1US death rates -- highest in what populations
≥85 yo
Native Americans, Hispanics
males
2Preferred dx test
nucleic acid amplification test (PCR) from URT
- highly sensitive and specific
3What populations are at highest risk of severe COVID-19
≥65 yo
CVD
T2DM
chronic respiratory disease
cancer
kidney disease
BMI > 40
Sickle cell
pregnancy
transplant / immunosuppression
4Classify -- test (+), but no sx
ASx or presymptomatic
5Classify -- various s/s without SOB, dyspnea, abnormal imaging
mild
6Classify -- evidence of lower respiratory disease by clinical assessment or imaging and O2sat ≥94% on room air
moderate
7Classify -- >30 breaths / min, *O2sat <94%* on room air, PaO2/FiO2 < 300, or lung infiltrates>50%
severe
8Classify -- respiratory failure, septic shock, +/- multiple organ dysfxn
critical
9Classify -- common persistent sx
persistent sx or organ dysfxn
10Pharm recommendation -- who gets dexamethasone
everyone hospitalized + oxygen
6 mg qd x 10 days (or discharge)
- no role of outpatient steroids in COVID
11Pharm recommendation -- who gets remdesivir
hospitalized + oxygen
- not mech ventilation though
12FDA approved pharm tx -- and indication
remdesivir -- for those who need O2 but not for mechanical ventilation
-for hospitalized ≥12 and >40 kg
- EUA: 3.5-40kg and <12 yo
13Remdesivir -- moa
nucleotide analog RNA polymerase inhibitor
14Remdesivir -- dosing
day 1: 200 mg
2: 100 mg q24h x 4 days (until discharge)
- admin over 30-120 mins
15Remdesivir -- monitoring
HSN during infusion
PT and LFTs at baseline and as indicated
CYP3a4, OAT, PGP DDIs
most common ADRS: N, inc LFTs
- CI: CrCl < 30 ml/min
16(3) meds not recommended currently -- only used in clinical trials
chloroquine/hydroxychloroquine +/- azithromycin
ivermectin
lopinavir / ritonavir
17IDSA -- if steroids are CI, remdesivir + _________ is recommended
baricitinib
18Steroid -- monitoring
hyperBG
secondary infxns
psychiatric effects
avascular necrosis
19Tocilizumab -- in trials for what patients
rapid respiratory decompensation
- ICU within 24 hours + ventilation or high flow nasal cannula
20Tocilizumab -- do not use if...
immunosuppressed significantly
ALT > 5ULN
high risk GI perforation
uncontrolled non-covid infection
ANC < 500
PLT < 50K
21Tocilizumab -- how admin
over 60 mins IV with dexamethasone for 10 days or discharge
22(2) mAbs
bamlanivimab 700 mg + etesevimab 1400 mg
casirivimab 1200 mg + imdevimab 1200 mg
23Why are mAbs used
prevent progression to severe COVID19
24Do not use mAbs if..
hospitalized or oxygen requirement
25Bamlanivimab monotherapy?
NO
26Convalescent plasma -- recommendation
not enough data for or against
- IDSA recommends against plasma unless in clinical trials
27Who gets mAbs
outpatient with mild-mod COVID19 at risk of clinical progression
- not hospitalized or requiring oxygen
28If use convalescent plasma -- (3)
high titer product
use early in hospital course
use before critical illness
29FDA -- plasma
authorized use for hospitalized pts with COVID
30Risk factors (other than COVID19) for VTE
hospitalization / critical illness
high BMI
lab abnormalities
high score on risk assessments (PADUA, etc)
31VTE prophylaxis
- all hospitalized pts
- continue home anticoag / antiPLT
- do not routinely discharge pts on prophylactic abx
- consider if sudden deterioration in pulmonary, cardiac, or neuro fxn
32What about continuing ACE, ARB, statin, steroids, NSAIDs
continue from home
33Pregnancy -- COVID (+) and need for hospitalization
need facility that can also monitor baby
34Remdesivir -- age
12+
- EUA for < 12 yo
35Multisystem inflammatory syndrome in children (MIS-C) -- clinical dx
- fever, labs = inflammation, severe illness req. hospital, multiorgan involvement
AND
- no alternate dx
AND
- recent COVID19 dx or exposure
36MIS-C is a ______ phenomenon rather than a direct viral process
post-infectious inflammatory