CME INDIA Presentation by Dr Basab Ghosh, Internist, Agartala.
COVID-19 is a clinical diagnosis and RT-PCR is to confirm the diagnosis. RT-PCR is positive in 80% cases, rest 20% can be clinically identified to isolate and treat. In COVID-19 treatment ‘timing’ is very important for all treatment options.
As anti-inflammatory drug steroid is lifesaving for COVID-19, but right time, right drug, right dose and right period of time is important.
Clinical assessment for treatment initiation is vital now, as a huge number of COVID-19 cases are now getting home treatment in home quarantine and our guidance should be on that directive to give better coverage to the sufferings.
In home quarantine, hardly laboratory tests or radiological support is possible in most of the Indian states in present pandemic situation. Rather main available tools in home quarantine treatment are clinical thermometer, self-monitored blood pressure instrument, pulseoxymeter, etc.!
Identification of day one of symptoms is vital in clinical guidance of treatment initiation in COVID-19.
If we see the infective course of the highly contagious SARS COV2 virus:
1. Incubation period: It is 3 to 5 days and mostly unidentified.
2. Symptomatic period: After incubation period 7 to 8 days of symptomatic period appears. Once infected, the virus is replicable till the symptomatic phase and the virus is at its peak replicable stage when symptoms start appearing. The incubation period and symptomatic phase are over by 10 to 12 days.
The symptoms are fever, malaise, headache, sore throat, dry cough, diarrhoea, etc. Clinically in mild symptomatic cases the patient can present with fever, dry cough, malaise with increased pulse rate of up to 100 per minute and normal respiratory of 12 to 20 per minute and stable oxygen saturation of >96% as measured in Pulseoxymeter. In moderate symptomatic cases, fever may rise, pulse rate may be >110 per minute, respiratory rate > or = 24 per minute and oxygen saturation <94% in room air.
The virus is replicable and culturable till 9th day of infection or from the day of first symptoms and from 10th day onwards it is non-replicable and non-culturable. But viral remnants are present up to three weeks and in few cases seen up to three months as reported in literature.
3. Pulmonary phase: After incubation period and symptomatic phase, next is pulmonary phase and first 4 to 5 days is early pulmonary phase and next is late pulmonary phase which may appear after 14 days of infection and may last for few weeks as described by experts.
Pulmonary phase or respiratory phase is the phase of inflammatory response due to the presence of viral debris. After symptomatic phase, virus is non-replicable and non-culturable, if viral load is more there will be huge viral debris and those will cause severe inflammation in the host cells. Early pulmonary phase is phase of thrombophilia for 3 to 4 days; thrombophilia is a condition in which there’s an imbalance in naturally occurring blood-clotting proteins, or clotting factors. This can put the patient at risk of developing blood clots. Next there is macrophage over activation syndrome and cytokine storm. Overall there is immune dysregulation in pulmonary phase.
Time for Antiviral treatment: It has to be given in symptomatic phase when virus is replicable; first eight days of the symptoms are ideal for any antiviral treatment including Remdisevir. Remdisevir is indicated in moderate symptomatic cases as mentioned earlier based on reduced oxygen saturation but patient should not be on high flow oxygen / NIV / mechanical ventilation. Even Convelacent Plasma and Interferon alpha are to be given in the first 10 days of symptoms when the virus is replicable. Any treatment module targeting the viral antigen including antivirals has to be initiated in the viral replicable period in both mild or moderate symptomatic cases.
Time for Steroid treatment: The anti-inflammatory steroid should be initiated early in the pulmonary phase to counter the immune dysregulation. Ideal time for steroid initiation is after eighth day of symptoms, when virus is very low replicable and inflammatory response is about to settle down. If steroid is started in the early viral replicable phase i.e. early phase of symptoms then there is a chance that the virus will replicate more.
In pulmonary phase steroid has to be given and start early with the standard dose, then after 24 hours, dose can be increased seeing the clinical and biochemical response and this is the ideal approach as suggested by many experts. There is profound inflammation in pulmonary phase, so anti-inflammatory steroid has huge role to counter the process.
Methylprednisolone is better than Dexamethasone and Dexamethasone is better than Prednisolone. Methylprednisolone penetrates much better into the lungs and binds much better into the glucocorticoid receptors among all steroids, so it gives best anti-inflammatory response. So, for steroid treatment right time, right drug, right dose and right duration is very important.
Pneumonia may develop much before than pulmonary phase on day 3 of symptomatic phase in clinically mild symptomatic presentation. In X-Ray chest, pneumonia is indicated on day 5 to 7, but in CT scan chest it is visible on day 2 to 3. To reduce morbidity and mortality diagnosis of pneumonia should be completed by day 5. Treatment module should be antibiotics to prevent super added bacterial infections, anticoagulant to prevent thrombophilia in pulmonary phase preferably by parenteral LMWH and steroid to counter the inflammatory storm preferably Methylprednisolone or Dexamethasone and all should be initiated by day 5. By the time steroid is initiated actually it is minimum 8th day of symptoms, so increased reliability is not a serious issue at that point. For high risk group like HCWs, diabetes, hypertension, prolonged immobilization, underlying hypercoagulable states, already on LMWH prophylaxis, high LDL, high CRP, etc. anticoagulant should be given on day 1, but steroid initiation is as per the clinician’s decision on day 1 as virus may replicate more because of steroid at the initial days of symptomatic phase. So the dictum for steroid treatment in COVID-19 should be start treatment early when the patient develops pulmonary sign.
Time for Anticoagulant Treatment: Severe COVID-19 disease is associated with features of disseminated intravascular coagulation (DIC) and hypercoagulable states which can manifest as venous thromboembolism (VTE) and / or microthrombosis. Microvascular thrombosis is hypothesized to be involved in hypoxemic respiratory failure in some patients with COVID-19. Autopsy studies show large vessel and microvascular thrombosis, pulmonary hemorrhage and high prevalence of Venous Thrombo Embolism (VTE). In early pulmonary phase there is thrombophilia, which is established after symptomatic phase due to inflammatory response to the presence of viral debris.
So, as per anticoagulant guidelines, all moderate and severe symptomatic COVID-19 patients age > or = 18 yrs. with clinical presentation of pulse rate >110, RR > 24, SpO2 <94%, either hospitalised or in home treatment should receive anticoagulant prophylaxis until contraindicated with bleeding disorders or low platelet counts.
Even with low grade fever with dry cough or sore throat in COVID-19 patients, pneumonia should be suspected in home treatment cases to avoid future emergencies. If clinically pneumonia is suspected by the history and clinical presentation of the disease or pneumonia is confirmed by X-Ray chest or CT scan chest, then LMWH should be initiated on day 5 or in case of high risk group on day 1, as discussed above.
In conclusion we can say, treat the viral period in symptomatic phase with antiviral, treat the immune system in inflammatory phase with anti-inflammatory steroid and use early anticoagulant to avoid thrombophilia in pulmonary phase.
Reference list:
1. www.flccc.net
2. www.evms.edu
3. EVMS critical care COVID-19 management protocol dt. 28th Sept, 2020.
4. Interim clinical guidance for management of COVID-19 (version 1.5), AIIMS, New Delhi dt. 8th September 2020
5. Investigation and treatment protocol for COVID-19 by Apollo Hospitals, Version 28 (updated 26th August, 2020).
CME INDIA Tail Piece
1. Incubation Period:
- Symptoms may develop 2 days to 2 weeks following exposure to the virus.
- A pooled analysis of 181 confirmed cases of COVID-19 outside Wuhan, China, found the mean incubation period to be 5.1 days and that 97.5% of individuals who developed symptoms did so within 11.5 days of infection. For COVID-19.
- Current estimates of the incubation period are in the region of 4–5 days.
2. Alert
- Clinicians should be aware of the potential for some patients to rapidly deteriorate 1 week after illness onset.
- The median time to acute respiratory distress syndrome (ARDS) ranges from 8 to 12 days.
- Lymphopenia, neutrophilia, elevated serum alanine aminotransferase and aspartate aminotransferase levels, elevated lactate dehydrogenase, high CRP, and high ferritin levels may be associated with greater illness severity.
3. Choice of Steroid as per CDC
- Whether use of prednisone, methylprednisolone or hydrocortisone for the treatment of COVID-19 provides the same benefit as dexamethasone is unclear.
- The total daily dose equivalencies for these drugs to dexamethasone 6 mg (oral or intravenous [IV]) are:
- Prednisone 40 mg
- Methylprednisolone 32 mg
- Hydrocortisone 160 mg
- Half-life, duration of action, and frequency of administration vary among corticosteroids.
- Long-acting corticosteroid: dexamethasone; half-life: 36 to 72 hours, administer once daily.
- Intermediate-acting corticosteroids: prednisone and methylprednisolone; half-life: 12 to 36 hours, administer once daily or in two divided doses daily.
- Short-acting corticosteroid: hydrocortisone; half-life: 8 to 12 hours, administer in two to four divided doses daily.
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Great Basab ,very informative a precise article. Proud of you. Keep posting such things .
Thanks for your response
Really the information furnished is of utmost importance for a clinician.
Are steroids indicated with abnormal inflammatory markers but normal CTchest.
I
In presence of abnormal inflammatory markers, with ‘strong clinical findings-suggestive of covid.19 picture, with low spO2’; there lies a strong indication of steroids’ use; even if CT scan ‘seems’ to be normal. As radiological appearances can be delayed/ misinterpretted to be normal because of otherwise hyperemia of the pulmonary parenchyma.
Super article. Clear, precise and simple for the clinician. Kudos, sir. Regards, Dr Rajan TD
MD Skin
Mumbai
Very good information on the covid19 infection it will guide to physicians
very clear and prescise msg Thanks a lot
Dr. Theerthanatha. D. V.
Sir
Very nice & informative.
Thank you sir
Role of Ivermectin and statins??
Very good guide line
Really this great information about COVID-19. It’s quite helpful for frontline Covid warriors. I am sharing this article with many more doctors so that they can rendered the best patient care. It helps to judiciously use of antiviral , steroids and anti coagulants well in time.
Great insights
Dr.ur article is precise & clear cut! ThanQ.
Do you have any data reg itreating preg woman in Labour & undergoing c.section for obstetric indications?
Clear cut idea n concepts when to use
Antivirals
Anticoagulent
Which Steroid
One thing should clear how much time preserve the Immunity devloped by disease
Another thing what treat should give to contact
Excellent Dr B Gosh
you pointed very right Timming is important👌👌
i 100% agree with this
same has been seen while treating covid 19 pts since 5 months
timing is very crucial
most of pt are lost we are wating till oxy saturation drops but reality is inflamatory process is damaging lungs by the time pt seen by physician lungs are more than 50% are damaged
what about tocilizumab
isnt it used in India
Very useful information on covid19.
We can improve our knowledge &add spread the same many more .
Thanx.
Excellent knowledge on covid
Very well explained clinical pathophysiology and management . At what hct score steroid should be started .at one point it is said that even on 2nd day of appearance of symptoms/or exposure Hct may be possitive ,should steroid be started early along with antiviral drugs
A precise informative article…nice
Thanks good informative for all Dr’s ,who are treting covid cases. I have sent this message to my friends living usa,gulf and srilank
Very useful guideline for all drs and peripheral small clinic to early clinical diagnosis and guide the covid19 patient .
Very concise info. Thx.
Can we have more such concise details for pediatric patients?
Very informative thank you
Very good information
Clear precise article. Will help docs with not much ICU experience ,to handle such patients especially in Rural India. Thanks for ur efforts in putting forth the information.
Thank you for kind words
Awesome sir
Very useful guidelines will help in managing this crisis of covid19
Thank you
Very informative and concise. Can you please elaborate on the use of anticoagulants in cases with no clinical signs of pneumonia but ct shows a score of up to 10 ?
Thank you sir. Really a good job. It gives a clear picture of the disease and the course of treatment. It also gives clear idea of when to expect what kind of complication and when to react…. Me and my hubby are Nurses and it really helps us to handle patients at different stages…. Thank you again sir for your valuable posts.
Till what date we should continue anticoagulant and steroids
In this critical situation of COVID-19 management, there are lots of confusion when to initiate three main confirmed treatment oxygen, steroid and LMWH! Here I tried to answer those confusions on the clinical course of the disease.
Very informative ande crisp
Thanks
Very much needed info..when disease gets into fourth or fifth week, Are the lungs really undergoing fibrosis??Or still in acute inflammatory phase with deposition of thick exudate….How long sd v continue steroid and dabagatrin…
Thanks Sir.
Comprehensive and pragmatic approach. I am also having same approach while treating covid-19 cases.
As per my observations-
1. Day 3, 4, 5, and 6 are most critical for monitoring and assessment of the COVID-19 positive case by clinic examination, routine blood investigations and measuring blood inflamatory biomarkers with chest imaging if possible HRCT chest as per CO-RADS classification with CTSS and planning of initiation of treatment accordingly.
2. Day 7 to 14 are days of COVID-19 complications or relaxation days as per above assessment.
These days may be period of intensification of treatment or tapering of treatment.
It’s humble request to all clinicians and patients,
Please Never miss initial 4 days of “clinical window period”
Dr. RS Matoria
Nodal officer COVID-19 for NWR zone
Chief consultant Neuropsychiatrist
Chief public health expert
Central Hospital NWR Jaipur
Very informative ,thank you very much sir
Very valuable information in this pandemic time.
Can we give aspirin and / or clopidogrel as LMWH is difficult to give in home quarantine patients?
I don’t think anticoagulant drug can be replaced by antiplatelet drug, because mechanism of action is different. So, antiplatelet Aspirin can’t be a suitable replacement to anticoagulant drugs which is required here to prevent thrombophilia.
However as Aspirin or Clopidogreal provides some benefits to thrombo-embolic disease, it could be an alternative in conditions where situation doesn’t permit anticoagulant.
Oral anticoagulants are very much available as Rivaroxaban or Apixaban.
A very comprehensive article,but you have used Ramdisavier as the first line treatment, what about flaviperavir? as the patients on home isolation/ quarantine can taken Flavi.tabs now available in pharmacy.pl clarify
For first 5 days of enoxaparin and then Oral Rivoroxaban 15mg is advisable as a oral anticoagulant
Plus tab ecosprin 75 mg Od as a anti platelet agent
Dabagatrin is more preferred to send the pt home…
Very informative article
Please sir, give due credit to dr paul marik, who came with this treatment protocol and published it way before this present article.
Thank you sir for your kind words. If you noticed, in ref list I mentioned EVMS critical care COVID-19 management protocol. This protocol is developed and updated by Dr Paul E. Marik. In MATH+ he used in own ‘HAT’ theory and it is based on Hydrocortisone, Ascorbic acid and Thiamine; of course I didn’t interfere on that. In the fig in my write up I mentioned that, it is collected from that webpage. However, I prepared this article, on the basis of clinical course of COVID-19 as shown in the fig to simplify the approach to the patient more on clinically!
Perfect Analysis and guidelines,it happens exactly same as personally experienced as moderate covid
Very nicely written and informative
One of best
Crisp and to the point , good job , keep it updated , thanks
Very well conveyed and written up to the mark.keep on updating
Nice and informative
Important information in brief and complete.
Very Informative .thanks for sharing. It will be very helpful in treating pt.
Good article.
How long do we continue oral anticoagulant beyond day 15?
Steroids are given even if there is absence of hypoxia ?
Information is very helpful to all doctors working in covid hospital & covid care centers all over the country meanwhile Govt guidelines we have to follow as per state expert committee decides, but more than
covid treatment , I think mentally depression is one of the cause for mortality
Very useful..thanks for sharing
Steroid treatment for how many days
According to severity of cases?
For mild cases can steroid be started in early pulmonary phases
If ct shows ggo ,it should be minimum of 5 days of symptomatic phase and start with MP 16mg bid, and watch inflammatory markers
Great information sir
Excellent
Complete and latest clinical information on. co v id management .I appreciate the efforts of author. Keep giving further info as feasible.
Very nice
Today’s this advice is very help full for our family (doctor)and our favorite patient .
We improve our treatment 99.99%…
Thanks boss
Nice article
Good article
Very much informative.thanks
Ur trial study is very much informative and beneficial for the community. God bless u
Excellent
A real useful article & very informative….
Precious and lifeseving information for both doctors and public .
Very useful information.
Tnx sir.
Excellent article,
found very beneficial.
Excellent and precise information
Very good information about COVID 19
Dr. Paul… Word to word ..
Compilation good
Very much informative for treating clinicians. Right intervention in right time can prevent death.
Well summarized
Thank you Sir. Very much useful for us like residents taking covid duty
Agree in toto. Timing of treatment initiation is vital akin to the game of cricket. Must overdo rather than underdo and land up in complications.
Precise briefing of Covid 19
Very good informative article.
The tapering schedule of the steroid treatment should be mentioned. It is seen that some covid patients are developing hiccups around and of the 1st week. Any comment?
Thanks for such valuable clinical experience and knowledge.
Very nice information. Thanks
Excellent review
Very informative
Very good information given..
Does antiviral drugs really work ?
As in case of H1N1.?
The cost of medicine s is too high ….
What is the role of Azithromycin in early-stage of disease?
Wow !!
Exquisite piece of Knowledge
Excellent lucid presentation of management,clears all concepts in management.
Good One very informative
Respected DrBasab,it is very informative &clears all aspects in management
Dear Dr.Basab it is informative and excellent guidelines for covid 19 management.
Nicely condensed information.
Thank you sir
Excellent information sir
The guidelines says that in severe cases(patients on high flow oxygen, NIV & Ventilator) Inj Remdesivir should be given for 10 days …. here Dr Ghosh is advising not to give. But overall it’s a good article. Thank you Sir
Remdisevir is an antiviral and antiviral should be given in viral stage or symptomatic phase when virus is replicable i.e within maximum 10 days of first symptoms clinically.
As per Apollo guidelines updated on 26th August it should be initiated as I mentioned in article.
Very informative article and useful for all clinicians to take timely decisions on starting antivirals,steroids and anticoagulant
Excellent, well thought article.
Sir thanks very much.
Comprehensive and pragmatic approach.
My approach of managing COVID-19 is also similar-
Respected all🙏
As per my observations-
1. Day 3, 4, 5, and 6 are most critical for monitoring and assessment of the COVID-19 positive case by clinic examination, routine blood investigations and measuring blood inflamatory biomarkers with chest imaging if possible HRCT chest as per CO-RADS classification with CTSS and planning of initiation of treatment accordingly.
2. Day 7 to 14 are days of COVID-19 complications or relaxation days as per above assessment.
These days may be period of intensification of treatment or tapering of treatment.
🙏🙏It’s humble request to all clinicians and patients,
Please Never miss initial 4 days of “clinical window period”
Dr. RS Matoria
Nodal officer COVID-19 for NWR zone
Chief consultant Neuropsychiatrist
Chief public health expert
Central Hospital NWR Jaipur
🤝🤝
Thanks Doc for the article being simple to understand even for those not related to medical profession.At the same time being available to answer deep and specific questions.I am mapping the timeline of my father around 65.We started Favipir on day 4-5 day of symptomatic phase in home quarantine and things have improved since and feeling better and the dose will get over soon spo2 level has been 97 to 98 through out.Wanted to ask for the pulmonary phase due to onset in couple of days. How to ascertain the impact and what are the indicators to watch out for in this phase even if things look positive now.
Dear Dr Ghosh, It is an excellent presentation explaining the concept of the timing of treatment. Very useful information.
Sir, nice elaboration…. Can you explain for how many days one can give anti-inflammatory and anti coagulant therapy for prolonged pulmonary morbidity?
Excellent article with perfect protocols
Very nice Article, as the severity of covid-19 has very clear line of treatment, on right time and in a right manner.
I am a paediatrician working in a hospital and have been reading about covid since 6 months.I am yet to read anything as precise,as crystal clear as your paper Dr Basab!I pray my god to profusely bless you.
Thank you sir
Very good article 👍👌 keep on posting any further information please
Roll of montilucost and ivermectin not mentioned
Nice
Writing from NY where fear of re-emergence is now on the rise. This a beautiful comprehensive yet succinct article at this point in the evolving knowledge of treatment.
I wonder if the Oxford group that recommended dexamethasone knows and accepts your reason for substituting methylprednisone? Let me know. In any event thanks for very good and necessary work.
Thank you for your kind response. Please take care and be safe in the crisis period of USA as a whole!
Which antiviral in mild cases to start with?
Wonderful article Dr Basab Ghosh Sir. It was acute need of time and will save thousands of lives…
Thank you very much sir..
Very useful summary.Picture is getting clearer..Steroids shd be used judiciously.Many patients when advised to start Favipiravir at home buy it but given the pill burden delay starting the drug in fear of “heavy dose dawai”.
Thank you
You have narrated wonderfully, symptoms, clinical features, investigations, treatment aspect.
Thank you for your kind words
Thanks a lot for sharing this essential information, especially about prednisolone and dexa.
It will be very helpful to us in the deciding the line of treatment for COVID 19
Thank you
Very informative and good
State wise prognosis is different,,,can we go with above treatment protocol,,,pan india
This is based on clinical course of the disease and it should be applicable for all COVID-19 treatment.
Very nice informative article Basab 👍👍👌
Keep writing in the interest of huminty in this crisis.
🙏
Excellent information, nicely analysed, to the point
Very nicely explained.. much informative.. thanq for such a clear cut article.
Even keeping timing, response to
medicines differ, so individual variations are very much.Still Time factor has important roll.
Ivermectin 12 mg daily with Doxycycline has shown goode results in mild cases
Inj.trimicilone is also a alternative
Please post information on post recovery duration of steroids, anticoagulants, etc. There is a lot of confusion there.
Very very informative and minute to minute treatment models
Thank for your response
Regarding use of prophylactic oral steroid in post recovery stage i.e in post-covid phase is not recommended in any guidelines as on date.
However prophylactic oral anticoagulant is recommended for all hospitalised patients during discharge and even for home treated symptomatic cases for 45 days. Apixaban 2.5mg bd or Rivaroxaban 10mg od for 45 days is recommended.
Very meticulously planned protocol
Thank you for your response
Very informative
Very good article,
Very informative article yet again from you Basab!! You are doing awesome Job! The fraternity will surely benefit from your article! Proud of you. What according to you is the role of Ivermectin in Covid patients?
Ihave been using ivermectin doxycycline zinc. On day one. Monitor cbc crp blood sugar spo2 temperature Few patients needed steroids The. Problem arose in patient whereinvestigation facilities are not available & or were rtpcr negative. I am empirically using this since. 3 rd week of April. This was shred at various platforms. & also. Dr. K k Aggarwl
Treatment with steroid in early viral stage or early symptomatic stage will increase viral replication leading to higher viral load and it may be harmful in inflammatory stage due to increase inflammatory response due to increase viral load. So, as per scientific literature anti inflammatory steroid is safe in inflammatory stage as shown in the fig in the article.
Nicely summarized.
What about use of aspirin?
Choice of antibiotic.
Thnx.
Very nice respected sir it’s in depth written as I have seen you are answering all queries well I also want to ask one question. Best time to start steroid you mentioned is day 8 and this is for antiinflammatory action and also you mentioned pneumonia occurs between 3-5 days and in that time we must start steroid in viral replication phase also so my question is in high risk group can we start steroid on day 2 as we all know once pneumonia develops it’s all complicated then and also we know starting steroid on day 2 will increase viral load too but in view of more complication once pneumonia developed how should we evaluate benefit v/s risk of starting steroids on day 2 in high risk patient.
Nice article
Best time to start ani inflammatory steroid is in the inflammatory stage if indicated clinically by pulse rate >110, RR >24, SpO2 95% patient.
If laboratory tests possible then always best is to confirm inflammatory response by raised inflammatory markers, otherwise go with clinical judgement and start steroid to avoid further deterioration.
For your kind notice, I mentioned in some cases pneumonia may develop in symptomatic phase (before pneumonia phase) might be in 3 to 5 days of the symptoms and in such cases steroid may be initiated in day 5 , which will correspond to 8th of viral replication phase, chance of increasing replication is less.
Regarding high risk whether steroid should be given on day 1 or 2 , it should be clinicians choice and if possible BETTER to avoid in early viral stage of symptomatic phase.
We must remember for treatment of viral pneumonia steroid is not must, rather controversial, in COVID-19 in cases steroid is must in pneumonia phase which is actually a state of inflammatory reaction to viral debris.
Best time for steroid is after 10 to 12 days of first symptoms.
Thankyou so much sir
Thank you sir for this nice and informative article.
But how many days continue stories initiated after 10-12day of first symptoms when pt. have no problem and spo2 remaining 97%
Thank you sir for this nice and informative article.
But how many days continue steroids initiated after 10-12day of first symptoms when pt. have no problem and spo2 remaining 97%
Nicely Summarised
But Some Information About OXYGEN THERAPY Depending On Spo2 & HRCT Could Also Be Added.
Brief Regarding VIRAL LOAD Also.
Role of methylene blue??
I have started pulse dose methylprednislone 500 mg od for 3 days
I have also given few patients urokinase 5 lac of for 3 days
Hope for the besT
Hello Dr.bhilwara…i wld like to know abt ur experience of urokinase….i have been using pulse doses since the starting and it has magical effects ,planned to use tenecteplase but cldnt use till now……started usring acitrom im those with high d dimer levels and that proved to be of some benefit…..
Very good summary no doubt but mantionabout off level investigational drugs
You have mentioned about which drug, sir? Actual intention of the article is to highlight and simplify the time of initiation of important group of drugs on the basis of clinical course of the disease
Most unpredictable viral infection ,Clinical features & lots of confusion With treatment. But Dear Doctor you have perfectly outlined & Nicely drafted the facts . It will help us all every time.
God Bless you.
Thank you sir
Very informative . Thanks for sharing very precise notes .My question is if CRP and Dimer are decline to normal but S Ferritin still rises then what to do ?
Q2 What to do with higCRP level on day 20 ?
Serum Ferritin is an important marker of severe inflammation and increases with the severity leading to cytokine storm. However isolated heperferitenimia is not clinically significant if other inflammatory and cytokine markers are not raised.
Regarding next query, high CRP value on day 20 might be indicating super added bacterial infection and NLR value of >3.14 will be confirmatory alongside high CRP value.
Thank you Sir
Very informative. Excellent clinical guide for covid-19 management.
Role of Ivermectin and Doxycycline for prophylaxis and treatment of mild symptomatic patient??
Is Favipiravir recommended for home isolation patient both mild symptoms or asymptomatic in same dose.
Ivermectin and Doxycycline along with Zn are having satisfactory results as experienced by many experts.
Flavipur is widely used in mild symptomatic cases, but not encouraged by experts and not included in any guidelines as on date.
Very useful information sir,thank you.
7Very informative keep on for best service of humanity &Doctors
Thank you sir
Very useful compile study.Thanks.
Useful info and practical also . Can be utilised as an comprehensive treatment guide .
Thank you
7 TIPS by Dr Atri Gangopadhyay, Pulmonologist, Ranchi seems smooth sailing in untidy sea:
1. Any chest / throat symptomatic, go for COVID testing first. Don’t wait for 2-3 days.
2. If COVID positive, advice CT chest, D dimer, CRP.
3. Extensive chest lesions- admit, Remdesivir, Antibiotics (doxycycline is the best friend whatever others may say).
4. Limited CT findings- NO ANTIVIRALS, no antibiotics, only micronutrient and antiallergic.
5. If COVID negative-Xray, treat for pharyngitis, with repeat COVID test after three days if deterioration.
6. In admitted moderate- severe COVID, repeat CT only after 72 hrs if deterioration/ no improvement. No repeat CT if improvement. You may repeat CT at discharge to know about post COVID.
7. Xray may be repeated in ICU admitted patients based upon clinical judgement.
However virus should be treated in the viral stage of symptomatic phase and anti inflammatory steroid should be used in inflammatory stage after viral replication stage.
Very much informative and useful
Thanx
Most informative and clear cut treatment in different stages of disease, thank you.
Welll written. Kindly Comment on Ivermectin, HCQ, Doxycycline & Azithromycin??
No role of Artesunate
Useful and narrated COVID 19 story
Simple and precise.Quite informative.
Nice article, thanks.
Very informative. .
Thanx for sharing. Regards
You have compiled all the information on practical ground for timely and proper dosing of drugs for COVID19 management Otherwise each and every single pts treatment depends on his condition and clinicians should take decision accordingly.Keep updating me. Thnx Dr Ghosh.
Nice and precise in current time of half baked information deluge.
Yes. Very precise. Very informative . Touched all points. I believe Favipiravir has a greater role in mild disease early in the course, 1st week initiation. Tocilizumab has very little role.
HCQ is still in ICMR, AIMS and govt protocols, any comments?
🙏👌🙏
As per my observation-COVID-19 Deaths-
Those having anosmia and loss of taste having very less mortality.
Those having GI symptoms having less mortality.
Those having renal diseases maximum mortality noted.
Excellent
How about ivermectin/Fabiflu
Steroids for how long in mod to severe cases
LMWH for how long
Very informative and timely
On the HRCT Thorac,How does the CO- RADS score and CT severity index, affect the treatment protocol
Concise, but very informative. Thanks for such a beneficial Article..👌
Thank you
The topic is very good.
Anti virals in early phase of disease
Anticoagulants is pulmonary phase is very good , specially in diabetics.
Steroids are very good in hypoxia patients specially in diabetics.
Pls publish details what doctors need to safeguard themselves from getting infected in incubation period and symptomatic period
A very useful guide, however the best combination for elderly patients and diabetes patients amongst following please narate anybody
Remdesvir
Ivernectin
Steroids
Azithromycin
Doxycycline
Aspirin ko/Clopidrogel
Plasma therapy
For the betterment of our fraternity
Excellent*.
keepit up*. Dexamethasone is tested to be effective in covid19 and not hydrocortisone (mineralocorticoid). Methylprednisolone , pednisolone well-known antiinflammatories . Please Give reference studied for covid19. Have a Nice time.
Very good informative article.
The tapering schedule of the steroid treatment should be mentioned. It is seen that some covid patients are developing hiccups around and of the 1st week. Any comment?
Really good guideline for home quarrentine.
Thank you sir
Excellent information.
Comments on duration of steroids & lmwh. What about cytokine strom? Your opinion about genetic predisposition of severity of disease.
Dr. Paul Marij, the inventor of MATH+ protocol, has similar views.
Brilliantly presented Dr. Basab.
Congratulations
Very useful guidelines
Thank you
Nice , very concise, useful and lucid presentation.
Dr. Paul Marik, the inventor of MATH+ protocol, has similar views.
Brilliantly presented Dr. Basab.
Congratulations
Dr Ghosh,
Excellent guideline sir, to avoid all confusions and mis-communications floating around. Well elaborated and explained for clear understanding of both medical and non-medical community. Great help.
Sir, as some comments indicated here, there exists a confusion on post- recovery phase. Is it possible to add an additional section for this?
A) symptoms again after 5 or 6 weeks of recovery, fever etc.
B) Heavy weakness post recovery if continue beyond 4 weeks
C) High CRP level after 5 weeks of recovery
D) Reducing haemoglobin towards 12 and below, post recovery
E) what to continue? What not to continue?
Your Guidance is highly appreciated and relevant.
Sir.
Thank you for your response and kind words. COVID-19 is only 10 months old disease and we are gradually gathering knowledge by clinical experience. Researchers will answer many unanswered questions in future!
However post-covid is a real concern now as the disease is getting old every day. COVID-19 is a thrombo-embolic disease and post-covid consequences are mostly related to that.
Till now during discharge from hospital prophylactic use of oral anticoagulant is recommended for 45 days either Rivaroxaban 10mg od or Apixaban 2.5mg bd alongside rest, nutritious diet, breathing exercises and other symptomatic treatments, if any.
Post-covid is a huge and different topic which must require separate attention and all your valuable points should be covered!
Dear Dr.Basab it is informative and excellent guidelines for covid 19 management.
Nicely condensed information.
Thank you sir
Right information at right time
20 weeks pregnancy Primi pt ,55 Kg ,height 154cm wiih fever and cough
CRP21mg/L ,D dimer
2.12 ng /dl ()<0.5 ) TLC 3100,DLC 92 ,5 ,3,0,0 and platelets 122 lac and RTPCR +
X-RAY and HRCT avoided
Should I keep her on HCQ ,0.4 LMWH and Augumentin. Should I start methylprednisolone 16 od
Plus other supportive medicines
What else should I do ?
What I believe in the clinical course of the disease day one of symptoms identification is important and thereafter treat with antiviral in the viral stage, treat with anti inflammatory steroid in the inflammatory stage and treat with LMWH if indicated in any stage.
I think you are in the right track. NLR is very high so antibiotic coverage should be sufficient to avoid super added bacterial infection. If possible culture should be sent. HCQ as antiviral in viral stage is ok evenin pregnancy. LMWH as indicated are ok as I believe to target thrombophilia, but many experts wait till oxygen saturation falls. Steroid is not indicated as I believe, but according to day of infection and clinical presentation, you can start if situation demands in inflammatory stage. Please see the fig in the write up.
You are doing tremendous job, madam.
Thank you Sir.
Thanks good informative for all Dr’s ,who are treting covid cases. I have sent this message to my friends living usa,gulf and srilank
Thank you sir.
In this pandemic crisis, if my write up could help my clinician friends and few lives are saved, it will be the great thing I ever dreamt!
Let us fight together in this covid crisis.
Very useful n precised information about treatment of Covid 19.what are the roles of Azithromycin, doxicycline n favipiravir in initial days of treatment of Covid 19?
Very good information about covid 19
Very precise and good information for everyone.You have rightly emphasized that right time and right medicines are the key to save lives in covid era.Because of lack of knowledge we are loosing people.
Thank you very much DrBasab Ghosh for sharing valuable information.
Great article and highly informative👏👍
Great precise and to the point article.
Very very informative.
Congratulations Dr.Basab.
Dear sir thanks for your courtsey and help to provide the covid treatment in digestive form. Dear sir God Bless u to achieve more u want.
Nice detailed ,informative one.
Thnks
Very informative and clarifying article on timely management of covid.thank u
Thank you for this very informative article with clear guidelines. A brief summary of this must be pasted in every physician’s office so that no time is wasted.
Nice ,updated information
Pls do updated with latest one in future
Sir,very high risk pts like heart disease ,COPD ,severe asthma , ILD( NSIP) ,uncontrolled diabetic etc . Such pts should be hospitalised from day one .Then such pt to be put on Fabiflu or straight to start Ramdesevir with LMWH ??
Very informative sir
Thanks for circulating
The drug timing,dose and duration given is very useful for medical professionals since many are preferring home quarantine and simultaneous treatment by family physician which is welcome unless otherwise indicated for hospital admission.
Sir,very high risk pts like heart disease ,COPD ,severe asthma , ILD( NSIP) ,uncontrolled diabetic etc . Such pts should be hospitalised from day one .Then such pt to be put on Fabiflu or straight to start Ramdesevir with LMWH ??
Flavipur is used by clinicians in mild symptomatic cases with fever, mild dry cough, sore throat, etc in home quarantine and also in hospital treatment. If given should be in the early symptomatic stages. However many experts don’t prefer this drug at all and no guidelines used it in treatment protocol.
Remdisevir was in the experimental drug list till last wk of August. But in Apollo protocol updated on 26th August, it is in the treatment module as an important drug in moderate symptomatic cases where pt requires external Oxygen supply but not on HFNO/ NIV/ Mechanical Ventilation. Being an antiviral it should be used in viral symptomatic phase.
Thank you .But my concern is to start Fabiflu or Ramdisivir in very high risk pts with ILD,heart pts in early viremia phase .
According to Dr Guleria of AIIMS Remdesevir and steroid are only to be started in moderate cases with hypoxia .Remdesevir having some immunomodulatory drug should better avoided in early viremia phase ,it may be rater harmful.
Flavipur can be avoided in present scenario as hardly any effect is seen by experts in any stage.
Of course Remdisevir has to be given in moderate symptomatic with hypoxia as I am telling you, but for Donald Trump it is used in early symptomatic phase, so I hope we are in the right track of discussion.
Thank you . Let’s what changes come in coming days .Nice discussion .
Excellent, well thought article.
A comprehensive treatment of Covid 19 going from mild to moderate is to initiate anti viral therpy rather than waiting for severe stage to reach… steroids..anti coagulants are timely drugs to help one recoup with the crisis…. thank you for updates
Thank you
If this is accepted by heart then what American doctors are following in the treatment of their President Donsld Trump.
In which phase Trump was admitted to Military Hospital and in which phase was he discharged to go back to white house?
Good treatment protocol.Thanks Dr Basab.
Any role of hcqs in prophylaxis of disease.
As per ICMR yes. Even I took for >3 months till got COVID-19, might be being high viral load also Whoever took HCQ got less symptoms and recovery was mostly uneventful.
Hello sir, What’s ur suggestion regarding
1.thrombolysis in severally hypoxic pts and pts with high DDIMER levels..?
If yes then which thrombolysing agent to prefer ( streptokinase, alteplase or tenactaplase) 2. Anticoagulant of choice for discharge medication ( Ward, Acitom, Dabigatron or Rivaroxaban) and can it be combined with Aspirin and Statins Thank u
Though steroids are very important,please elaborate further about their use in presence of GGO,S but spo2 >94%
Very useful & informative;thanks for sharing
Thank you
Academic, crisp and clinical article. 👍
Thank you
If this is accepted by heart then what American doctors are following in the treatment of their President Donald Trump.
In which phase Trump was admitted to Military Hospital and in which phase was he discharged to go back to white house?
If this is accepted by heart then what American doctors are following in the treatment of their President Donald Trump.
In which phase Trump was admitted to Military Hospital and in which phase was he discharged to go back to white house?
Thankyou for useful information
Nowadays with change of weather we are getting lot of URTI cases. Should all of them with comorbidities undergo covid 19 testing. Should all of them be started on LMWH and steroids
Most clear picture of the disease COVID 19, and judicious use and role of various drugs in the management.
VERY CLEAR.
Thank you sir
Nice precise information and guideline based on scientific evidence.Thanks for sharing
Thank you
The article is very precise and informative thank you very much.
What special care in the treatment of pts with type two diabetes and hypertension under control and what is the role of ACE (angiotensin converting enzyme) and its effects on these patients.
Resp.sir, you article is very informative . Gives clearcut idea for treatment. Please let me know ., What special care is needed in treating patients with hypertension and type two diabetes under control and the role of ACE ( angiotensin converting enzyme and its effects on these patients. Thanks..and regards.
Regarding T2DM treatment both Metformin and Gliptin have shown promising results in COVID-19 beyond glycemic control. Glycemic control is very very important in covid time like all critical care management. Regarding BP control, change of any antihypertensive is not needed, certainly good BP control has extended benefits. Heart patients hospitalized with COVID-19 can safely continue with ACEI or ARB, according to the BRACE CORONA trial.
Role of mefenamic acid as anti inflammatory and also as antipyretic in vividh .
Role of satins ?
Please discuss .
Wonderful precise yet uptodate article.
Hello sir,
What’s ur suggestion regarding
1.thrombolysis in severally hypoxic pts and pts with high DDIMER levels..?
If yes then which thrombolysing agent to prefer ( streptokinase, alteplase or tenactaplase)
2. Anticoagulant of choice for discharge medication ( Ward, Acitom, Dabigatron or Rivaroxaban) and can it be combined with Aspirin and Statins
Thank u
So far, I never read about thrombosis in stead of LMWH in any stage of symptomatic COVID-19.
During discharge either Rivaroxaban or Apixaban can be advised as anticoagulant, but anticoagulant combined with Aspirin is not advised by any experts or guidelines.
However Statin has useful role in COVID-19 treatment as it has pleotrophic effect which helps in anti inflammatory stage.
Correction for the above comment: The word “thrombosis” will be replaced by “treatment with thrombolysis”.
Very very informative article It will guide physicians & general practitioners in the initial stage of CORONA management. Thanks for the article
It is most informative articles to all medical practitioners and is realy appreciable by all health professionals. Thanks a lot for sharing this article.
Thank you for your kind words. If my write up could serve the humanity!
Extremely good write up, which
has practical implications
Congratulations Dr. Basab Ghosh,
Keep it up…👍
In depth and good information. Thanks
Awesome article , very informative.
Extremely good write up, which
has practical implications
Congratulations Dr. Basab Ghosh,
Keep it up…👍
Congratulations ,Dr. Basab Ghosh,for the meticulous presentation
Thank you each and every one for your kind words. If this write up extends some help in COVID-19 crisis, it will be service to humanity!
Explained very clearly.
Able to understand as a medical practitioner and a COVID 19 pt myself.Thanks for the article.
What about newer oral anti coagulants? esp when D-dimer is in 4-5 thousand with patient with no symptoms and normal vitals
In such cases prophylacticaly Inj LMWH 40mg s/c od for 5 days, followed by Tablet Rivaroxaban 10mg od or Apixaban 2.5mg bd, for 4 weeks, would be a good choice as many experts appreciated.
I do agree with all the concepts you have offered in your post. They are really convincing and will definitely work. Thank you for the post.