Covid-19 treatment guidelines cut down on drugs, steroids: Details here

The recent guidelines for management of Covid patients — asymptomatic, mild to moderate and severe — by the Directorate General of Health Services (DGHS) have laid out the dos and don’ts of their treatment with a greater clarity. The government has dropped drugs for treating mild and asymptomatic cases, while cautioning against many other treatments being given to patients — from steroids and anticoagulants to medicines such as remdesivir and tocilizumab. The guidelines also ask for rational use of the chest CT scan while stressing on promoting Covid-appropriate behaviour — wearing mask, practising strict hand hygiene, physical distancing. Drugs that became popular during Covid such as hydroxychloroquine, ivermectin, doxycycline, zinc and multivitamins find no place in these guidelines. 

What do the guidelines recommend for asymptomatic and mild cases?

For mild and asymptomatic cases, no specific medication is required. DGHS has recommended the six-minute walk test (walk at your normal pace for six minutes) and self-monitoring of symptoms for such patients along with a good diet and Covid-appropriate measures. For mild cases, it is suggested that inhalational budesonide be given through a metered dose inhaler for cough. 

What do the guidelines say about the use of remdesivir?

This drug has been in great demand, with patients scrambling to get a dose. In its nine-page guidelines, the DGHS has, however, clearly advised physicians to exercise extreme caution in using remdesivir as it is only an experimental drug with potential to harm. The drug is not indicated as treatment in mild Covid-19 patients who are in home care or in Covid care centres. 

In a very specific way, DGHS has also said remdisivir is to be used only in select moderate or severe hospitalised Covid-19 patients on supplemental oxygen within 10 days of the onset of the disease. The guidelines reiterated that this drug should be procured and provided by the hospitals only; the patient’s attendants and relatives should not be asked to procure remdesivir from the retail market. The drug must be advised by senior faculty members and specialists directly involved in the patient’s care. 

Who can take tocilizumab? 

If the patient shows no signs of improvement in terms of oxygen requirement even after 24-48 hours of steroids being administered or has significantly raised inflammatory markers, this drug can be given. 

Tocilizumab, DGHS said, is an immunosuppressant and has been approved by the regulator for use as an off-label drug only in severe and critically ill patients of Covid-19. It must be ensured that the patient is free of any bacterial, fungal or tuberculous infection when this drug is given. 

What about the use of steroids?

It has been stated in bold that steroids are harmful in asymptomatic and mild cases of Covid-19 and patients must avoid self-medication with steroids. Steroids are to be given only to hospitalised moderately severe and critically ill Covid-19 cases. DGHS has recommended the use of steroids at “the right time, in right dose and for right duration.”

Monitoring of blood glucose is mandatory in all patients put on steroids. “It must be also remembered that steroids may prolong viral shedding, and hence caution is required,” the guidelines state. Excessive use of steroids is said to be a reason for the increase in post-Covid complications such as mucormycosis (black fungus). 

What about the use of anticoagulants?

Prophylactic doses of anticoagulants are to be used in moderate and severe cases of Covid-19, ensuring there is no high risk of bleeding. A therapeutic dose, or dose for treatment, has to be used only if there is evidence of thromboembolism — obstruction of a blood vessel by a blood clot. 

What is the advice on the high-resolution CT (HRCT) scan of the chest?

Such routine imaging of the chest in Covid-19 patients is not recommended. The radiation exposure due to repeated HRCT imaging may be associated with risk of cancer later in life. Nearly two-thirds of persons with asymptomatic Covid-19 have abnormalities on HRCT chest imaging, which cannot be assigned to a particular cause. In the first week of the illness, the scam might often underestimate the extent of lung involvement, giving a false sense of security. The scan is not required to assess response to treatment. DGHS said, “More often, the lung lesions show radiological progression despite clinical improvement.”

However, cases of moderate Covid-19 who continue to deteriorate clinically even after appropriate therapy should get this scan done, especially when there is high risk of invasive fungal infection.