CME INDIA Presentation by Admin.

COVID-19 virus is mutating and so is the status of guidelines. Reality is hard. People refrain to go for test due to administrative torture. HRCT is considered more useful by physicians than rtPCR. And, once positive, even advised for admission, most of the facilities are worse than hell. So, home treatment is trending and physicians use their intellect and experience more than the stereotyped guidelines.

Here we present you these scenarios.

First, few scientific facts by Dr Sudhir Kumar, and then experiences of physicians from different parts of the country, namely, Kolkata, Jamshedpur, Sambalpur and Giridih.

Dr Sudhir Kumar, DM. Pulmonolgy, Patna on few important issues in COVID-19:

1. Role of Tocilizumab in COVID ARDS

Tocilizumab is indicated in cytokine storm when both IL6 and ferritin levels are very high. One dose is enough but sometimes repeat dose is also required. In some appropriately select patients it has been found to highly effective in bringing remarkable improvement in the clinical condition. Secondary coinfection must be ruled out. Also, secondary infection post tocilizumab must be watched for.

2. Certain patients with >80% lung involvement don’t develop ARDS, but pts with less than <20% lung involvement develop ARDS. Why?

ARDS can be due to multiple factors and those factors are independent of lung involvement:

1. Cytokine storm
2. Secondary infections
3. Pulmonary vascular thrombosis
4. Some other mechanism yet not deciphered.
5. Even in pneumonia ARDS is not always proportional to the lung involvement

Though not validated HScore scoring system has been proposed to predict developments of ARDS in COVID-19 based on a dozen parameters.

3. Role of Ulinastatin and Sepsivac in COVID:

• It’s also under clinical trials but has been recommended by thirty experts at 2019 Shanghai expert consensus.
  • For progressive lung disease 0.6 to 1.0 million units per day till improvement.
  • For prevention or treatment of cytokines storm 1.6 million units per day.
  • For ARDS 1.0 million to 1.6 million units per day.

Reference: https://www.ijccm.org/doi/IJCCM/pdf/10.5005/jp-journals-10071-23415

• Sepsivac is under clinical trials and is not recommended yet by Indian society of critical care medicine.

4. Why only certain patients develop cytokine storm, that too middle to elderly patient whose immunity is waning but young patient whose immunity is so good does not develop at all?

The answer is not apparent but hyper immune response is directly related to immuno competent patients is a bit too simplistic. It is rather hyper response in any person possibly due to immune imbalance induced by the pathogen. Hypothesis is that it’s linked to genetic factors and decreased immunity status. In young age, there is a perfect balance but as age advances some aberration in balance starts trickling in. DNA starts decaying extremely slowly after the peak age of 25 years

5. How early steroids can be given and if at all what dose to be given in the 1st & 2nd week of illness?

Steroids are indicated when secondary infection is ruled out and usually are given from seventh day to third week. Lung shadows with negative procalcitonin, high ESR, CRP, LDH, Ferritin, IL6 are indicators. In cytokines storm, anecdotal evidence says high dose iv methylprednisolone is lifesaving.

With these few inputs, let us scan, what is exactly happening at metro, semi metro and district levels…

Scenario at Metro level:

Dr Bijoy Patni, Diabetologist, Kolkata: Till date I have diagnosed 218 patients with COVID19. This includes 7 families and support staffs also. (Family strength are as follows: 5,6,8,8,9,11,13).

Presentation of the 218 patients:

• Asymptomatic – 72 (33%); had h/o contact and were also found to be positive.
• Mild symptoms – 53 (24.3%) patients’ prominent symptoms were body ache, feverish and weakness.
• Rest presented with fever (< F) °100.5. Very few presented with high temperature (> F) °100.5.

Associated symptoms were:

• Profound weakness (40 percent),
• Sore throat (45 percent)
• Cough (25 percent)
• Loss of taste and loss of smell in good numbers (roughly – 30-35percent) – variable recovery from 7- 45 days.

Comorbid Conditions:

• Diabetes present in 17% (n=37); In these patients -COVID-19 Pneumonia in 45% (n= 17) with 35% (n= 6) requiring admission
• COPD/ BA present in 14.5% (n=31) of patients with admission of 3 patients (One had diabetes as well)
• Hypertension present in 11% (n= 23) of patients with one admission who also had diabetes
• CAD was present in 5.5% (n= 12) with no admissions.
• Renal dysfunction seen concomitantly with diabetes and/or hypertension in 6 cases. No ESRD

Treatment undertaken in home isolation:

• All patients were given Zinc, Vit. C & Vit. D.
• Asymptomatic- Only Zinc, Vit. C & Vit. D.
• Mild symptoms & young – HCQS -21% (n=45) mostly asymptomatic but had high ESR or CRP.
• In Diabetics & Hypertensives – Doxycycline & Ivermectin in 18% (n= 39).
• Azithromycin only added if cough or sore-throat present.
• Faviparavir in 13% (n= 28) only who had high CRP & IL6 along with raised temperature.
• Patients receiving Ecosprin & Statin were continued on it.
• Only 2 patients in home isolation were given LMWH (high D-DIMER but no admission).
• No steroid given in home isolation.
• Quarantine for all for 14 days.
• Repeat testing done in almost 30 percent, usually after 17 days. About half of them were found to be still positive.

Residual issues:

• Majority of symptomatic patients became asymptomatic by 7-9 days.
• Fever persisted in few (5) for more than a month – low grade.
• Weakness persisted in some for more than 14 days.
• Almost all admitted patients had post discharge residual lung dysfunction but only one requiring intermittent oxygen.

Conclusion:

• Most of the patients were either asymptomatic or had mild symptoms.
• Treatment basically symptomatic with additions of vitamins and zinc.
• HCQ, Doxycycline and Ivermectin in most.
• Fabiflu and Azithromycin in some.
• Total admission – 8 out of 218 pts.
• Residual lung injury seen in admitted COVID Pneumonia cases.

Scenario at Semi-Metro level:

Dr R K Mishra, Diabetologist, Jamshedpur (Personal Communication): So far treated 200 COVID positive cases. As a rule, advices HRCT on 3rd day. Many cases, HRCT is the most important indicator of COVID, and after that rtPCR follows. His policy is not to wait and watch. From day 1, started LMWH, Methylprednisolone 1mg/kg bodyweight, Vit Zinc, Antibiotic, Ivermectin, and in most cases Faviflu. Many cases, after consultation did not find bed in hospitals and continued on same regimen at home. 75% were above age 50 and with multiple co-midbodies. Even 80 yr. aged man with CAD, CKD, CHF also well recovered. None of 200 had major issue post COVID, all survived. Routinely, he goes for Tropin-I and NT -BNP pro. Uses heavy dose Carnitine in selected cases. His message is, start anticoagulation and steroids at earliest, this the game changer policy.

Dr Bikash C Nanda, Sambalpur, Odisha:

75 yr. old obese hypertensive patient started with fever for 1st day, mild cough, which subsided and progressed to asthenia and fatigue – Day 11 (on telephonic consultation).

D DIMER is raised beyond 1000 and ESR CRP both raised. I have planned to start LMWH BD Should steroids be also given as ESR and CRP is raised?

Patient is adamant on not moving out of house to get RTPCR done.

Dr Ravi A, Prof Med Stanley Med College, Chennai: Justification for starting steroids?

Dr Surendra Kr Goyal, Kota: Is O2 saturation low?

Dr Somnath, Hyderabad: Steroid and LMWH are cornerstone as per my personal experience.

VERY UNUSUAL THINKING

“Steroids and anticoagulants are two major breakthroughs in the management of COVID-19; these can be administered to all high-risk cases on Day 1 of the illness, instead of waiting for Day 3 to give them.”

🕸️Disclaimer: This is a consensus statement by a group of experts. CME INDIA does not endorse or refute it. Webinar discussion “Lateral thinking in COVID era” 19th September, 2020 Experts: (Dr K K Aggarwal, Dr Ashok Gupta, Dr Jayakrishnan Alapet, Dr J A Jayalal, Dr Alexander Thomas, Dr D R Rai, Dr Anita Chakravarti, Dr Atul Pandya, Prof Bejon Misra, Dr Anil Kumar, Dr K K Kalra, Mrs Upasana Arora, Ms Ira Gupta, Dr S Sharma).

Dr Somnath, Hyderabad: I don’t prefer oral anticoagulant. After LMWH, advise antiplatelet.

Dr S C Jha, Physician, Darbhanga: What about guidelines?

Dr Somnath, Hyderabad: In COVID, I prefer no guidelines as everyday there are new guidelines and views. Except pregnancy, all symptoms and signs are being attributed to COVID.

Dr Alka Desh Panday, Mumbai: 👌Except pregnancy and fractures.

Dr Vivek Gupta, Physician, Surat: We give tab. rivaroxaban (Xarelto) 10 mg once a day for 1 month if d dimer high. Usually d dimer between 500 and 1000 – We prefer ecosprin 75. More than 1000 we prefer tab. rivaroxaban.10mg od for 1 to 1 and half month.

Scenario at a district level:

Dr A K Deo, MD, Med, Physician, Giridih, Jharkhand: Regimen adopted by me, till now excellent outcome. Affordable to poorest of the poor is most interesting part—– For adults strongly suspected or positive for COVID 19 without complications. Sharing it to CME INDIA.

Dr Sudhir Kumar Patna, DM, Pulmonology: Patna: Zinc, why you left?

Dr N K Singh: Why Acitrom (Acenocoumarol)? Any patient who is admitted to hospital during the COVID-19 pandemic and is taking warfarin (or any other coumarin anticoagulant e.g. phenindione, acenocoumarol) should be considered for switching to a direct oral anticoagulant (DOAC). This is to avoid the need for ongoing monitoring in hospital and clinics.

Dr A K Deo: Yes, rivaroxaban not available.

Dr Sudhir Kumar, Patna, DM, Pulmonology: What about (dabifib) dabigatran?

Dr N K Singh: What is harm in using Acitrom in COVID if DOAC not available?

Dr Satish Kumar, Cardiologist, Bokaro: No harm at all.

CME INDIA Learning Points:

• “A highly-developed values system is like a compass. It serves as a guide to point you in the right direction when you are lost.” – Idowu Koyenikan.
• COVID has destroyed all developed compasses.
• World-wide scientists are trying to sail in very untidy sea and trying to settle the science.
• No point in strictly following the ever-changing concepts.
• “The art of medicine consists of amusing the patient while nature cures the disease.” – Voltaire. This is 100% true for COVID-19.
• What is recommended today is a very shaky science; this has led to experience based practice. This reality is disastrous or lifesaving, time will decide.

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