Standard of care for Clinical Management Strategy for COVID-19

The approach for treatment of COVID-19 is largely based on asymptomatic and supportive care, since there is no cure as yet.  Maintaining good hydration is also essential.  Based on severity of symptoms, COVID-19 can be categorised into 3 groups: mild, moderate and severe.  In a Video Conference with States on 10.07.2020 and a virtual meeting on “COVID Case Management by State / UT Centres of Excellence” on 10.07.202, ICMR and AIIMS, New Delhi emphasised the theme that in the absence of a cure, the standard of care treatment for mild, moderate and severe cases as described in the Clinical Management Protocol of Ministry of Health & Family Welfare (MoHFW), would be most effective.

For moderate and severe cases, adequate oxygen support, appropriate and timely administration of anti coagulants and widely available and inexpensive corticosteroids, in accordance with the protocol, can be considered to be the mainstay of COVID-19 therapy.  For mild cases, which are nearly 80% of the total cases, Hydroxychloroquine (HCQ) has been recommended.  The standard of care treatment strategies have shown to yield positive results.

The pursuit of an effective treatment for COVID-19 has also resulted in repurposing of several drugs which are not a part of the main Clinical Management Protocol but have been indicated as “investigational therapies”.  These can be used in specific sub-groups of patients on the basis of informed and shared decision making with the patient before prescribing these drugs.  These drugs have still not been approved by the Drugs Controller General of India (DCGI) and are only permitted for restricted Emergency Use for COVID-19.  The States as well as the Medical College hospitals designated as Centres of Excellence were reminded by ICMR and AIIMS that their indiscriminate use or use in conditions for which they are not desirable, may cause more harm than good.

The States were also told that the available evidence for Remdesivir suggests that it may decrease the time for clinical improvement when used in moderate to severe cases.  However, there have been no benefits in terms of reduced mortality.  It has to be used with extreme caution due to its potential for serious adverse effects including liver and kidney injury.  Similarly, for Tocilizumab studies have not shown any benefits in mortality reduction.  However, if used for patients with severe conditions, proper informed consent is required.  Rampant use is to be discouraged since the effect of the drug is directed at the ‘cykotine storm’.

All the ‘investigational therapies’ are required to be carried out only in proper health care facilities where close monitoring of patients is possible so that potential complications can be managed.  ICMR strongly recommended that the focus of clinical management should continue to remain on oxygen therapy (including high flow nasal oxygen), steroids (which are widely available and inexpensive), appropriate & timely administration of anti-coagulants and high quality supportive care, including mental health counselling for patients and families, proning, management of pre-existing illness and palliation of symptoms.

healthysoch