COVID-19 Management (Updated @ 21.09.2020)

 Disease Severity

	Clinical Stage
MILD	1	Asymptomatic	No antiviral treatment required
	2	Symptomatic, No Pneumonia	ü No antiviral treatment required in the absence of warning signs ü Close observation of vital signs and oxygen saturation ü Look for warning signs at each review. Treat as category 4 if any warning signs present
	3	Symptomatic, Pneumonia	ü Antiviral treatment required in the absence of risk factors / warning signs ü Close observation of vital signs and oxygen saturation ü Look for warning signs at each review. Treat as category 4 if any warning signs present ü Treat as category 4 if patient has any of the following risk factors: Age ≥ 50 years or ESRF
SEVERE	4	Symptomatic, Pneumonia, Requiring supplemental oxygen
	5	Critically ill with multiorgan involvement

 

 

Updated COVID-19 Drugs and Dosing (Used by ID , HQE)

	Drug	Dose Recommended	Remark(s)
1	Favipravir 200 mg Tab*	1800 mg bd for 1 day then 800 mg bd (5 – 10 days)	·        Teratogenic effect; Contraindicated for women of childbearing potential and men whose partner is of childbearing potential. ·        Avoid if GFR < 30 mL/min
2	Interferon Beta-1b 250 mcg Inj* (NO LONGER RECOMMENDED SINCE OCT 2020)	250 mcg stat then EOD for 3-5 doses	·        Use in the first week of illness as viral activity may predominate. ·        It may not be useful if started in the second week of illness.
3	Tocilizumab*	4-8 mg/kg single dose (MAX: 800 mg/dose)	·        Given that we will be giving dexamethasone more routinely, the need for Tocilizumab will drop. ·        But it still has a role in the following situations: o   Coming in late with evidence of advanced CRS disease – Grade 3/4 o   Rapidly progressive disease Ø Fold increases, net increases, or rate of change in cytokine levels may provide better correlates of CRS severity than absolute cytokine levels.* Ø CRP levels serve as a reliable surrogate for IL-6 bioactivity.*
4	Dexamethasone	6 mg OD (5-7 days)	·       Recommended in all patients needing supplemental oxygen > 7 day of illness ·       Benefits of use in patients < 7 day of illness is still uncertain
5	Methylprednisolone	0.5-1 mg/kg (5-7 days)

 

*May refer to Askdis Blogspot for details of administration

*Dosing suggested is for normal patient. Dose may need to be renally / hepatically adjusted PRN. Please double check.

 

As per agreed with ID HQE, Hydroxychloroquine, Kaletra and Ribavirin are no longer part of COVID-19 management.

 

References:

1)       Slides: COVID-19 Clinical Updates (by Dr Suresh, ID Physician, Hospital Sg Buloh)

2)       Slides: Mesyuarat Pengurusan Pesakit COVID-19 bersama TKPK(P) [28 Ogos 2020]

The 2018 European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation [Extracts]

NOAC & INDICATIONS

NOAC & contraindications

SWITCHING BETWEEN ANTICOAGULANTS

Vitamin K antagonist to non-vitamin K antagonist oral anticoagulant

The NOAC can immediately be initiated once the INR is <_2.0. If the INR is 2.0–2.5, NOACs can be started immediately or (better) the next day. For INR >2.5, the actual INR value and the half-life of the VKA need to be taken into account to estimate the time when the INR value will likely drop to below this threshold value [half-lives for acenocoumarol 8–24 h, warfarin 36–48 h, phenprocoumon 120–200 h (6 days)]. The proposed scheme (also shown in Figure 2, top panel) tries to unify different specifications from the SmPCs, which state that NOAC can be started when INR is ≤3 for rivaroxaban, ≤2.5 for edoxaban, and ≤2 for apixaban and dabigatran.

Non-vitamin K antagonist oral anticoagulant (NOAC) and Vitamin K antagonist (VKA)

Because of the slow onset of action of VKAs, it may take 5–10 days before the INR is in the therapeutic range, with large individual variations (see also chapter 20). Therefore, the NOAC and VKA should be administered concomitantly until the INR is in a range that is considered appropriate (Figure 2, lower panel)—similar to the situation when low molecular weight heparins (LMWHs) are administered during VKA initiation. A loading dose is not recommended for acenocoumarol and warfarin, but is appropriate with phenprocoumon (see chapter 20).

As NOACs may have an impact on INR measurements, it is important that the INR (i) is measured just before the next intake of the NOAC during concomitant administration and (ii) is re-measured early after stopping the NOAC (i.e. reflecting solely VKA therapy) to assure adequate anticoagulation. It is also recommended to closely monitor INRs within the first month until stable values have been attained (i.e. three consecutive measurements yielded values between 2.0 and 3.0). At the end of the ENGAGE-AF trial, patients on edoxaban transitioning to VKA received up to 14 days of a half dose of the NOAC until the INR was within range, in combination with the above intensive INR testing strategy.

The 2018 European Heart Rhythm Association Practical Guide on the ues of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation [ European Heart Journal (2018) 00, 1-64 ]

Dosing Guides for Apixaban in non-valvular AF: •      Generally use 5 mg BD •      Dose adjustment to 2.5 mg twice daily is recommended for patients with at least 2 of the following characteristics:            age ≥80 years   ;   body weight ≤60 kg   ;   serum creatinine ≥1.5 mg/dL or (≥ 133 mcmol/L)

NOAC & renal function

NOAC & HEPATIC FUNCTION

NOAC & LABORATORY COAGULATION PROFILE

Topical Preparation in Hospital Keningau

	TOPICAL PREPARATION	DOSING		PRESCRIBER CATEGORY		REMARK
BACTERIAL SKIN CONDITION
Impetigo (Superficial Skin Infection)	Fusidic Acid 2% Cream	q8-12h for 7 days		A		⚫ Do not use for more than 2 weeks. ⚫ May use again if infection relapse
	Mupirocin 2% Ointment	q8-12h for 5 days		A
Cellulitis	Potassium  Permanganate 5%	OD-TDS		C
PARASITIC SKIN INFECTION
Scabies   Also may refer to this link: https://askdis.blogspot.com/2019/07/scabies-2019.html	Emulsion Benzyl Benzoate (EBB) 25%	OD x 2-3/7 Wash off after 24 hours (with a bath taken in between each application)		C
	Permethrin 5%	Once , repeat 1 week later Wash off after 8-12 hours		A/KK		NOT available for JPL
	Crotamiton 10%	Once daily up to 7 days (for nodular scabies TDS for 7-14 days)		B
	Calamine with 6% Sulphur	OD x 3/7 Wash off after 24 hours (with a bath taken in between each application)		C
	Patient Category		Choices Available
	Newborn to 2 months of age		Calamine with 6% Sulphur		Crotamiton 10%
	Children (2 mo to 2 yrs)		Calamine with 6% Sulphur		Crotamiton 10%		Permethrin 5%
	Children (2-12yrs)		Emulsion Benzyl Benzoate (EBB) 12.5%		Crotamiton 10%		Permethrin 5%
	Adult		Emulsion Benzyl Benzoate (EBB) 25%		Crotamiton 10%		Permethrin 5%
	Pregnant Woman		Permethrin 5%		Calamine with 6% Sulphur
Head Lice	Permethrin 1% Shampoo	Once, then reapply after 7-10 days		B
	Benzene Hexachloride GBH 0.1%	Not available
FUNGAL SKIN INFECTION
Dermatophyte infections (Dermatophytoses)	Miconazole cream 2%	Apply twice daily to affected area optimally for 4 weeks including 2 weeks after lesions have cleared.		B		Apply 2-3 cm beyond advancing margin of lesion.
	Clotrimazole cream 1%			B
	Miconazole powder	Not available
Pityriasis Versicolor	Selenium Sulphide 2.5 % Shampoo	Apply daily for 1 week to affected areas for 10-15 minutes followed by a shower & rinse off. Then apply 2-3 times per week.		A/KK
	Ketoconazole shampoo	Not available
	Topical Imidazole -Miconazole cream -Clotrimazole cream	Apply twice daily to affected area optimally for 4 weeks including 2 weeks after lesions have cleared.		B		Apply 2-3 cm beyond advancing margin of lesion.
Cutaneous Candidiasis	Miconazole cream 2%	Apply twice daily to affected area optimally for 4 weeks including 2 weeks after lesions have cleared.		B		Apply 2-3 cm beyond advancing margin of lesion.
	Clotrimazole cream 1%
	Nystatin cream	Not available
	Whitfield Ointment	Twice daily in a thin layer to the affected parts of the skin.		C		Treatment              may                                       take several weeks

 

VIRAL SKIN INFECTIONS
Warts	Salicylic Acid 1-20 %	Once to twice daily	C	**Prepared by HKGU , available in 1%, 2%, 5%, 10%, 20%
	Podophyllum  10-20 %	Not available
	Imiquimod 5% cr eam	Not available
Eczema & Dermatitis	1) Emollient
	Aqueous Cream	As a soap ⚫ To apply cream/ ointment on cotton wool. Then wet the body, smear the cotton wool onto the skin. Wash and then use the dry cotton wool to remove excess oil. As an emollient ⚫ To apply after taking a bath or showering when the skin is moist. ⚫ To apply emollients liberally (at least 2-4 times a day).	C
	Liquid paraffin		C
	Glycerin + Aqueous Cream		C	**Prepared by HKGU , available as Glycerin 10% + Aqueous cream or Glycerin 20% + Aqueous cream
	White soft paraffin		C
	Cerbamide (Urea) 10% Cream	Not available
	Emulsifying ointment	Not available
	2) Topical corticosteroid
	Hydrocortisone 1% cream	Three times daily over face, ear or flexural or elderly with thin skin	B	Mild potency
	Betamethasone 1:10 cream (0.01%)		B
	Betamethasone 1:4 cream (0.025%)	Two- three times daily over any site	B	Moderate potency
	Betamethasone 1:2 Cream (0.05%)	Once daily over body and limbs	B	Potent
	Betamethasone 1:1 Cream (0.1%)		A
	3) Topical Calcineurin Inhibitors (TCIS)
	Tacrolimus 0.03 %  &  0.1%  ointment	Not available
	Silver nitrate 0.5% ,  2%, 5%, 10%	Not available
Psoriasis	1) Topical Corticosteroid  -  as mentioned above
	2) Tar based preparation
	Tar Ointment	Apply sparingly to affected areas 1-3 times daily starting with low strength preparation	B	**Prepared by HKGU , available in 1%, 2%, 3%, 6%, 8%   Usually apply at night due to unpleasant smell
	Coal Tar 20% Solution	1 cap (15 ml) added to 10L of water in a pail. Soak diluted solution for 20 minutes	B
	3) Vitamin D Analogue  -  Not available
	4) Dithranol (Anthralin) -  Not available
Acne Vulgaris	1) Cetrimide 1%	Apply solution onto the face twice daily	B	Mix with water on palms, rub hand together until froth, apply froth on face,  rinse off with water
	2) Benzyl peroxide	Not available
	3) Adapalene,  Tretinoin	Not available
	4) Azelaic acid 20% cream	Not available

 

Remark

·       Availability may change from time to time depending on supplier, contract change, etc.

·       Please do consult pharmacist for latest availability.

·       Menthol may be added into certain preparation (usually aqueous cream) upon request.

·       Item maybe be kept by Hospital Keningau if allowed by Dermatology HQE.

 

References:  (1) Topical Preparations Counselling Guide for Pharmacist, 2018 ; (2) Hospital Keningau Drug Formulary, August 2020 ; (3) UptoDate ; (4) Bluebook

 Reviewed on 25/8/2020 by Nabiha  ; Edited on 04/09/2020 by JCK Ho