How to manage a Covid19 patient who has comorbidity or risk factors.
At Security Adviser, we have always focused on giving you practical advice that will enable you to take action and keep yourself safe. In this important post, Dr. Holliday provides an in-depth guideline for prevention to COVID exposure, self-care in the case of a positive diagnosis, the development of serious symptoms and the path to hospitalization. The post has valuable information for people that are healthy, people with comorbidity factors and medical professionals who have taken up the sword against the virus and are looking for other professional perspectives. This post will also add value to those who manage workforces and need to keep an eye on the health of staff.
The pandemic is escalating
The Covid pandemic is escalating quickly. The second wave is threatening to be big and medical professionals can expect to be swamped with many anxious patient queries. In anticipation of my patient’s need for information, I propose this treatment approach and guidelines for both patients and doctors. I have tried to simplify terminology for the layman but have left technical terms in place for health care professionals.
Patients under 50
Patients under 50 are unlikely to contract severe complications of Covid19 but should consider their risk factors anyway. The standard approach to low risk patients is to:
- Take symptomatic treatment and
- Wait to get better.
Testing will offer no benefit to them in the heat of the epidemic as the diagnosis will be obvious.
Recommended treatment guidelines
Several recommended treatment guidelines have been proposed, but experience and protocols are changing fast. I have compiled this protocol after careful consideration of other protocols and reports from journals regarding the disease as well as consultation with colleagues and academics from many disciplines such as cardiology, pulmonology, pathology, paediatrics, haematology, nephrology and internal medicine. Some controversial treatments such as the use of Plasmoquine are included because the general consensus by many specialists that the use of low doses is harmless. Furthermore, it has a proven effect against SARS (Covid19’s older brother) and that there is adequate anecdotal evidence for its use prophylactically despite no proven clinical trials yet.
Covid19 has been in South Africa for just over three months so knowledge and experience has been limited to few centres. As we gain knowledge of this virus’s ability to cause disease, we have seen specialists and academics shift in recommendations and advice. This disease has found a way to attack myriad systems and cause severe illness in unusual ways. It typically presents with three clusters of symptoms: Respiratory, Gastrointestinal and Musculoskeletal. Other areas that may cause complications concern blood and clotting. Much new interest is being shown in anticlotting therapies for endothelial microangiopathy (artery lining inflammation) which causes micro-clotting and is associated with poor outcomes. Covid19 is usually mild, but in at-risk patients it can later accelerate unpredictably into a severe form. Children seem to be relatively untouched because of their immaturity in the ACE2 receptor development (the keyhole through which the virus gains entry into the cell).
Part 1 Proactive steps for the healthy and those with high susceptibility risk profiles
- Lockdown has prepared hospital facilities for treating those with severe infections. Furthermore, the minor viral illnesses that we see mostly in winter are at an all-time low due to school closures. This will be helpful to doctors because their symptoms confusingly can imitate many Covid 19 symptoms. An added benefit is that by delaying our peak we have the experience of many clinical trials done in other countries to our North.
- People should have had their flu and pneumonia vaccines by now. These are important for several reasons: Should you get Covid19 we are less likely to confuse it with flu, you will contribute to the flu herd immunity, you are less likely to take up a hospital bed, we are unlikely to perform unnecessary tests and we are unlikely to give you unjustified antibiotics. Also, your body manufactures Interferon which may give you strong antiviral protection for up to a month. It’s not too late to have it now.
- Find out your susceptibility: The risk factors are well known: obesity, smoking, diabetes, heart disease, lung disease, high BP, kidney and liver disease, elderly, male…. Your GP can help you establish how much risk an infection will pose to you. One of the tests that may not have been considered is an hs-CRP which measures the inflammation in endothelium (the lining of arterial walls) and a possible source of clotting complications. An hs-CRP level greater than 3 should make your doctor consider some intervention. This may also prove useful later when considering anti-clotting agents. He will also record your baseline Oxygen Saturation level for later comparison.
- If you are susceptible then I suggest the following course of action: 1)- Take 50 000 Units of Vitamin D weekly until spring. 2)- Take low dose zinc daily or every other day at least. 3)- Take Plasmoquine 200mg weekly. We don’t have Hydroxychloroquine in SA (with a 3-week dosage interval) so we have to use Plasmoquine once a week because of its shorter half-life. 4)- If BP is not perfectly controlled, consider adding an ACE inhibitor or switching to an ACE inhibitor. These were originally suspected to be bad for Covid19, but a large registry analysis has associated them with better outcomes in hospital cases. 5)- If you have a nagging tooth, now is the time to visit your dentist. Dental infections are a source for bacterial sepsis in the blood vessel walls and heart valves. 6)- A high baseline hs-CRP may induce your doctor to reduce endothelial inflammation by giving you statins and low dose aspirin for the duration of the epidemic. 7)- Do not enter an area that is likely to give you an initial high dose of virus such as homes of sick people, closed vehicles, crowded shops…
Part 2 Diagnosis and Treatment for those with risk factors
Early illness: (mild to moderate illness occurs in 81% of cases) The current national plan is to treat you at home.
Presenting Symptoms: As the epidemic numbers rise and we recognize a close encounter with someone sick the following symptoms and their frequency occur: Fever 90%, Cough70%, Fatigue 60%, Lack of appetite 50%, Body aches 25%, Shortness of breath 35% and mucus/phlegm30%.
Less frequently seen are: headache, nausea, vomiting, stuffy nose and loss of smell.
Home treatment – what can you do?
I suggest the following course of action:
- Steam or heat our sinuses with the hairdryer twice a day.
- Gargle with 1% Peroxide or hot salt water. This will slow down the initial uptake of the virus and give your immune system more time to react.
- Use Panado for symptoms. Anti-inflammatory drugs were originally thought to aggravate the Cytokine Storm Syndrome, but this has been disproved. They do however have more side effects and are riskier in kidney disease.
- If you fall into a high-risk category it would be wise to take a low dose of aspirin (anticlotting, not anti-inflammatory dose of less than 100mg per day). T
- Take an extra dose of Plasmoquine 200mg at the onset of symptoms irrespective of when you last took one; this will be your last Plasmoquine dose.
- Go to bed: Sickness behavior such as this and loss of appetite reorganizes your system’s priorities to help cope with infectious diseases. Furthermore, by restricting your movement it reduces your ability to contaminate others.
- Discuss your symptoms and possible contact with infectious persons with your doctor. As doctors become more experienced with the disease and its presentation, they will rely less on testing to confirm diagnosis. A positive PCR test at this time will almost definitely confirm the diagnosis, but a negative test (with positive symptoms) is not to be trusted and the treatment protocol described above should be followed. A 2nd test can be done after 48 hours. Tests that your doctor will do if you have high risk factors should include: LFT, CRP, Ferritin, FBC, Prothrombin time and D-Dimer. Your doctor can expect lymphopaenia, neutrophilia and a rise in inflammatory markers and transaminases. High LDH, CRP, prolonged Prothrombin time and D-Dimer are associated with severity.
Symptoms to watch out for
As your sickness progresses: (severe illness occurs in 14% of cases). Unpredictably the disease can initially improve and then accelerate in severity between 8 and 12 days after onset.
Symptoms to watch out for are:
- Worsening shortness of breath
- Wheezy cough and chest pain.
- Simple monitoring signs of concern are: confusion, blue lips, a breathing rate of more than 30 breaths a min, pulse rate greater than 100 a minute, the appearance of chilblains or rashes.
This is the time to call your doctor who will compare your signs with pre-sickness measurements and will measure your oxygen saturation and arrange for a D-dimer blood test to exclude clotting in the blood vessels. Your co-morbidities should be monitored in anticipation of a decline. Depending on symptoms and test results (D-dimer>1) you should be started on low molecular weight heparin injections (Clexane 40mg) or oral anticoagulant such as Xarelto 10mg daily. These can be started safely by your GP before going to hospital whilst you are in bed. If oxygen is available, it can be used at home to keep saturation above 94% in the Highveld (for readers across the globe, we live in a high-altitude area).
Nebulisation with bronchodilators and steroids may be helpful with lung symptoms. Mild doses of steroids may be started in anticipation of a possible hospital admission.
Entrance into hospital
Deterioration, Hospital admission:(5% will develop respiratory failure, shock and multi organ failure).
With all the above measures in place you are less likely to deteriorate to the point of hospitalization; but the main role of a hospital is to provide oxygen and monitor your progress. Chest X-rays can only be done as an in-patient, and organ deterioration can be tracked. Complications of long-term bed rest such as deep vein thrombosis and lung collapse will be treated. Doctors in hospital can now determine whether you may benefit from the introduction of new drugs such as Remdesivir and Avigan that have been shown to shorten ICU stays. Monitoring your rate of decline in hospital will determine if a quick transfer to ICU may save your life.
ICU: Intense specialist care will include: nursing the unconscious, ventilation, dialysis, dissolving clots, treating heart attacks and strokes. Currently about 46% of ICU admissions die!
Treatment options shifting
Treatment options are shifting. The treatment of this new disease evolves daily and the world’s unfolding Covid experience will help scientists to better understand this complex contagion and treatment options. Data updates are fluid and for now, a vaccine remains elusive. Until a safe one is developed and tested, doctors will rely on protocols such as this one to treat our patients.
The empirical information shifts fast. Watch this space for updates….
Dr Mark Holliday
14 June 2020
PS: Controversies regarding active treatment interventions
PS: Controversies regarding active treatment interventions of this new disease abound and journal articles such as the large registry study in the Lancet were retracted only to have a new large study published this week refuting Chloroquine at high doses as an in-hospital treatment. Prophylactic use has not been refuted as yet. Tamiflu, originally a very influenza-specific drug was originally prescribed, but recent studies have shown no benefit. ACE inhibitors seem to improve hospital outcomes while ARB’s don’t despite similar properties. High dose Vit D is questioned in sunnier climates thus my prescriptions in SA are only valid until spring. Niacin (Vit B3) is believed by some to confer a benefit prophylactically. Intracellular Zinc has been shown to inhibit RNA virus replication; the serum concentrations required to promote this effect are unknown, but the recommended daily dose is not likely to cause side effects.
The original symptoms that we were warned about in February included headaches, sore throats, diarrhoea and conjunctivitis. These are much less frequently seen.
Dr Mark Holliday Associates: Drs Detlev Venter, Pam Taylor, Marina De Klerk, Amy Elliott.
June 17, 2020