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UNIVERSITY HOSPITAL MONKLANDS

CLINICAL POINTERS & TIPS FOR MANAGING PATIENTS WITH SUSPECTED COVID-19

Lead Authors: Dr Andrew Blunsum, Dr Peter Davies, Dr Timothy Jones and Dr Adam Williamson

Reference Group: UHM Bronze Clinical Forum Members

This is a brief guide to the practical aspects of managing suspected COVID-19 patients at University Hospital

Monklands for frontline clinicians.

*This is an evolving area! Guidance and evidence is rapidly changing. Please discuss individual cases with colleagues or review more up to date

guidance if required*

Please contact Andrew.blunsum@nhs.net if anything is unclear or if there’s anything we can add that would be useful- suggestions welcome!

VERSION 4 UPDATES:

1. Screening and triage

2. HIV testing

3. Diabetic recommendations

4. Anticoagulation

5. Delirium

6. COVID HDU update

7. Discharge to care home criteria

Quick Reference:

ASSESSMENT Page 2

BASELINE INVESTIGATIONS Page 3

TESTING AND MANAGEMENT Page 4

NON-INVASIVE RESPIRATORY SUPPORT Page 6

IPC AND STEPDOWN Page 8

PALLIATIVE CARE AND DEATHS Page 8

Appendix 1. Admission pathway Page 9

Appendix 2. NOTES ON ROUTINE MEDICATIONS IN COVID PATIENTS Page 10

Appendix 3. Repeat testing pathway Page 11

Appendix 4. Discharge pathway Page 12

Appendix 5. POTENTIAL FUTURE DRUG TREATMENTS Page 13

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Novel coronavirus (COVID-19) Guidance for secondary care

TRIAGE FOR COVID-19

All patients will undergo triage in Primary care and/or the UHM Emergency Department for symptoms compatible

with possible underlying COVID-19, based on the case definition above. Patients identified as ‘possible’ COVID-19

cases who require hospital admission will be transferred to MAU (‘red stream’), rather than AMRU (‘green stream’),

for a detailed assessment.

CLINICAL ASSESSMENT AND ADMISSION PATHWAY

A clinical assessment will be made of ‘possible’ cases in MAU by a senior decision maker. Patients should be

classified as ‘low’, ‘moderate’ or ‘high’ clinical suspicion of COVID-19 based on the history, examination findings,

chest X-ray and blood test results. All these ‘possible’ patients will be tested for COVID-19 and will need to remain

within a ‘red stream’ clinical area (MAU or a ‘red’ down-stream ward) until the COVID-19 PCR test is back; however,

the COVID-19 PCR result must be interpreted in light of the clinical suspicion of COVID-19, rather than in isolation.

See Appendix 1 for Admission Pathway for further details

EPIDEMIOLOGICAL SCREENING FOR OVER 70s (NOT BASED ON CLINICAL SUSPICION)

All patients >70 should be screened for COVID on admission and then every 4 days

Patients should be managed on ‘green’ areas pending these results if there is no clinical suspicion of COVID

ASSESSMENT HPS Case definition for individuals requiring hospital admission: Clinical or radiological evidence of pneumonia OR Acute respiratory distress syndrome OR Influenza like illness (fever ≥37.8°C) and at least one of the following respiratory symptoms, which must be of acute onset: persistent cough (with or without sputum), hoarseness, nasal discharge or congestion, shortness of breath, sore throat, wheezing, sneezing) OR Loss of/ change in sense of smell or taste OR Clinicians should also consider testing any patient in hospital (whether a new admission or existing patient) with new respiratory symptoms, fever or worsening of a pre-existing respiratory condition. Be alert to the possibility of atypical and nonspecific presentations in older people with frailty, pre-existing conditions and the immunocompromised. Inpatients must be assessed for bacterial sepsis or other causes of symptoms as appropriate.

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CLINICAL EXAMINATION AND PPE

COVID-19 infection is usually transmitted by droplets either directly or indirectly. When patients cough or sneeze,

droplets are transmitted at up to 1m distance. Infection is transmitted through contact with droplets, either by

direct exposure to mucous membranes. Fluid resistant mask, apron and gloves with frequent hand washing are

protective apart from when aerosol generating procedures (AGP) are performed. FFP3 masks should therefore be

reserved to protect staff when AGP are being performed.

Guidance on appropriate PPE, and what constitutes an AGP is available via the PHE website:

Public Health England - COVID-19: PPE for Secondary Care Environments

COVID-19: personal protective equipment use for NON-AEROSOL generating procedures

COVID-19: personal protective equipment use for AEROSOL generating procedures

Masks

Current PHE-HPS advice for secondary care is that fluid repellent surgical masks should be worn in all clinical areas

irrespective of whether COVID suspected or positive patients are being managed. FFP3 masks should only be used in

areas were AGPs are occurring and should be used on a sessional basis.

Masks can be worn for multiple patients on a “sessional basis” and removed if wet, soiled, uncomfortable or leaving

the clinical area. Aprons and gloves should be doffed appropriately between patients.

** Do NOT partially remove masks in clinical areas e.g. hanging loosely. Do NOT touch masks following patient

contact. Remove and replace if uncomfortable**

Stethoscopes

Think carefully about whether auscultation will affect your management of the patient or change your clinical

appraisal, use should be minimised.

If using a stethoscope consider how you remove your stethoscope to avoid self-contamination. Be sure to

decontaminate your stethoscope on leaving the room.

BASELINE INVESTIGATIONS

Routine investigations are recommended as per clinical judgement and differential diagnosis, to include FBC, U&E,

LFT, bone profile, coag, CRP and chest X-ray where indicated. No established prognostication is available.

Of note:

o Lymphopaenia and mild thrombocytopaenia (but normally >100) are most common findings.

o Troponin, LDH, CRP and Ferritin are commonly elevated

o Consider an HIV test for anyone presenting with an acute respiratory illness, especially with abnormal radiology.

This is both to avoid missing an HIV patient presenting with an opportunistic infection mimicking COVID-19 (e.g

PCP) and also to identify those with COVID-19 with underlying immunosuppression.

Radiology

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CXR changes:

Typical findings are patchy peripheral and basal ground glass changes that may be unilateral or bilateral.

Pleural effusions, lymphadenopathy, cavitation and masses are uncommon.

Patients with radiological evidence of COVID pneumonitis should have a follow-up CXR at 12 weeks. This should be

arranged at the time of discharge.

CT scans:

The Royal College of Radiologists do not recommend routine use of CT scanning to establish a diagnosis of COVID,

particularly when viral PCR testing exists.

Surgical Patients:

Where abdominal surgery is being considered, a combined statement from the royal colleges of surgery suggests

where an abdominal CT scan preoperatively is required, clinicians should have a low threshold to extend to a CT

chest to risk stratify. However a negative CT chest does not exclude COVID-19.

Royal College of Radiologists position on the role of CT in patients suspected with COVID-19 infection

DIAGNOSIS

Sensitivity of PCR testing for COVID 19 is most reliable between 1 and 5 days since onset, with Scottish data

suggesting >90% sensitivity. Sensitivity is improved by good sampling technique. Please consult the videos below to

optimise sampling technique.

HPS – COVID Swab Testing Video

It is well recognised that swabs are less likely to be positive in patients presenting after 7 days. In such cases multiple

repeat testing is of little benefit and risks compromising testing capacity.

Patients with a low clinical suspicion of COVID-19 and a single negative PCR result can be stepped down to the ‘green

stream’, with Trak updated to reflect this result (green ‘splat’). Patients with a moderate or high index of suspicion

(characteristic radiological findings, isolated lymphopenia, typical clinical history) and an initial negative PCR result

are more challenging to assess and categorise; they should remain in the ‘red stream’ and with Trak reflecting

possible COVID-19 (purple ‘splat’) whilst undergoing further evaluation. The evaluation pathway indicated in

Appendix 3 should be followed.

MANAGEMENT

Current treatment is supportive care. Please consider the following:

Antibiotics

Common bacterial infections will continue to occur in absence of COVID-19 and should be managed as per existing

NHS Lanarkshire guidelines. Remember to review for potential intravenous to oral switch (IVOST) within 72h.

Monklands Antibiotics Guide or ‘Antimicrobial’ App SAPG Guidelines for COVID-19 Patients

Antibiotics are not routinely required, consider stopping if COVID PCR positive. If bacterial pneumonia or IECOPD is

suspected, e.g. production of purulent sputum or neutrophilia, see local guidance for CAP

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Notes:

- Avoid co-administration of Doxycycline with multivalent cations (iron, calcium, magnesium, aluminium, zinc, sulfacrate;

enteral feeds, oral supplements e.g. Ensure). These chelate Doxycycline and reduce serum levels by up to 90-100%

- Avoid Co-amoxiclav and fluoroquinolones in frail elderly patients

- consider Doxycycline rather than clarithromycin if concern re atypical organisms

Routine Medications

Decisions about withholding routine medications should be made in the normal way. Advice about specific routine

medications which may affect COVID-19 outcome can be found in Appendix 2.

Anticoagulation

The evolving data suggests that COVID-19 is pro-thrombotic, especially in critically ill patients. Below is a summary

of Lanarkshire guidelines:

- Consider D-dimer and coag screen in inpatients when confirmed positive for COVID-19

- All COVID-19 hospitalised patients, without contraindications, should receive prophylactic LMWH unless

platelets <30 or fibrinogen <1g/l

- Double dose prophylactic clexane considered only in ICU patients

- CTPA/ Doppler should be based on clinical features, not adequately explained by ARDS rather than raised d-

dimer – which are commonly positive in COVID-19

- Consider switching to LMWH from warfarin, if any difficulty with INRs/ clinical deterioration, and from

DOACs if deteriorating renal function or anti-viral interactions.

- Aim for DOACs in new AF/ VTE in to limit pressure of anticoagulation service.

Fluid management

Shock is rare on admission, even amongst those who are critically unwell. Over-exuberant fluid resuscitation may

worsen COVID-19 ARDS. Equally patients developing acute kidney injury appear to have a worse outcome. The aim

should be normovolaemia.

Delirium

Delirium may be challenging to manage in COVID-19 positive patients. The British Geriatrics Society has released

consensus advice which focuses on early recognition and non-pharmacological management where possible. Where

pharmacological management is essential due to the risk of harm to the patient and others, patients should be

monitored closely and we should be mindful of cautions and contraindications (eg prolonged QTc or Parkinsonism

and Haloperidol).

See appendix of the below document for pharmacological treatment options. Please discuss with senior decision

maker (registrar or consultant) if unsure. DELERIUM GUIDELINE LINK

Nebulisers

Advice from PHE and HPS is that nebulisation is not a viral aerosol generating procedure. However, if patients can be

managed with multi-dosing and spacers, this may avoid the need for nebulisation.

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ESCALATION AND USE OF HACP/ TELP

Early discussions with patients and families with COVID-19 should reflect the risk of deterioration. Mortality is closely

related to: 1) age, 2) frailty and 3) co-morbidities. Risk factors for poor outcome include: pre-existing

immunosuppression, renal failure, diabetes, HTN. NICE advises the use of the Clinical Frailty Score in patients over

the age of 65 in aiding decision making for admission to ITU. (NICE COVID-19 Critical Care)

At admission a clear escalation plan (HACP) should be made for ALL patients, including whether they should be

considered a candidate for discussion with intensive care. A dedicated HACP (TELP) for use during the epidemic

has been produced and should be used.

Timing of referral to critical care

Early recognition of the deteriorating patient is important. Respiratory failure for COVID patients can rapidly

escalate. Referral to ICU should be prompted if:

Rapidly escalating oxygen requirements…. OR

60% oxygen requirement to maintain saturations > 93% ….OR

40% oxygen requirement to maintain saturations > 93% and unclear if candidate for IPPV

RESUSCITATION

Cardio-respiratory resuscitation is considered to be an Aerosol Generating Procedure (AGP) by the UK Resuscitation

Council and their guidance on PPE is currently being followed in Lanarkshire. As such full PPE (gown, FFP3 mask,

gloves, eye protection) is currently advised for resuscitation. This includes CPR as well as airway management.

Resuscitation Council UK Statements on COVID-19

However, please note that that HPS/ PHE disagree with CPR being classified as an AGP and are currently in dispute

with the Resuscitation Council regarding this important issue.

NON-INVASIVE RESPIRATORY SUPPORT (NIRS) – CPAP, BIPAP AND NHFO

The preferred treatment modality for respiratory failure in COVID-19 is early transfer to ITU for intubation and

ventilation. (see ‘Escalation and use of HACP/TELP’ above)

BiPAP, CPAP and NHFO are aerosol generating procedures and as such any potential COVID patients on these require

nursing in full PPE with FFP3 masks, surgical gowns, visor and gloves. If used, NIRS must be delivered within the ‘red’

medical HDU area, Ward 2, in a negative pressure room (see below).

Indications for CPAP for in patients who are COVID 19 positive

CPAP is emerging as a potential option for selected patients with COVID-19. The main role for CPAP is as a bridge to

ITU (e.g. if ITU capacity is under severe pressure) and sometimes as a step-down option from IPPV. CPAP is less

frequently appropriate in patients who are not considered suitable for escalation to ITU for IPPV, but may sometimes

be used for patients where HDU is the agreed ceiling of care.

An SOP is available for the initiation of CPAP on Ward 2. A SIGN guideline is also available.

https://www.sign.ac.uk/ (see CPAP guidance Appendix 1)

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Indications for BiPAP in COPD patients who are pending COVID-19 result:

The role for BiPAP in severe COPD may be limited in the context of the COVID-19 pandemic; early discussion with the

on-call medical consultant is mandatory. If a COPD patient is appropriate for ITU and IPPV, they should usually be

referred to ICU rather than started on NIRS.

BiPAP is generally reserved for patients who are felt to have a ‘pure’ exacerbation of COPD with no x-ray changes,

who have failed to respond to proper initial medical management (steroids, nebs, titrated oxygen) and have serial

gases showing non-resolving acidosis and elevated pCO2. Those patients who do have COVID perform poorly on

BiPAP.

Faculty of intensive Care medicine standpoint

COVID High Dependency Unit – Ward 2

Ward 2 functions as the ‘red’ medical COVID HDU (7 beds); it also has a number of non-HDU ‘red’ beds. A separate

protocol on criteria to Ward 2 HDU is available to provide further detail. These reflect the same admission criteria as

for Green HDU.

ALL admissions to ward 2 COVID HDU MUST BE DISCUSSED WITH THE WARD 2 CONSULTANT ON CALL (9-5PM), or

ON-CALL MEDICAL CONSULTANT (5PM – 8AM). Patients in MAU being considered for HDU/NIRS should be

discussed initially with the on-call Acute Physician covering MAU (08.00 -24.00), prior to contacting the Ward 2

consultant. If the patient is for potential full escalation to ITU, then the ITU consultant should also be consulted.

PALLIATIVE CARE

Early use of SC/IV bolus medication in those with severe symptoms are recommended, alongside early

commencement of syringe pumps to minimise nursing exposure.

Oxygen in the palliative setting has a limited role in treating the sensation of breathless and should be weaned down

if patients are not symptomatically benefitting. Instead the use of Morphine and/or Midazolam is recommended as

first line treatment in managing dyspnoea. Suction is not recommended for secretions. Consider Hyoscine

Butylbromide or Glycopyrronium. In terminal delirium or restlessness suggest combination Midazolam and

Levomepromazine. See guideline below for dosing. Scottish Palliative Care Guidelines – COVID-19

CONFIRMATION OF DEATH and DEATH CERTIFICATION

Confirmation of death should follow the usual process, assessing for signs of life. If a stethoscope is used avoid self-

contamination when removing from ears, and wash with clinel wipes. The usual PPE should still be worn.

Death certification

(i). The use of the terms COVID-19 disease or SARS-CoV-2 infection as cause of death are both acceptable.

(ii). COVID-19 disease is a notifiable disease. Part D. (Hazards), DH1 should be ticked

(iii). Deaths related to (or presumed to be related to) COVID-19 are exempt from the requirement to report them to

the Procurator Fiscal, unless: a) the deceased was resident in a care home (this includes residential homes for

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adults, the elderly and children) when the virus was contracted or (b) there are reasonable grounds to suspect that

the deceased may have contracted the virus in the course of their employment or occupation

Usually, where a patient dies from a disease or organism which poses an acute and serious risk to public health, the

death should be reported to the Procurator Fiscal. This decision will be reviewed in July 2020.

Discharge summaries for deceased patients should include the co-morbidities suffered by the patient to aid with

coding.

https://www.copfs.gov.uk/

STEPDOWN FROM COVID-19 IPC MEASURES AND DISCHARGE FROM HOSPITAL

Please consult Appendix 4 for the agreed pathway for the stepdown of infection prevention and control (IPC)

measures and discharge considerations. This pathway is a summary of UK/ Scottish guidance.

HPS – stepdown of infection control and discharge procedure

Discharging COVID-19 positive patients home

HPS guidance advises that patients who are clinically stable or have recovering respiratory function are potentially

suitable for discharge, irrespective of their COVID-19 status. However, the patient’s clinical and home

circumstances should always be carefully considered prior to arranging discharge.

All patients must be given written and verbal information at discharge covering worsening advice, household

isolation, shielding and any other relevant issues.

Discharging COVID-19 patients to a care facility

This is a very sensitive area and must always be carefully considered and planned, with appropriate multi-disciplinary

advice sought. Junior doctors should always discuss these discharges with their consultant.

All patients should be isolated for a minimum of 14 days from symptom onset, or first positive test if

symptom onset is unclear

2 negative tests at least 24h apart are required prior to discharge to a residential or care home, in addition

to a clear plan to complete 14 days isolation if this has not yet been completed9920300631

OTHER SHIELDING All patients (who may be COVID-19 negative or positive) who are identified are requiring shielding (shield displayed on Trackcare) require special consideration. Asymptomatic ‘green stream’ COVID-19 patients who are shielding at home and then admitted to UHM for non-COVID-19 issues must initially be isolated in a side rooms on a GREEN ward. All such patients should be routinely tested for COVID-19. If asymptomatic and COVID-19 negative, cohorting with other similar patients in a 4-bedded room can be undertaken - UHM does not have enough side-rooms for all COVID-19 negative shielding patients to have a single room – but only after discussion with a consultant and the nurse in charge. Separate guidance is available on shielding and this should be followed.

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Appendix 1. Admission Pathway

TRIAGE TO ‘RED STREAM’ &

PERFORM N&T SWAB FOR PCR

SENIOR DECISION MAKER REVIEW

LOW CLINICAL SUSPICION OF COVID-19 MODERATE OR HIGH CLINICAL SUSPICION OF COVID-19

NEGATIVE PCR RESULT x1 POSITIVE PCR RESULT

FIT FOR

DISCHARGE?

FIT FOR

DISCHARGE?

DISCHARGE

WITH

ADVICE*

DISCHARGE

WITH

ADVICE*

GREEN

WARD

RED

WARD

NEGATIVE PCR RESULT x1 POSITIVE PCR RESULT

FIT FOR

DISCHARGE?

DISCHARGE

WITH

ADVICE*

RED

WARD

FIT FOR

DISCHARGE?

DISCHARGE

WITH

ADVICE*

RED

WARD

No Yes No Yes Yes Yes No No

All patients with possible or confirmed COVID-19 must be provided with verbal and written advice at the point of discharge, covering worsening advice,

household isolation, shielding and any other relevant issues. Written advice to support discharge can be downloaded from the Scottish Government

COVID-19 website: https://www.gov.scot/publications/coronavirus-covid-19-clinical-advice/, with additional information on household isolation on the

NHS Inform website https://www.nhsinform.scot/guidance-for-households-with-possible-coronavirus-infection

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Appendix 2. – NOTES ON ROUTINE MEDICATIONS

ACEi/ARBs – European Society of Cardiology recommend that patients should continue their treatment, consider

withholding in more severe disease or AKI.

Ibuprofen - There is no clear evidence of harm with NSAIDs in COVID-19. Patients regularly taking NSAIDs can

continue unless clearly contraindicated e.g. AKI/ UGI bleed.

SGLT-2 inhibitors e.g. empagliflozin - withhold in view of increased risk of DKA/ HHS – see diabetes UK guidelines.

Immunosuppression - For COVID patients on immunosuppression, please discuss this with their parent team.

Steroids (including those with COPD or Asthma exacerbations)

Steroids in general should not be used. Steroids may increase viral shedding and haven’t been shown to be of benefit

in prior SARS or MERS epidemics.

The British Thoracic Society suggest patients should receive steroids if clinically indicated e.g. bronchospasm or

wheeze (BTS COVID-19 Guidance). A pragmatic approach would be prednisolone 30mg OD for 5 days for

exacerbations of COPD or Asthma in the context of COVID-19.

Do not stop steroids in those on long term steroids. Increase these if required.

Steroids may be used in context of COVID-19 in the RECOVERY trial, a multi-arm open label randomised controlled

trial taking place at UHM. Patients may be randomised to Dexamethasone as part of this, this will be documented in

the notes.

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Appendix 3. Repeat Testing pathway

MODERATE OR HIGH CLINICAL SUSPICION OF COVID-19

NEGATIVE PCR RESULT

FIT FOR

DISCHARGE?

DISCHARGE

WITH ADVICE

ADMIT/ KEEP ON

RED WARD

(with purple ‘splat’)

PRODUCING SPUTUM?

(usually if late presentation with

CXR changes)

SPUTUM FOR COVID-19 PCR

& TEST FOR BACTERIAL

PATHOGENS (M,C & S)

+/- FURTHER IMAGING

CONSIDER ONE* REPEAT N&T

SWAB FOR COVID-19 PCR &

OTHER VIRAL PATHOGENS

+/- FURTHER IMAGING

CONSIDER POSSIBLE

EXPLANATIONS FOR PCR RESULT:

-Poorly taken swab?

-Swab taken very early (<1 day) or

late ( >8 days) from symptom

onset?

-Alternative diagnosis?

-Chance? (test is ~91% sensitive)

POSTIVE PCR RESULT NEGATIVE PCR RESULT

CONTINUE COVID-19 MANAGEMENT UPDATE ‘SPLAT’ TO RED

CONTINUE COVID-19 MANAGEMENT, UNLESS CLEAR ALTERNATIVE DIAGNOSIS. ‘SPLAT’ REMAINS PURPLE

Yes No

*Do NOT send multiple repeat

N&T swabs for COVID-19 PCR

with no clear clinical indication!

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Appendix 4. Discharge Pathway

CONFIRMED (red ‘splat’) OR SUSPECTED (purple ‘splat’) COVID-19

FIT FOR DISCHARGE TO OWN

HOME OR RELATIVE?

COMPLEX

-HDU or ITU

admission

-Immunosuppressed

-Shielding

-Household contains

someone who is

shielding

UNCOMPLICATED

-No Critical Care

needed

-Not

immunosuppressed

-Not shielding

-Nobody at home

that is shielding

DISCHARGE TO NURSING OR

CARE HOME?

REQUIRES ONGOING HOSPITAL

ADMISSION?

Self-isolation for 7

days (minimum) from

symptom onset (or

first positive test if

symptoms onset

undetermined) with

absence of fever for

48 hours (without use

of antipyretics)

Self-isolation for 14

days (minimum) from

symptom onset (or

first positive test if

symptoms onset

undetermined) with

absence of fever for

48 hours (without use

of antipyretics)

Manage on a RED stream ward for 14

days minimum, unless discharged

IPC measures can be discontinued

after 14 days from symptom onset (or

first positive test if symptoms onset

undetermined), IF:

-clinical improvement with at least

some respiratory recovery

-absence of fever (> 37.8oC) for 48

hours

-no underlying severe

immunosuppression*

-no shielding measures being

followed*

*Confirm a negative swab x1 for these

patients prior to stepdown, at day 12

(rpt after 3 days if positive)

Manage on a RED stream ward for

14 days minimum, unless discharged

Isolate for a min of 14 days from

symptom onset (or first positive

test if symptoms onset

undetermined) and absence of

fever for 48 hours (without use of

antipyretics).

AND

2 negative tests, at least 24 hrs

apart, before discharge (can be

commenced day 8)

AND

completion of the remaining 14-day

isolation in the care home or in

hospital depending upon clinical

suitability for discharge

All patients with possible or confirmed COVID-19 must be provided with verbal and written advice at the point of discharge, covering worsening advice, household

isolation, shielding and any other relevant issues. Written advice to support discharge can be downloaded from the Scottish Government COVID-19 website:

https://www.gov.scot/publications/coronavirus-covid-19-clinical-advice/, with additional information on household isolation on the NHS Inform website

https://www.nhsinform.scot/guidance-for-households-with-possible-coronavirus-infection

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Appendix 5 – POTENTIAL FUTURE DRUG TREATMENTS

Although a number of therapeutic options have been suggested, there is no established antiviral for treatment of

COVID-19. Potential therapies should be considered only within well-defined clinical trial criteria.

Monklands hospital is part of the RECOVERY trial this is now actively recruiting. It is a multi-arm open label trial

comparing standard care to Dexamethasone, Hydroxychloroquine, Lopinavir/ Ritonavir and Azithromycin. If any

juniors want to be involved in patient recruitment then contact: Dr Claire McGoldrick -

Claire.McGoldrick@lanarkshire.scot.nhs.uk

For interest, potential therapeutic agents being investigated internationally include:

Remdesivir – broad spectrum antiviral agent. Activity include against Ebola, as well as in vitro evidence for emerging

viral pathogens including coronaviruses. Ongoing trials in China and the USA. No secure UK supply available.

Chloroquine/Hydroxychloroquine – Antimalarial, with evidence of anti-inflammatory and antiviral properties in vitro,

clinical trials are ongoing. Some groups have trialled this in combination with Azithromycin, however these reports

are also conflicting with concern regarding sample size and questions over methodology.

Lopinavir/Ritonavir (Kaletra) – Anti-retroviral which has been used in some patients with other coronaviruses

(MERS/SARS) however the latest evidence suggest that there is no confirmed benefit in COVID-19.

Beta-Interferon- an acute phase protein important in control of viral infections. It has been suggested COVID-19

supresses production of B-IFN, which might otherwise suppress viral replication.

Favipiravir – An antiviral drug used for influenza in Japan. Preliminary studies suggest improved time to clinical

recovery and symptom resolution.

Convalescent plasma – plasma transfusion from those recovered from COVID19. Anecdotal reports with

compassionate use and small prospective studies, in severely unwell intubated ICU patients, suggest significant

clinical improvement in viraemia, biochemistry and wider clinical parameters. Further trials are ongoing.

Immunomodulatory therapies It has been suggested that morbidity and ARDS in severe COVID-19 infection are

secondary to a dysregulated immune response. Different strategies are proposed to address this, including IL-1

inhibitors (Anakinra), IL-6 inhibitors (Tocilizumab), JAK inhibitors (Barcitinib), amongst others. Trials are ongoing with

some of these drugs in China and European countries, but none currently in the UK.