Thursday, March 26, 2020

COVID-19 and Paediatric Dosing

Reference
Lopinavir/Ritonavir (Kaletra) 200mg/50mg Tablet

Lopinavir/Ritonavir (Kaletra) 80mg/20 mg per mL Syrup
Hydroxychloroquine Sulphate 200 mg
(Plaquenil or Uniquin)
Ribavirin 200 mg
 (Copegus)
Hospital Kuala Lumpur [HKL]

Updated 20.03.20
Age 14 days to 6 months: Lopinavir component 16 mg/kg BD (or 0.2 mL/kg BD)

Age 6 months to 18 years:
·   15-25 kg: 200mg/50mg 2.5mL syrup or 1 tab BD
·   26-35 kg: 300 mg/75 mg (3.75mL) BD
·   >35 kg: 400 mg/100 mg 5mL or 2 tabs BD
<18 years:
10 mg/kg (max: 400 mg/dose) BD x 1 day
then 3 mg/kg (max: 200 mg/dose) BD
-
Hospital Umum Sarawak [HUS]

Updated 23.03.20
2wk – 6 mth:
16mg/4mg LPV/r per kg BD
(0.2 mL/kg BD)

6 months – 18 years:
§ 7 to <15kg: 12mg/kg/dose BD (0.15 mL/kg BD)
§ 15-40kg: 10mg/kg/dose BD (0.125 mL/kg BD) ; Max 400mg/100mg BD
§ >40kg: As per adult dosing: 2 tabs BD or 5 mL BD
Tablet / Extemporaneous suspension:
Day 1: 5-6 mg/kg/dose BD (Max 400mg/dose)
Day 2-5: 1.5-3 mg/kg/dose BD (Max 200mg/dose)

Prepare oral suspension of 25mg/ml:
15 tabs to 120ml of X-temp. Keep in amber bottle, stable at room temperature (25 ± 2°C) for 90 days.
-
UptoDate:
Refer to Drug Information for each individual drug(s)

Accessed 13.04.2020
Lopinavir/ritonavir is currently under investigation for use in the treatment of coronavirus disease 2019 (COVID-19). At this time, safety and efficacy have NOT been established in adult or pediatric patients.
Hydroxychloroquine sulfate 200 mg is equivalent to 155 mg hydroxychloroquine base. 

Children and Adolescents:
Oral: 6.5 mg/kg/dose twice daily on day 1; maximum day 1 dose: 400 mg/dose; followed by 3.25 mg/kg/dose twice daily on days 2 through 5; maximum dose: 200 mg/dose (ASTCT 2020)

Note: These dosing recommendations are specifically for patients who have undergone hematopoietic cell transplant (HCT) or other cellular therapy. However, some centers are reporting internal protocols/plans to use this dose in hospitalized pediatric patients who are not HCT patients.
At this time, while there are a number of medicines being investigated for treatment and/or prevention of COVID-19, none have yet to demonstrate safety and efficacy in humans diagnosed with or exposed to COVID-19.
An Algorithmic Approach to Diagnosis and Treatment of Coronavirus
Disease 2019 (COVID-19) in Children: Iranian Expert’s Consensus
Statement

Updated 05.03.20
All dosing based on lopinavir:

14 days to 12 months:
16 mg/kg/dose BD PO or
300 mg/m2/dose BD PO

12 months to 18 years:
v  Based on BSA:
230 mg/m2/dose BD PO (max 400 mg BD PO)

v  Based on weight:
Ø  Less than 15 kg: 12 mg/kg/dose BD PO
Ø  15-40 kg: 10 mg/kg/dose BD PO
Ø   Greater than 40 kg: 2 tabs BD PO (1 tab = 200/50)
IV, hydroxychloroquine sulfate:
Infants and children
3-5 mg/kg/day (max dose 400 mg), BID For 5 days

[No oral HCQ recommendation, only IV available]
Over 3 years old:
ü  < 47 kg: 7.5 mg/kg BD
ü  47-59 kg: 400 mg BD
ü  60-73 kg: 400 mg OM,
600 mg ON
ü  > 73 kg: 600 mg BD

For up to 14 days, depends on patient’s response.

Michigan Medicine: Emergency Department Guidance for Treatment of COVID-19 in Adults and Children

Updated 25.03.20
-
All doses are for < 18 years old.

Admitted / Pending admission:
*10 mg/kg (max: 600 mg/dose) PO BID x2 (load), then 3 mg/kg PO TID (max: 200 mg/dose)
*Minimum 5 days; may be extended if slow clinical improvement or clinical worsening

Discharged from emergency department:
*8 mg/kg PO BID x2 doses (max: 400 mg/dose), then 4 mg/kg PO BID (max: 200 mg/dose) 
*Total 5 days
-
Caution(s) / Remark(s)
ž Dispense in amber bottles.[HUS]
ž   May consume with sweets or tangy food (e.g. orange juice, chocolate syrup) to improve palatability.[HUS]
ž Caution: Syrup contains 42.4% ethanol and 15.3% ethylene glycol, hence potentially incompatible with polyurethane feeding tubes [HKL]
ž Hence for oral solution (NG tube feeding): Only use silicone & polyvinyl chloride (PVC) feeding tube. [HKL/HUS]
ž Administer UNDILUTED / PURE. Rinse feeding tube with milk (NOT water). [HKL/HUS]
ž For adult or child > 40 kg that uses tablet in tube feeding:
*     Exposure of Lopinavir can be reduced by 45% when the tablet is crushed
*     May increase to 3 or 4 tabs BD x 10-14 days [HKL/HUS]
ž Caution with GI symptoms and liver function [HUS]
ž Generally for 5 - 14 days, depends on physician’s judgment.[Iran]
ž  Tablet can be crushed and dispersed in water.[HUS]
ž  ECG prior to starting chloroquine and after onset of drug, cardiac monitoring is recommended [Iran]
ž Use with caution in patient at risk for QT prolongation [Michigan]

For NG tube feeding: Tablet can be crushed. However use double glove and protective gown, as drug has teratogenic potential to men and women trying to conceive (Ensure precautionary notes is attached).[HUS]
May enhance QT-prolonged effect when 2 of the following administered together:
AMIODARONE, Azithromycin, Ciprofloxacin, Fluconazole, Chloroquine, Hydroxychloroquine, Kaletra®

* Off-label Treatment Patient Consent Form is needed.
* So far there is no established paediatric dosing of ribavirin, interferon beta 1b and tocilizumab for COVID-19.
Updated 13.04.2020 by JCK Ho (Hospital Keningau)



ANYHOW THIS IS JUST A ROUGH GUIDANCE THAT MAY ASSIST YOU DURING SCREENING.
EVENTUALLY, PLEASE FOLLOW THE DOSING PRESCRIBED BY OUR PAEDIATRIC ID (Infectious Disease) TEAM.

FOR HEALTHCARE PROFESSIONAL USE ONLY

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