary, unpublished analysis from a large, multicenter, randomized, open-label trial for hospitalized patients in the United Kingdom showed that patients who were randomized to receive dexamethasone had a reduced rate of mortality compared to those who received standard of care.7 This benefit was observed in patients with severe COVID-19 (defined as those who required supplemental oxygen) and was greatest in those who required mechanical ventilation at enrollment. No benefit of dexamethasone was observed in patients who did not require supplemental oxygen at enrollment.
Based on these preliminary results:
- The COVID-19 Treatment Guidelines Panel (the Panel) recommends using dexamethasone (at a dose of 6 mg per day
for up to 10 days) in patients with COVID-19 who are mechanically ventilated (AI) and in patients with COVID-19 who require supplemental oxygen but who are not mechanically ventilated (BI).- The Panel recommends against using dexamethasone in patients with COVID-19 who do not require supplemental oxygen (AI).
Clinicians should refer to the Additional Considerations section below for further guidance before prescribing dexamethasone for a patient with COVID-19.
Considerations for Certain Concomitant Medications in Patients with COVID-194
Last Updated: June 25, 2020
| Summary Recommendations |
|---|
Angiotensin-Converting Enzyme (ACE) Inhibitors and Angiotensin Receptor Blockers (ARBs):
CorticosteroidsFor Management of COVID-19:
For Patients on Chronic Corticosteroids:
Pregnancy Considerations:
HMG-CoA Reductase Inhibitors (Statins):
Nonsteroidal Anti-Inflammatory Drugs (NSAIDs):
|
ts with COVID-19 who require supplemental oxygen but who are not mechanically ventilated (BI).Zinc5
Zinc is an essential mineral that is naturally present in some foods, added to others, and available as a dietary supplement. Zinc is also found in many cold lozenges and some over-the-
counter drugs sold as cold remedies.
Zinc is involved in numerous aspects of cellular metabolism. It is required for the catalytic activity of approximately 100 enzymes [1,2] and it plays a role in immune function [3,4], protein synthesis [4], wound healing [5], DNA synthesis [2,4], and cell division [4]. Zinc also supports normal growth and development during pregnancy, childhood, and adolescence [6-8] and is required for proper sense of taste and smell [9]. A daily intake of zinc is required to maintain a steady-state because the body has no specialized zinc storage system [10].
Vitamin C6
Vitamin C, also known as L-ascorbic acid, is a water-soluble vitamin that is naturally present in some foods, added to others, and available as a dietary supplement. Humans, unlike most animals, are unable to synthesize vitamin C endogenously, so it is an essential dietary component [1].
Vitamin C is required for the biosynthesis of collagen, L-carnitine, and certain neurotransmitters; vitamin C is also involved in protein metabolism [1,2]. Collagen is an essential component of connective tissue, which plays a vital role in wound healing. Vitamin C is also an important physiological antioxidant [3] and has been shown to regenerate other antioxidants within the body, including alpha-tocopherol (vitamin E) [4]. Ongoing research is examining whether vitamin C, by limiting the damaging effects of free radicals through its antioxidant activity, might help prevent or delay the development of certain cancers, cardiovascular disease, and other diseases in which oxidative stress plays a causal role. In addition to its biosynthetic and antioxidant functions, vitamin C plays an important role in immune function [4] and improves the absorption of nonheme iron [5], the form of iron present in plant-based foods. Insufficient vitamin C intake causes scurvy, which is characterized by fatigue or lassitude, widespread connective tissue weakness, and capillary fragility
It’s a lot to Digest!
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Bibliography
- https://www.covid19treatmentguidelines.nih.gov/whats-new/
- https://en.wikipedia.org/wiki/Remdesivir
- https://www.covid19treatmentguidelines.nih.gov/dexamethasone/
- https://www.covid19treatmentguidelines.nih.gov/concomitant-medications/
- https://ods.od.nih.gov/factsheets/Zinc-HealthProfessional/
- https://ods.od.nih.gov/factsheets/VitaminC-HealthProfessional/
