COVID-19: State revises treatment guidelines

The State has brought out a revised treatment protocol for COVID-19, based on the latest evidence and essentially focussing on mortality reduction, especially in those considered to be at the highest risk of developing complications.

“What we have highlighted is a therapeutic stewardship of COVID-19, which essentially means the right drug at the right time, dosage, and for the right duration, to the right patient. The protocol clearly says antibiotics like Azithromycin or vitamins are not indicated for COVID-19 patients. The primary aim of this revised protocol is to ensure that mortality is further brought down by focussing on the highest risk groups like pregnant women and those with end-stage organ damage due to diabetes,” says R. Aravind, Head of Infectious Diseases, Thiruvananthapuram Government Medical College.

There is no change in the risk stratification of patients as mild, moderate and severe. However, the mild and moderate category patients would be re-assessed every 24-48 hours. Category A, mild patients need isolation, rest and intensive monitoring and there is no role for antibiotics or vitamins for them.

In category B, moderate patients, focus is on those with the highest risk factors. Those with the “highest risk factors” are defined as diabetes patients with an HbA1C levels over 10 and those with end-stage organ disease due to diabetes.

“For these patients with the highest risk factors, who could develop COVID-19 pneumonia, the treatment protocol recommends the administration of monoclonal antibodies [Casirivimab and Imdevimab], to prevent disease progression. It has to be administered early in the disease course before hypoxia develops, as a pre-emptive therapy,” Dr. Aravind says.

Monoclonal antibodies are not recommended for those who require oxygen therapy due to COVID-19 or more than 10 days from symptom onset.

Treatment strategy for COVID is basically classified into four: aggressive vaccination, pre-emptive therapy, definitive therapy like immunomodulators, and treatment of complications.

The new protocol has removed drugs like Ivermectin, Favipiravir, and Hydroxychloroquine that were not really supported by evidence; Remdesivir has been retained on the basis of emergency use authorisation; Tocilizumab remains. The new addition in this list is JAK inhibitors (Baricitinib/Tofacitinib).

Another highlight of the new protocol is a separate chapter on critical care guidelines for treating pregnant women. Kerala had seen mortality among pregnant women contracting COVID-19 shooting up in the second wave. The other important chapter deals with Multisystem Inflammatory Disease in Adults.

The protocol also stresses on infection control and antibiotic stewardship.