TEN COMMANDMENTS: WBDF Interim Guidance on Covid-19 Therapeutics

29.05.2021
The treatment of Covid-19 should be evidence-based. Use well done RCTs, preferably published in peer-reviewed and accepted journals of repute (not pre-print only) with at least phase three RCTs. Opinion pieces, case reports, observational series and media reports are only hypothesis generating. If resources do not allow individual article tracking, use evidence-based guidelines from scientific bodies around the world, like the WHO, NICE, NIH, IDSA, ISCCM or ERS. Be sceptical of guidelines without references, authorship and discussion of rationale and levels of evidence.

1. Patients with mild disease should be in home isolation and self-monitor under supervision of a doctor.
2. Blood test or CT scans have not been shown to alter management in early or mild disease and are generally unhelpful except in rare circumstances. The single most important test is resting oximetry and SpO2 should be checked if in home isolation specially from the end of the first week.
3. Vitamins, minerals, favipiravir, HCQS, azithromycin, doxycycline, montelukast, ivermectin, antihistamines have not demonstrated benefit in any well controlled RCTs and should be avoided. Paracetamol should be used for fever and body aches.
4. Antibiotics do not work in viral infections and covid is no exception. In the small minority where a secondary bacterial infection occurs (<5%), antibiotic should be used. CRP is not useful to initiate antibiotics, but raised White Cell Count may be. Where available Procalcitonin may be used.
5. An SpO2 level of 93 % or less should trigger alert, physician consultation and potential hospitalisation. Patients with earlier COPD and eastablished lower level in normal situation should be kept in mind by physicians .
6. An SpO2 level BELOW 94% should trigger steroids – 6 mg of dexamethasone IV/PO for 10 days is the most researched dose – there is no need to tail off. This may be started at home while waiting for a hospital bed. Earlier use of steroids is strongly recommended against as it has been shown to HARM patients.
7. Oxygen is initiated as required to keep SpO2 90-92% but escalation beyond 6 L/min nasal oxygen needs specialised hospital care with non-invasive ventilation, CPAP or HFNO and ultimately invasive ventilation.
8. Tocilizumab may be used in hospital in select cases under specialist supervision only. There is no evidence that Remdesivir improves mortality, but it may have modest benefits in moderately ill patients (as suggested in USA study, that was not replicated in India in a WHO study, hence dropped in WHO recommendation). Convalescent plasma use is not beneficial.
9. All patients admitted to hospital need prophylactic anticoagulants unless contraindicated (Enoxaparin 40mg sc once daily or heparin 5000 units sc twice daily). Do not use D-Dimer to stratify anticoagulant use – this has been proven to be unhelpful. Post discharge oral anticoagulation with NOACs are not recommended generally, but may be used in select high risk patients using DVT risk scores. Using D-Dimer as a standalone test to decide on post discharge anticoagulation is not recommended.
10. Diabetes must be controlled adequately with Insulin if required.

These recommendations are subject to change as and when new information comes in. Several chronic diseases (COPD, asthma, renal failure, heart failure and other cardiac diseases, cerebrovascular diseases to name a few) are common in patients who get Covid and should be managed independently.

(Prepared collectively by Dr. Swarup Sarkar, Prof. Santanu Tripathi and Dr. Sumit Sengupta. It is after a WBDF zoom meet on May 22, 2021 involving more than 290 doctors.