Health Ministry revises guidelines for management of adult Covid-19 patients; know more here

The revised guidelines, which have been issued amid rising Covid cases in the country, also suggest that there is no evidence of benefit for injectable steroids in those not requiring oxygen supplementation, or on continuation after discharge in moderate risk category.

It states that anti-inflammatory or immunomodulatory therapy (such as steroids) can have risk of secondary infection such as invasive mucormycosis when used too early, at higher dose, or for longer than required — which was the case during Delta Plus-driven second Covid wave.

AIIMS/ICMR-COVID-19 National Task Force/ Joint Monitoring Group (Dte.GHS), @MoHFW_INDIA issues Clinical Guidance for Management of Adult COVID-19 Patients revised on 14/01/2022. It is accessible at https://t.co/yvgOGSwOFK@PIB_India @mygovindia #CoronaUpdatesInIndia pic.twitter.com/Wj97STgH7H

— ICMR (@ICMRDELHI) January 17, 2022

The guidelines, drafted by experts from the Indian Council of Medical Research-Covid19 Task Force, AIIMS, and Directorate General of Health Services, continue to not recommend medicines like antibiotics doxycycline and azithromycin, and antiparasitic Ivermectin for mild cases of Covid-19, which are to be managed at home in isolation.

Dr Shuchin Bajaj, founder director, Ujala Cygnus Group of Hospitals told indianexpress.com that in the latest guidelines, all previous medicines like Ivermectin, oral steroids, oral antivirals and plasma therapy, etc, have completely been removed.

All the drugs that were included before or that were being prescribed all this while, including antibiotics like Doxycycline, Azithromycin which actually work on bacteria and not on virus, said Dr Trupti Gilada, infectious disease specialist, Masina Hospital, Mumbai.

“Ivermectin which is a anti worm medicine and doesn’t work on the virus again so these three medicines have been excluded and have got no role in management of mild COVID. The other drugs that do not find their place in the guidelines are Favipiravir; the recently approved Molnupiravir about which ICMR did express its concerns over adverse effects, so those have not been included in the guideline and therefore, should not be prescribed the way they still are being prescribed extremely commonly. The third important drug that is excluded from the guidelines but is still being prescribed is monochronal antibody cocktails – they are effective only in those individuals who have high risk of progression from a moderate to a severe disease and have not had previous immunity and most importantly if it is a delta variant, monochronal antibody cocktails have no role in the management of Omicron and we all know the vast majority of cases we are seeing currently are Omicron,” said Dr Gilada.

For mild cases, the guidelines state home isolation with physical distancing, indoor mask use, and strict hand hygiene. It is paramount to seek immediate medical attention if there is difficulty in breathing or oxygen saturation drops below 93, or high grade fever/severe cough last for more than five days, the guidelines states.

Moderate patients will have to be admitted in ward if the oxygen levels of SpO2: 92-96 per cent (88-92 per cent in patients with COPD) is not met.

Covid-19 is classified mainly into three types: mild cases — one without breathlessness and no oxygen requirement; moderate — breathlessness or oxygen requirement of Sp02 level 90 to 93 per cent, and severe — patient with respiratory distress or Spo2 level less than 90 per cent. “Hospital care is required for patients with moderate and severe disease. Patient with mild disease can be managed with symptomatic treatment and home isolation with regular monitoring of temperature and oxygen saturation,” said Dr Rakesh Rajpurohit MD, consultant pulmonologist and critical care medicine, Jain multi speciality Hospital Mira Road.

-Preferred devices for oxygenation: non-rebreathing face mask

– Awake proning is encouraged in all patients requiring supplemental oxygen therapy (sequential position changes every 2 hours).

The guidelines continue to recommend emergency use of remdesivir in moderate to severe disease level of patients with 10 days of onset of symptoms. However, the patients should not be on IMV or ECMO which require supplemental oxygen support. “Even remdesivir has been given only a very extremely limited role to be given in some selected patients. It’s not to be given freely. Only inhalational and injectable steroids should be given in severe cases,” said Dr Bajaj.

Not all cases require hospitalisation (Source: Express Photo by Amit Mehra)

The guidelines mention

Consider remdesivir for five days to treat hospitalised patients with Covid-19 (No evidence of benefit for treatment more than 5 days)
*Not to be used in patients who are not on oxygen support or in home setting.
*Monitor for RFT and LFT (remdesivir not recommended if eGFR5times UNL)(not an absolute contraindication).
Recommended dose: 200 mgIV on day1 followed by 100mg IV OD for next four days.

The most commonly reported symptoms of Covid-19 are:

*Dry cough, cold, sore throat
*Fever or chills
*Fatigue, tiredness, muscle or body aches
*Headache
*Congestion or runny nose
*Shortness of breath or difficulty breathing
*Loss of appetite/taste/smell

Experts say that the severity and duration of symptoms for people who have Covid-19 can vary; for most people, usually the symptoms take 7-14 days to subside. Some people may have no symptoms while others may require hospitalisation. Recovery from symptoms varies from person to person.

So, what is the takeaway from the latest guidelines?

The most important takeaway from the current guidelines is that almost all cases with mild Covid-19 can be managed without using too many drugs and just giving symptomatic treatment. “This means paracetamol for fever, decongestants for congestion, and cough syrup for cough. It can also be managed without doing too many investigations. So there is no role of doing blanket CT Scans or blanket blood tests or blanket X-Rays for every individual that come in with Covid-19. These patients can be managed just the way other viral fevers are managed with symptomatic treatment without doing too many investigations or no investigations at all,” asserted Dr Gilada.

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