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The revised ‘Clinical Guidance for Management of Adult COVID-19 Patients’ issued by AIIMS, ICMR-COVID-19 National Task Force and Joint Monitoring Group (DGHS) under the health ministry on Monday underlined there is no evidence of injectable steroids benefitting Covid patients not requiring oxygen supplementation or in continuation after discharge.
Anti-inflammatory or immunomodulatory therapy, such as steroids, can have the risk of secondary infection like invasive mucormycosis, when used too early, at higher dose or for longer than required, they highlighted.
If cough persists for more than two-three weeks, one should opt for investigation for tuberculosis and other conditions, the revised guidelines stated.
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According to the guidelines, EUA or off-label use of the tocilizumab drug may be considered for use in the presence of severe disease, preferably within 24 to 48 hours of the onset of severe disease or intensive care unit (ICU) admission. Tocilizumab may be considered for patients with significantly raised inflammatory markers, and not improving despite the use of steroids with there being no active bacterial, fungal or tubercular infection, they stated.
Coronavirus patients have been classified into those affected by mild, moderate, and severe diseases, the guidelines stated. Injection methylprednisolone 0.5 to one mg/kg in two divided doses, or an equivalent dose of dexamethasone, can be given usually for a duration of five to 10 days in moderate cases, the guidelines stated. The same drug in two divided doses of one to two mg/kg can be given for the same duration in severe cases.
”Inhalational budesonide (given via metered-dose inhaler/dry powder inhaler) at a dose of 800 mcg BD for five days can be given in mild cases if symptoms (fever and/or cough) are persistent beyond five days of disease onset,” it was stated in the guidelines.
According to the guidance note, upper respiratory tract symptoms without shortness of breath or hypoxia have been categorized as mild disease and have been advised home isolation and care. Those suffering from mild Covid should seek medical attention if they have difficulty in breathing, high-grade fever, or severe cough lasting for more than five days.
Those having breathlessness with SpO2 fluctuating between 90-93 percent, can get admitted to a ward, and they will be considered moderate cases. Such patients should be given oxygen support and awake proning should be encouraged in all patients requiring supplemental oxygen therapy, in sequential position changes every two hours, the guidelines stated. Respiratory rate over 30 per minute, breathlessness or SpO2 lower than 90 percent on room air should be considered as a severe disease and such patients have to be admitted to an ICU as they will need respiratory support, they said.
Such patients should be put on respiratory support. Non-invasive ventilation (NIV) — helmet or face mask interface depending on availability — may be considered in those with increasing oxygen requirements if work of breathing is low. High flow nasal cannula should be considered in patients with increasing oxygen requirements. Intubation should be prioritized in patients with high work of breathing if NIV is not tolerated and institutional protocol for ventilatory management should be used when required, the new guidelines stated.
Those aged above 60 years, or those having cardiovascular disease, hypertension, and coronary artery disease diabetes mellitus, and other immunocompromised states, such as HIV, active tuberculosis, chronic lung, kidney or liver disease, cerebrovascular disease, or obesity are at high risk for severe disease and mortality, the guidelines stated.