The Covid-19 pandemic has crossed the one-year milestone and continues to devastate lives and livelihoods across India. Scientists across the world have displayed an amazing collaborative spirit and have been working round the clock to generate knowledge and tools to fight the pandemic. Clinicians have been sharing their experiences of managing patients with varied clinical presentations. Information, both right and wrong, is instantaneously available to everyone in the interconnected world. People are both using and misusing this information. We are witnessing primal human responses to this pandemic-induced crisis. In this context, people should have access to factual information that they can easily understand and trust. The facts presented below are meant to serve this very purpose says Dr Krishna Reddy Nallamalla President, InOrder
Country Director, ACCESS Health International
Which investigations are enough to diagnose and treat a suspected patient with Covid-19?
The Rapid Antigen Test and the RT-PCR are tests that detect the virus are essential to diagnose Covid. If results from the above are negative, but clinical suspicion based on exposure, presentation, and other basic lab tests is high, a high-resolution CT scan of the chest (HRCT-Chest) will provide information related to characteristic lung involvement. It should be noted that similar findings can also be present with other lung infections (bacterial and viral). Serology tests that detect the presence of antibodies against the Covid virus are also useful in cases tested a week after the onset of illness. Detection of IgM antibodies will suggest recent infection.
Tests that detect ongoing immune response (ESR, CRP, D-Dimer, IL-6, Ferritin etc.,) are needed only in a few cases, to guide treatment decisions. They are not needed in asymptomatic and mild cases. Patients who are at high risk (due to age or presence of multiple co-morbidities like diabetes, high blood pressure, kidney disease, or heart disease or prior stroke) may undergo the D-Dimer test to provide blood thinners (anticoagulants) for preventing clots in blood vessels. Repeated testing for these parameters is not needed in majority of cases. Oxygen should be monitored every 4 to 6 hours if patients develop increasing cough or breathing difficulty.
Which treatments have been validated for managing Covid patients?
Steroids (hydrocortisone, prednisolone, methylprednisolone, and dexamethasone) that moderate unwarranted immune responses are highly recommended to treat all patients with falling oxygen levels (below 90 to 93%) as measured at room air. Steroids are shown to reduce the need for ventilations and reduce deaths. They are not shown to benefit patients who do not have low oxygen levels. Hence, they should not be used for patients who are asymptomatic or have mild illness. They are recommended to be given for a duration of seven to 10 days. Markedly elevated immune response markers may warrant extended therapy in a few cases.
Anticoagulants (injectable – heparin, enoxaparin, and fondaparinux and oral drugs like warfarin, apixaban, rivaroxaban, dabigatran etc.,) are used to prevent and treat blood clots associated with Covid. All patients with moderate to severe illness who need hospital admission are given anticoagulants to prevent blood clots. The dose used for prevention is lower than that used to treat blood clots. Those patients who develop blood clots receive full dose of these drugs. Five to 10 days of anticoagulants are sufficient in a majority of patients for prevention. In a few patients who are at a higher risk of strokes, it may be given for longer periods, especially if D-Dimers continues to be high. However, those who need treatment for developed blood clots in veins (which drain blood) will need them for 3 to 6 months.
Antiplatelets (aspirin, Clopidigrel, ticagrelor, prasugrel) also prevent blood clots. They are used in all patients with known cardiovascular disease (CVD) and in those who are at high risk for developing CVD (patients with diabetes, high blood pressure, high cholesterol, who smoke, who have family history etc.,) for preventing events like heart and brain stroke.
Oxygen is the mainstay of treatment in patients with falling oxygen levels (below 93%). Home oxygen may be sufficient in the beginning. However, patients at high risk should get hospitalized. Oxygen can be given through nasal cannula, face mask, non-invasive ventilation (NIV), or invasive ventilation as per patient’s ongoing monitoring & assessment.
Remedesivir, an anti-viral drug developed for other viral illnesses, has been approved for use in Covid patients. In trials conducted in US, the drug was shown to reduce hospital stay by 3 to 4 days. However, it did not reduce the need for invasive ventilation or deaths. In the trial conducted by the WHO, there was no proven benefit from Remedesivir. In a trial conducted in China, Remedesivir did not reduce the viral load in the respiratory tract. The use of Remedesivir should be moderated, given the limited benefit and the very high costs.
Convalescent plasma has not shown significant benefit in various trials. Monoclonal antibodies, approved in US, are not available in India. The benefit is seen when it is given at an early stage in the course of the illness. Other anti-inflammatory drugs (Tocilizumab etc.,) under investigation have plus/ minus benefits. They are highly expensive. Multiple randomized trials have ruled out the benefits of Ivermectin and Chloroquine. Routine use of antibiotics is not recommended for the prevention of superadded bacterial infections. They should be used only when there is high clinical and laboratory suspicion or definite evidence of infection. Indiscriminate use of antibiotics is contributing to the growing epidemic of antimicrobial resistance (AMR).
Life style during the times of Covid
A healthy and balanced diet (plenty of vegetables, fruits, millets, milk products, fish and poultry etc.,) along with adequate physical exertion are enough to keep people healthy. There is no need for various unproven immune boosters and supplements. Many people are going through fear, anxiety, and depression. A flood of information, being confined to their homes, financial stresses and the fear of the unknown are adding to the growing problem. Easy access to home monitoring devices for heart rate, blood pressure, and oxygen levels, while useful under proper direction and understanding, are proving to raise anxiety levels. It is causing indiscriminate self-medication and self-investigation among people.
Current medications and the Covid vaccine
Due to the inadvertent wrong messaging on blood thinners, prior to starting the country-wide vaccination program, there is continuing confusion related to blood thinners. It is a general precaution, taken whenever intramuscular injections are given. As explained above, there are two types of blood thinners – antiplatelets (aspirin, clopidigrel, ticagrelor, and prasugrel) and anticoagulants (acitrom, warfarin, apixaban, rivaroxaban, dabigatran etc.,). Antiplatelets need not be stopped prior to vaccination. Anticoagulants, if used only for prevention, are stopped 4 days prior to vaccination. If anticoagulants are being used for treatment (patients with mechanical heart valves, patients who had blood clots in leg veins or in lungs within 3 months etc.,), they should always consult their treating physician.
It is hoped that the above information based on growing scientific evidence will make people better aware.
Dr Krishna Reddy Nallamalla
Country Director, ACCESS Health International