Coronavirus disease 2019 (COVID-19)
Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
Look out for this icon: for treatment options that are affected, or added, as a result of your patient's comorbidities.
Patients with suspected or confirmed mild disease (i.e., symptomatic patients meeting the case definition for COVID-19 without evidence of hypoxia or pneumonia) and asymptomatic patients should be isolated to contain virus transmission.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1
Manage patients in a healthcare facility, in a community facility, or at home. Home isolation can be considered in most patients, with telemedicine or remote visits as appropriate.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1 [3]National Institutes of Health. Coronavirus disease 2019 (COVID-19) treatment guidelines. 2021 [internet publication]. https://covid19treatmentguidelines.nih.gov/ This decision requires careful clinical judgement and should be informed by an assessment of the patient’s home environment to ensure that: infection prevention and control measures and other requirements can be met (e.g., basic hygiene, adequate ventilation); the carer is able to provide care and recognise when the patient may be deteriorating; the carer has adequate support (e.g., food, supplies, psychological support); the support of a trained health worker is available in the community.[642]World Health Organization. Home care for patients with suspected or confirmed COVID-19 and management of their contacts: interim guidance. 2020 [internet publication]. https://www.who.int/publications-detail/home-care-for-patients-with-suspected-novel-coronavirus-(ncov)-infection-presenting-with-mild-symptoms-and-management-of-contacts The location of care will depend on guidance from local health authorities and available resources.
Pregnant women with suspected or confirmed mild disease may not require acute care in a hospital unless there is concern for rapid deterioration or an inability to return to hospital promptly.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1
Comorbidities in pregnancy and in children
The information in the BMJ Best Practice comorbidities tool relates to non-pregnant adults.
It is not intended for pregnant patients or for children. In these circumstances, please seek specialist obstetric/gynaecology or paediatric advice on how any comorbidities the patient has may affect your management of COVID-19.
Be aware of any comorbidity-associated risk of clinical deterioration and severe disease
Consider the presence of any comorbidities when deciding the setting for care and levels of monitoring.
The US Centers for Disease Control and Prevention's list of pre-existing conditions that do, or may increase the risk of severe illness with COVID-19 includes among others:[208]Centers for Disease Control and Prevention. Coronavirus disease 2019 (COVID-19): people at increased risk. 2021 [internet publication]. https://www.cdc.gov/coronavirus/2019-ncov/specific-groups/people-at-higher-risk.html
Chronic kidney disease
COPD
Coronary artery disease
Heart failure
Type 1 and type 2 diabetes
Asthma (moderate to severe)
Stroke
Hypertension
Dementia.
The World Health Organization adds that having a mental health disorder increases the risk of severe illness or death.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1
Older people are at increased risk of mortality with COVID-19.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1 [208]Centers for Disease Control and Prevention. Coronavirus disease 2019 (COVID-19): people at increased risk. 2021 [internet publication]. https://www.cdc.gov/coronavirus/2019-ncov/specific-groups/people-at-higher-risk.html
The Office of National Statistics reported that dementia was the most common pre-existing health condition in people whose deaths involved COVID-19 in England and Wales between March and June 2020.[280]Office for National Statistics. Deaths involving COVID-19, England and Wales: deaths occurring in June 2020. 2020 [internet publication]. https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsinvolvingcovid19englandandwales/deathsoccurringinjune2020
A large cohort study in England found that mortality risk was higher in people with type 1 compared with type 2 diabetes, when risk was adjusted for demographic factors and cardiovascular comorbidities.[229]Barron E, Bakhai C, Kar P, et al. Associations of type 1 and type 2 diabetes with COVID-19-related mortality in England: a whole-population study. Lancet Diabetes Endocrinol. 2020 Oct;8(10):813-22. https://www.thelancet.com/journals/landia/article/PIIS2213-8587(20)30272-2/fulltext http://www.ncbi.nlm.nih.gov/pubmed/32798472?tool=bestpractice.com
Monitor patients with risk factors closely, due to the possible risk of deterioration.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1
Consider discussing your patient with the specialist team managing their long-term condition, and/or referring to other healthcare professionals in the multidisciplinary team.
Multidisciplinary collaborative care is recommended for older people with COVID-19 to help ensure all aspects of care (including comorbidities) are adequately addressed.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1
Advise patients and household members to follow appropriate infection prevention and control measures:
Discontinue transmission-based precautions (including isolation) and release patients from the care pathway: 10 days after positive test (asymptomatic patients); 10 days after symptom onset plus at least 3 days without fever and respiratory symptoms (symptomatic patients).[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1 The US Centers for Disease Control and Prevention (CDC) recommends discontinuing home isolation once at least 10 days (or up to 20 days in patients who are severely immunocompromised) have passed since symptoms first appeared, and at least 24 hours have passed since last fever without the use of antipyretics, and symptoms have improved, if a symptom-based strategy is used. In asymptomatic people, the CDC recommends discontinuing home isolation once at least 10 days have passed since the date of a positive test. For severely immunocompromised patients who are asymptomatic, isolation may be discontinued when at least 10 days and up to 20 days have passed since the date of a positive test; consider consultation with infectious diseases specialists and infection control experts. Alternatively, the CDC recommends at least two negative reverse-transcription polymerase chain reaction (RT-PCR) tests on respiratory specimens collected 24 hours apart before ending isolation if a test-based strategy is used. A symptom-based strategy is preferred; however, a test-based strategy can be considered in severely immunocompromised patients.[662]Centers for Disease Control and Prevention. Discontinuation of isolation for persons with COVID-19 not in healthcare settings. 2021 [internet publication]. https://www.cdc.gov/coronavirus/2019-ncov/hcp/disposition-in-home-patients.html If the patient is hospitalised, CDC guidance for discontinuing isolation is the same as for moderate disease (see below). Guidance on when to stop isolation depends on local recommendations and may differ between countries. For example, in the UK the isolation period is 10 days in patients with milder disease who are managed in the community.[663]Public Health England. Guidance for stepdown of infection control precautions and discharging COVID-19 patients. 2020 [internet publication]. https://www.gov.uk/government/publications/covid-19-guidance-for-stepdown-of-infection-control-precautions-within-hospitals-and-discharging-covid-19-patients-from-hospital-to-home-settings/guidance-for-stepdown-of-infection-control-precautions-and-discharging-covid-19-patients
Treatment recommended for ALL patients in selected patient group
Closely monitor patients with risk factors for severe illness and counsel patients about signs and symptoms of deterioration or complications that require prompt urgent care (e.g., difficulty breathing, chest pain).[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1 [3]National Institutes of Health. Coronavirus disease 2019 (COVID-19) treatment guidelines. 2021 [internet publication]. https://covid19treatmentguidelines.nih.gov/
Pulse oximetry monitoring at home is recommended in symptomatic patients with risk factors for progression to severe disease who are not hospitalised. Patient education and appropriate follow-up are required.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1
Check baseline kidney function and monitor closely
Monitor kidney function especially closely if your patient with chronic kidney disease (CKD) or risk factors for CKD becomes ill with an acute condition.[759]National Institute for Health and Care Excellence. Acute kidney injury: prevention, detection and management. 2019 [internet publication]. https://www.nice.org.uk/guidance/ng148
CKD is a significant risk factor for acute kidney injury (AKI).[760]Hsu CY, Ordoñez JD, Chertow GM, et al. The risk of acute renal failure in patients with chronic kidney disease. Kidney Int. 2008 Jul;74(1):101-7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2673528/ http://www.ncbi.nlm.nih.gov/pubmed/18385668?tool=bestpractice.com
AKI in patients with COVID-19 may be common, although exact prevalence is uncertain. AKI is associated with increased mortality.[496]National Institute for Health and Care Excellence. COVID-19 rapid guideline: managing COVID-19. 2021 [internet publication]. https://www.nice.org.uk/guidance/ng191
Patients with CKD and COVID-19 will be at increased risk of AKI, which may be related to, among other factors, fever, dehydration, and use of non-steroidal anti-inflammatory drugs.
Explain to your patient with CKD that they are at increased risk of developing AKI when they become ill. Have mechanisms in place so patients being treated at home can be monitored closely for signs of disease progression.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1
For any patient with COVID-19 admitted to hospital, including those with CKD, check kidney function on admission, and ensure regular monitoring.
For patients with CKD:
Compare kidney function with last available results
Monitor kidney function daily, along with careful volume status monitoring (based on expert opinion).
Monitor for and respond to oliguria.[759]National Institute for Health and Care Excellence. Acute kidney injury: prevention, detection and management. 2019 [internet publication]. https://www.nice.org.uk/guidance/ng148
Treatment recommended for ALL patients in selected patient group
Advise patients to avoid lying on their back as this makes coughing ineffective. Use simple measures first (e.g., a teaspoon of honey in patients aged 1 year and older) to help cough.[496]National Institute for Health and Care Excellence. COVID-19 rapid guideline: managing COVID-19. 2021 [internet publication]. https://www.nice.org.uk/guidance/ng191 A meta-analysis found that honey is superior to usual care (e.g., antitussives) for the improvement of upper respiratory tract infection symptoms, particularly cough frequency and severity.[671]Abuelgasim H, Albury C, Lee J. Effectiveness of honey for symptomatic relief in upper respiratory tract infections: a systematic review and meta-analysis. BMJ Evid Based Med. 2021 Apr;26(2):57-64. https://ebm.bmj.com/content/early/2020/07/28/bmjebm-2020-111336 http://www.ncbi.nlm.nih.gov/pubmed/32817011?tool=bestpractice.com
Advise patients about adequate nutrition and appropriate rehydration. Advise patients to drink fluids regularly to avoid dehydration. Fluid intake needs can be higher than usual because of fever. However, too much fluid can worsen oxygenation.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1 [496]National Institute for Health and Care Excellence. COVID-19 rapid guideline: managing COVID-19. 2021 [internet publication]. https://www.nice.org.uk/guidance/ng191
Advise patients to improve air circulation by opening a window or door.[496]National Institute for Health and Care Excellence. COVID-19 rapid guideline: managing COVID-19. 2021 [internet publication]. https://www.nice.org.uk/guidance/ng191
Provide basic mental health and psychosocial support for all patients, and manage any symptoms of insomnia, depression, or anxiety as appropriate.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1
Consider treatment for olfactory dysfunction (e.g., olfactory training) if it persists beyond 2 weeks. There is no evidence to support the use of these treatments in patients with COVID-19.[672]Whitcroft KL, Hummel T. Olfactory dysfunction in COVID-19: diagnosis and management. JAMA. 2020 Jun 23;323(24):2512-4. https://jamanetwork.com/journals/jama/fullarticle/2766523 http://www.ncbi.nlm.nih.gov/pubmed/32432682?tool=bestpractice.com
Support patients with known depression
Support patients treated at home who have pre-existing mental health conditions, such as depression. They may be experiencing increased emotional distress.
The US Center for the Study of Traumatic Stress recommends psychiatrists discuss strategies with their patients to reduce distress and the impact of quarantine, and that they identify and provide additional support to high-risk patients.[761]Center for the Study of Traumatic Stress. Taking care of patients during the coronavirus outbreak: a guide for psychiatrists. 2020 [internet publication]. https://www.cstsonline.org/assets/media/documents/CSTS_FS_Taking_Care_of_Patients_During_Coronavirus_Outbreak_A_Guide_for_Psychiatrists_03_03_2020.pdf
Advise your patient on where to find locally relevant information and sources of support, for example:
There is limited evidence on the effect of quarantine due to the COVID-19 pandemic on people with pre-existing mental health conditions, but it is likely that people who have poor mental health may need additional support.[449]Brooks SK, Webster RK, Smith LE, et al. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. Lancet. 2020 Mar 14;395(10227):912-20. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30460-8/fulltext http://www.ncbi.nlm.nih.gov/pubmed/32112714?tool=bestpractice.com
Consider use of telemedicine to facilitate remote consultations.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1 [762]Shore JH, Schneck CD, Mishkind MC. Telepsychiatry and the coronavirus disease 2019 pandemic-current and future outcomes of the rapid virtualization of psychiatric care. JAMA Psychiatry. 2020 May 11 [Epub ahead of print]. https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2765954 http://www.ncbi.nlm.nih.gov/pubmed/32391861?tool=bestpractice.com [763]Hubley S, Lynch SB, Schneck C, et al. Review of key telepsychiatry outcomes. World J Psychiatry. 2016 Jun 22;6(2):269-82. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4919267/ http://www.ncbi.nlm.nih.gov/pubmed/27354970?tool=bestpractice.com
Treatment recommended for ALL patients in selected patient group
In consultation with the patient with dementia and their carers, agree an escalation plan as early as possible, as you would with any patient (based on expert opinion).
This should include:[764]Fritz Z, Slowther AM, Perkins GD. Resuscitation policy should focus on the patient, not the decision. BMJ. 2017 Feb 28;356:j813. https://www.bmj.com/content/356/bmj.j813.long http://www.ncbi.nlm.nih.gov/pubmed/28246084?tool=bestpractice.com
Resuscitation status (i.e., ‘Do Not Attempt Cardiopulmonary Resuscitation’ [DNACPR] decision)
Ceiling of care (e.g., suitability for intubation or intensive care admission).
Escalation plans should take account of advanced care planning, including legally binding advanced directives.[764]Fritz Z, Slowther AM, Perkins GD. Resuscitation policy should focus on the patient, not the decision. BMJ. 2017 Feb 28;356:j813. https://www.bmj.com/content/356/bmj.j813.long http://www.ncbi.nlm.nih.gov/pubmed/28246084?tool=bestpractice.com
In some situations, the patient with dementia will lack the mental capacity to make decisions for the escalation plan.
Assess and document mental capacity (the ability to make decisions at a specific time a decision needs to be made).[765]National Institute for Health and Care Excellence. Decision making and mental capacity. 2018 [internet publication]. https://www.nice.org.uk/guidance/ng108 Follow the appropriate legislation in your region.
In England and Wales, health professionals must comply with the 2005 Mental Capacity Act.[766]Department of Health. Mental Capacity Act 2005 [internet publication]. https://www.legislation.gov.uk/ukpga/2005/9/contents Assessments should follow the principles in the Act.[766]Department of Health. Mental Capacity Act 2005 [internet publication]. https://www.legislation.gov.uk/ukpga/2005/9/contents
If a patient is assessed to lack mental capacity, ensure decisions are made in the best interests of the patient.[765]National Institute for Health and Care Excellence. Decision making and mental capacity. 2018 [internet publication]. https://www.nice.org.uk/guidance/ng108 [766]Department of Health. Mental Capacity Act 2005 [internet publication]. https://www.legislation.gov.uk/ukpga/2005/9/contents
If the patient is assessed to lack mental capacity, consult with next of kin to make ‘best interests’ decisions.[766]Department of Health. Mental Capacity Act 2005 [internet publication]. https://www.legislation.gov.uk/ukpga/2005/9/contents
According to the 2005 Mental Capacity Act in England and Wales, if a patient is unbefriended and a decision is not time-critical, an independent mental capacity advocate (IMCA) should be sought to perform this role.[767]Social Care Institute for Excellence. Independent mental capacity advocate (IMCA). 2011 [internet publication]. https://www.scie.org.uk/mca/imca/do
Check the appropriate legislation for your territory.
Treatment recommended for SOME patients in selected patient group
Paracetamol or ibuprofen are recommended.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1 [496]National Institute for Health and Care Excellence. COVID-19 rapid guideline: managing COVID-19. 2021 [internet publication]. https://www.nice.org.uk/guidance/ng191 There is no evidence at present of severe adverse events in COVID-19 patients taking non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, or of effects as a result of the use of NSAIDs on acute healthcare utilisation, long-term survival, or quality of life in patients with COVID-19.[664]European Medicines Agency. EMA gives advice on the use of non-steroidal anti-inflammatories for COVID-19. 2020 [internet publication]. https://www.ema.europa.eu/en/news/ema-gives-advice-use-non-steroidal-anti-inflammatories-covid-19 [665]US Food and Drug Administration. FDA advises patients on use of non-steroidal anti-inflammatory drugs (NSAIDs) for COVID-19. 2020 [internet publication]. https://www.fda.gov/drugs/drug-safety-and-availability/fda-advises-patients-use-non-steroidal-anti-inflammatory-drugs-nsaids-covid-19 [666]Little P. Non-steroidal anti-inflammatory drugs and covid-19. BMJ. 2020 Mar 27;368:m1185. https://www.bmj.com/content/368/bmj.m1185 http://www.ncbi.nlm.nih.gov/pubmed/32220865?tool=bestpractice.com [667]Medicines and Healthcare products Regulatory Agency; Commission on Human Medicines. Commission on Human Medicines advice on ibuprofen and coronavirus (COVID-19). 2020 [internet publication]. https://www.gov.uk/government/news/commission-on-human-medicines-advice-on-ibuprofen-and-coronavirus-covid-19 [668]World Health Organization. The use of non-steroidal anti-inflammatory drugs (NSAIDs) in patients with COVID-19: scientific brief. 2020 [internet publication]. https://www.who.int/news-room/commentaries/detail/the-use-of-non-steroidal-anti-inflammatory-drugs-(nsaids)-in-patients-with-covid-19 [669]National Institute for Health and Care Excellence. COVID-19 rapid evidence summary: acute use of non-steroidal anti-inflammatory drugs (NSAIDs) for people with or at risk of COVID-19. 2020 [internet publication]. https://www.nice.org.uk/advice/es23/chapter/Key-messages [670]Wong AY, MacKenna B, Morton CE, et al. Use of non-steroidal anti-inflammatory drugs and risk of death from COVID-19: an OpenSAFELY cohort analysis based on two cohorts. Ann Rheum Dis. 2021 Jan 21 [Epub ahead of print]. https://ard.bmj.com/content/early/2021/01/20/annrheumdis-2020-219517.long http://www.ncbi.nlm.nih.gov/pubmed/33478953?tool=bestpractice.com
Ibuprofen should only be taken at the lowest effective dose for the shortest period needed to control symptoms. It is not recommended in pregnant women (especially in the third trimester) or children <6 months of age (age cut-offs vary by country).
NSAIDs in patients with chronic kidney disease, heart failure, or asthma
Non-steroidal anti-inflammatory drugs (NSAIDs):
Avoid NSAIDs in patients with chronic kidney disease and/or with heart failure (based on expert opinion)
NSAIDs can worsen symptoms in some patients with asthma, so check whether your patient has a known sensitivity.[768]Global Initiative for Asthma. Global strategy for asthma management and prevention. 2020 [internet publication]. https://ginasthma.org/gina-reports/
Primary options
paracetamol: children: consult local drug formulary for guidance on dose; adults: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day
paracetamol open_in_new: children: consult local drug formulary for guidance on dose; adults: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day
paracetamol: children: consult local drug formulary for guidance on dose; adults: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day
OR
ibuprofen: children: consult local drug formulary for guidance on dose; adults: 300-600 mg orally (immediate-release) every 6-8 hours when required, maximum 2400 mg/day
ibuprofen open_in_new: children: consult local drug formulary for guidance on dose; adults: 300-600 mg orally (immediate-release) every 6-8 hours when required, maximum 2400 mg/day
ibuprofen: children: consult local drug formulary for guidance on dose; adults: 300-600 mg orally (immediate-release) every 6-8 hours when required, maximum 2400 mg/day
These drug options and doses relate to a patient with no comorbidities.
Primary options
paracetamol: children: consult local drug formulary for guidance on dose; adults: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day
paracetamol open_in_new: children: consult local drug formulary for guidance on dose; adults: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day
paracetamol: children: consult local drug formulary for guidance on dose; adults: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day
OR
ibuprofen: children: consult local drug formulary for guidance on dose; adults: 300-600 mg orally (immediate-release) every 6-8 hours when required, maximum 2400 mg/day
ibuprofen open_in_new: children: consult local drug formulary for guidance on dose; adults: 300-600 mg orally (immediate-release) every 6-8 hours when required, maximum 2400 mg/day
ibuprofen: children: consult local drug formulary for guidance on dose; adults: 300-600 mg orally (immediate-release) every 6-8 hours when required, maximum 2400 mg/day
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Primary options
OR
The Renal Handbook
Treatment recommended for SOME patients in selected patient group
Consider appropriate experimental or emerging therapies.
Antiviral therapies will have a greater effect early in the course of the disease, whereas immunosuppressive/anti-inflammatory therapies are likely to have a greater effect later in the course of the disease.[3]National Institutes of Health. Coronavirus disease 2019 (COVID-19) treatment guidelines. 2021 [internet publication]. https://covid19treatmentguidelines.nih.gov/
See the Emerging external link opens in a new windowsection for more information.
Take the patient’s comorbidities into account when considering experimental therapies
The World Health Organization (WHO) recommends that you consider potential adverse effects and drug-drug interactions in patients with COVID-19.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1
One example of this is the effect on the QT interval. A patient may be on a drug that prolongs the QT interval. The patient may then receive another drug for COVID-19 that also prolongs the QT interval.
Consider your patient’s comorbidities and current treatments when prescribing any new medication.
Follow local drug protocol guidelines and consult senior colleagues before starting any new treatments.
Treatment recommended for ALL patients in selected patient group
Guidelines from several professional respiratory organisations agree that patients with asthma or COPD should be advised to continue to take their inhalers as prescribed (including inhaled corticosteroids), whether they do or do not also have COVID-19.[769]Global Initiative for Asthma. Recommendations for inhaled asthma controller medications. 2020 [internet publication]. https://ginasthma.org/recommendations-for-inhaled-asthma-controller-medications/ [770]British Thoracic Society. Advice for healthcare professionals treating people with asthma (adults) in relation to COVID-19. 2020 [internet publication]. https://www.brit-thoracic.org.uk/about-us/covid-19-information-for-the-respiratory-community/ [771]Global Initiative for Chronic Obstructive Lung Disease. GOLD COVID-19 guidance. 2020 [internet publication]. https://goldcopd.org/gold-covid-19-guidance/ [772]National Institute for Health and Care Excellence. COVID-19 rapid guideline: community-based care of patients with chronic obstructive pulmonary disease (COPD). 2020 [internet publication]. https://www.nice.org.uk/guidance/ng168 [773]Hasan SS, Capstick T, Zaidi STR, et al. Use of corticosteroids in asthma and COPD patients with or without COVID-19. Respir Med. 2020 Aug-Sep;170:106045. https://www.resmedjournal.com/article/S0954-6111(20)30185-2/fulltext http://www.ncbi.nlm.nih.gov/pubmed/32843175?tool=bestpractice.com
It is still unclear whether infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may trigger an exacerbation of asthma or COPD, but if it were to occur it could further compromise pulmonary reserve.[773]Hasan SS, Capstick T, Zaidi STR, et al. Use of corticosteroids in asthma and COPD patients with or without COVID-19. Respir Med. 2020 Aug-Sep;170:106045. https://www.resmedjournal.com/article/S0954-6111(20)30185-2/fulltext http://www.ncbi.nlm.nih.gov/pubmed/32843175?tool=bestpractice.com
The overall aim for continuing inhaled corticosteroids is to reduce the risk of an exacerbation of asthma or COPD.[773]Hasan SS, Capstick T, Zaidi STR, et al. Use of corticosteroids in asthma and COPD patients with or without COVID-19. Respir Med. 2020 Aug-Sep;170:106045. https://www.resmedjournal.com/article/S0954-6111(20)30185-2/fulltext http://www.ncbi.nlm.nih.gov/pubmed/32843175?tool=bestpractice.com
There is no evidence that inhaled corticosteroids are related to COVID-19 infection in people with asthma.[774]Centre for Evidence-Based Medicine; Hartmann-Boyce J, Hobbs R. Inhaled steroids in asthma during the COVID-19 outbreak. 2020 [internet publication]. https://www.cebm.net/covid-19/inhaled-steroids-in-asthma-during-the-covid-19-outbreak/ There is also no evidence they increase the risks associated with COVID-19 in people with COPD.[772]National Institute for Health and Care Excellence. COVID-19 rapid guideline: community-based care of patients with chronic obstructive pulmonary disease (COPD). 2020 [internet publication]. https://www.nice.org.uk/guidance/ng168
Patients being cared for at home or in hospital with an acute medical condition can forget to tell you about their inhalers prescribed for COPD or asthma. Remember to check and prescribe if appropriate.
Many inhalers contain a combination of medications, so ensure no dual prescribing.
Patients with COPD or asthma who develop acute kidney injury with an estimated GFR <50 mL/minute/1.73 m² may need to temporarily stop their usual inhaled long-acting muscarinic receptor antagonist, depending on which specific drug is used. Check local formulary or seek pharmacist advice.
Other prescribed medication
Patients with severe asthma or COPD who take oral corticosteroids as regular prescribed maintenance therapy should also continue to take these at the lowest dose possible, as their condition may deteriorate if these are stopped.[769]Global Initiative for Asthma. Recommendations for inhaled asthma controller medications. 2020 [internet publication]. https://ginasthma.org/recommendations-for-inhaled-asthma-controller-medications/ [772]National Institute for Health and Care Excellence. COVID-19 rapid guideline: community-based care of patients with chronic obstructive pulmonary disease (COPD). 2020 [internet publication]. https://www.nice.org.uk/guidance/ng168 [775]National Institute for Health and Care Excellence. COVID-19 rapid guideline: severe asthma. 2020 [internet publication]. https://www.nice.org.uk/guidance/ng166
The UK National Institute for Health and Care Excellence rapid guideline on severe asthma recommends that patients who take regular biological therapy for asthma should continue to take this during the COVID-19 pandemic, but if they become ill with COVID-19, patients should contact the specialist team responsible for their care.[775]National Institute for Health and Care Excellence. COVID-19 rapid guideline: severe asthma. 2020 [internet publication]. https://www.nice.org.uk/guidance/ng166
Treatment recommended for ALL patients in selected patient group
If your patient with COVID-19 is being managed at home, advise them to follow their personalised action plan if they think they are having an exacerbation of asthma and to seek medical advice.
Based on the evidence available to date, it is the opinion of the UK Primary Care Respiratory Society (PCRS) that the risk of inadequately treating an asthma exacerbation is likely to be worse than the risk from COVID-19 in most people with asthma.[776]Primary Care Respiratory Society. PCRS pragmatic guidance: diagnosing and managing asthma attacks and people with COPD presenting in crisis during the UK Covid 19 epidemic. 2020 [internet publication]. https://www.pcrs-uk.org/resource/pragmatic-guidance-crisis-management-asthma-and-copd-during-uk-covid-19-epidemic
The PCRS recommends to follow established guidelines if asthma worsens, and to start oral corticosteroids as indicated for asthma exacerbations.[773]Hasan SS, Capstick T, Zaidi STR, et al. Use of corticosteroids in asthma and COPD patients with or without COVID-19. Respir Med. 2020 Aug-Sep;170:106045. https://www.resmedjournal.com/article/S0954-6111(20)30185-2/fulltext http://www.ncbi.nlm.nih.gov/pubmed/32843175?tool=bestpractice.com [776]Primary Care Respiratory Society. PCRS pragmatic guidance: diagnosing and managing asthma attacks and people with COPD presenting in crisis during the UK Covid 19 epidemic. 2020 [internet publication]. https://www.pcrs-uk.org/resource/pragmatic-guidance-crisis-management-asthma-and-copd-during-uk-covid-19-epidemic [777]British Thoracic Society; Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma: a national clinical guideline. 2019 [internet publication]. https://www.sign.ac.uk/media/1048/sign158.pdf
Ensure safety netting measures are in place in case the patient does not improve or the situation changes.[776]Primary Care Respiratory Society. PCRS pragmatic guidance: diagnosing and managing asthma attacks and people with COPD presenting in crisis during the UK Covid 19 epidemic. 2020 [internet publication]. https://www.pcrs-uk.org/resource/pragmatic-guidance-crisis-management-asthma-and-copd-during-uk-covid-19-epidemic
Practical tip
Asthma exacerbation and COVID-19 may be difficult to differentiate clinically, and they may present together. Cough and shortness of breath are features of both; however, additional symptoms such as fever, fatigue, and change in taste or smell are more likely to suggest COVID-19.[770]British Thoracic Society. Advice for healthcare professionals treating people with asthma (adults) in relation to COVID-19. 2020 [internet publication]. https://www.brit-thoracic.org.uk/about-us/covid-19-information-for-the-respiratory-community/ Advise your patient with known COVID-19 to seek medical advice if there is a deterioration in symptoms.
Treatment recommended for ALL patients in selected patient group
If an exacerbation of COPD is suspected in a patient with COVID-19 and pre-existing COPD, follow the patient’s personalised action plan. If your patient is at home, ensure they know to seek medical advice.
Based on the limited evidence available, the Global Initiative for Chronic Obstructive Lung Disease recommends to follow established guidelines on the management of an exacerbation of COPD, including prescription of short-term oral corticosteroids if clinically indicated.[778]Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease. 2021 [internet publication]. https://goldcopd.org/2021-gold-reports/ [773]Hasan SS, Capstick T, Zaidi STR, et al. Use of corticosteroids in asthma and COPD patients with or without COVID-19. Respir Med. 2020 Aug-Sep;170:106045. https://www.resmedjournal.com/article/S0954-6111(20)30185-2/fulltext http://www.ncbi.nlm.nih.gov/pubmed/32843175?tool=bestpractice.com
See our topic Acute exacerbation of COPD.
Differentiate from other conditions, such as acute coronary syndrome, acute heart failure, and pneumonia, as well as from complications of COVID-19.
Treatment recommended for ALL patients in selected patient group
The World Health Organization recommends that antihypertensive drugs should not routinely be stopped in patients with COVID-19, but may need adjusting depending on the patient’s clinical condition, particularly their blood pressure and kidney function.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1
Despite concern about possible increased risk of infection or more severe disease in patients prescribed ACE inhibitors or angiotensin-II receptor antagonists, due to upregulation of angiotensin-converting enzyme-2 (ACE2) receptor expression, the UK National Institute for Health and Care Excellence states that the current evidence is insufficient to draw any conclusion.[779]National Institute for Health and Care Excellence. COVID-19 rapid evidence summary: angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) in people with or at risk of COVID-19. 2020 [internet publication]. https://www.nice.org.uk/advice/es24/chapter/Key-messages
Several professional societies have recommended that during the pandemic patients who are already on these medications (e.g., for hypertension, heart failure, coronary artery disease, CKD, or complications of diabetes) continue to take them (if they don’t have COVID-19). If patients become ill with COVID-19, it is recommended they receive a full clinical assessment by their doctor before making any decisions to stop these medications.[780]American Heart Association; Heart Failure Society of America; American College of Cardiology. Patients taking ACE-i and ARBs who contract COVID-19 should continue treatment, unless otherwise advised by their physician. 2020 [internet publication]. https://newsroom.heart.org/news/patients-taking-ace-i-and-arbs-who-contract-covid-19-should-continue-treatment-unless-otherwise-advised-by-their-physician [781]European Society of Cardiology Council on Hypertension. Position statement of the ESC Council on Hypertension on ACE-inhibitors and angiotensin receptor blockers. 2020 [internet publication]. https://www.escardio.org/Councils/Council-on-Hypertension-(CHT)/News/position-statement-of-the-esc-council-on-hypertension-on-ace-inhibitors-and-ang [782]British Cardiovascular Society; British Society for Heart Failure. BSH & BCS joint statement on ACEi or ARB in relation to COVID-19. 2020 [internet publication]. https://www.britishcardiovascularsociety.org/news/ACEi-or-ARB-and-COVID-19 [783]The Renal Association. The Renal Association, UK position statement on COVID-19 and ACE inhibitor/angiotensin receptor blocker use. 2020 [internet publication]. https://renal.org/health-professionals/covid-19/ra-resources/renal-association-uk-position-statement-covid-19-and-ace
The UK Renal Association and the British Cardiovascular Society recommend following standard current guidance for patients with any intercurrent acute illness when weighing up benefit versus risk of these medications in patients ill with suspected COVID-19.[782]British Cardiovascular Society; British Society for Heart Failure. BSH & BCS joint statement on ACEi or ARB in relation to COVID-19. 2020 [internet publication]. https://www.britishcardiovascularsociety.org/news/ACEi-or-ARB-and-COVID-19 [783]The Renal Association. The Renal Association, UK position statement on COVID-19 and ACE inhibitor/angiotensin receptor blocker use. 2020 [internet publication]. https://renal.org/health-professionals/covid-19/ra-resources/renal-association-uk-position-statement-covid-19-and-ace [784]Clark AL, Kalra PR, Petrie MC, et al. Change in renal function associated with drug treatment in heart failure: national guidance. Heart. 2019 Jun;105(12):904-10. https://heart.bmj.com/content/105/12/904.long http://www.ncbi.nlm.nih.gov/pubmed/31118203?tool=bestpractice.com These include to:
Do an individual clinical assessment
Consider the original indication for any renin-angiotensin-aldosterone system (RAAS) inhibitors (ACE inhibitors, angiotensin-II receptor antagonists, mineralocorticoid receptor/aldosterone antagonists) and degree of prognostic benefit
If medication is temporarily withheld, consider when to re-introduce again once health improves.
Consider calculating a frailty score as patients with higher frailty scores may be more likely to experience medication-related harm when acutely unwell (based on expert opinion).
Consider the benefit versus risk of stopping other medications associated with an increased risk of acute kidney injury during intercurrent illness, such as other antihypertensives and diuretics.
If your patient with chronic kidney disease has been taking non-steroidal anti-inflammatory drugs, advise them to stop taking these when they are ill.
Patients who self-manage their heart failure in a community setting may wish to reduce their dose of diuretics during an intercurrent illness that may result in dehydration (based on expert opinion).
Seek advice from the patient’s cardiology or nephrology team if they have complex conditions (e.g., on renal replacement therapy or immunosuppressive therapy).
Treatment recommended for ALL patients in selected patient group
If a patient with diabetes becomes ill at home with mild COVID-19, advise them to follow sick-day rules and seek medical advice.[785]European Society of Endocrinology. COVID-19 and endocrine diseases: a statement from the European Society of Endocrinology. 2020 [internet publication]. https://www.ese-hormones.org/media/2223/covid-and-endocrine-diseases-ese-statement-final_23032020.pdf
Despite limited evidence for this situation, diabetes self-management generally still follows the standard sick-day rules.[786]Centre for Evidence-Based Medicine; Hartmann-Boyce J, Morris E, Goyder C, et al. Managing diabetes during the COVID-19 pandemic. 2020 [internet publication]. https://www.cebm.net/covid-19/managing-diabetes-during-the-covid-19-pandemic/
Practical tip
Ensure your patient has adequate supplies of their diabetes medication and blood glucose monitoring equipment. If your patient has type 1 diabetes, ensure they also have a ketone meter and ketone strips.
Advise patients to follow sick-day rules from their individual healthcare provider or relevant national or regional professional diabetes organisation.[787]American Diabetes Association. COVID-19: If you do get sick, know what to do. 2020 [internet publication]. https://www.diabetes.org/blog/coronavirus-covid-19-know-what-to-do [788]Trend Diabetes. Trend releases updated sick-day rules leaflets. 2020 [internet publication]. https://trend-uk.org/trend-uk-releases-updated-sick-day-rules-leaflets/ [789]Primary Care Diabetes Society. How to advise on sick day rules. 2020 [internet publication]. https://www.diabetesonthenet.com/journals/issue/607/article-details/how-to-advise-on-sick-day-rules [790]NHS England. Diabetes COVID-19 key information: sick day rules. 2020 [internet publication]. https://www.england.nhs.uk/london/london-clinical-networks/our-networks/diabetes/diabetes-covid-19-key-information/ [791]International Diabetes Federation Europe. How to manage diabetes during an illness. 2020 [internet publication]. https://idf.org/our-network/regions-members/europe/europe-news/196-information-on-corona-virus-disease-2019-covid-19-outbreak-and-guidance-for-people-with-diabetes.html [792]Diabetes Australia; Royal Australian College of General Practitioners. Diabetes management during the coronavirus pandemic: be proactive and prepared. 2020 [internet publication]. https://static.diabetesaustralia.com.au/s/fileassets/diabetes-australia/6aab1606-d77f-45bc-8f4f-df58f0471d0e.pdf
Key general points include to:[788]Trend Diabetes. Trend releases updated sick-day rules leaflets. 2020 [internet publication]. https://trend-uk.org/trend-uk-releases-updated-sick-day-rules-leaflets/ [789]Primary Care Diabetes Society. How to advise on sick day rules. 2020 [internet publication]. https://www.diabetesonthenet.com/journals/issue/607/article-details/how-to-advise-on-sick-day-rules
Contact their family doctor
Increase blood glucose monitoring
Drink sugar-free fluids to prevent dehydration, as this can contribute to quick progression to:
Hyperglycaemia
Diabetic ketoacidosis (DKA)
Maintain carbohydrate intake (this may be with sugary fluids if not able to eat or vomiting)
Rest and avoid strenuous exercise
Understand at what stage to seek further medical help (e.g., blood glucose levels remain higher than usual, they feel unwell and are not improving, they are not sure how to manage their condition themselves).
Advise your patient with diabetes to seek urgent medical help if they are unable to keep any fluids down and cannot control their blood glucose.
Practical tip
Be aware that blood glucose can increase during illness even when not eating. People who are ill with COVID-19 appear to have an even greater risk of developing hyperglycaemia with ketones, even if they have type 2 diabetes.[793]National Inpatient Diabetes COVID-19 Response Group. Concise advice on inpatient diabetes during COVID-19: front door guidance. 2020 [internet publication]. https://abcd.care/resource/concise-advice-inpatient-diabetes-during-covid-19-front-door-guidance
People with type 1 diabetes
In addition to the general points above, make sure patients with type 1 diabetes are aware of the need to:[789]Primary Care Diabetes Society. How to advise on sick day rules. 2020 [internet publication]. https://www.diabetesonthenet.com/journals/issue/607/article-details/how-to-advise-on-sick-day-rules
Monitor their blood glucose at least every 4 to 6 hours
Test their blood for ketones and understand what these levels mean and what actions are required
Never stop insulin and adjust the dose if necessary.
Insulin dose increases are needed, even when not eating or vomiting, if blood glucose levels are >11 mmol/L (>198 mg/dL).
Consult local protocols for detailed step-by-step guidance on managing insulin dosing and frequency of blood glucose and ketone monitoring.
If your patient with type 1 diabetes usually takes a sodium-glucose cotransporter-2 (SGLT-2) inhibitor (e.g., dapagliflozin, canagliflozin, empagliflozin), most COVID-related consensus statements recommend these should be stopped during acute illness.[794]Hartmann-Boyce J, Morris E, Goyder C, et al. Diabetes and COVID-19: risks, management, and learnings from other national disasters. Diabetes Care. 2020 Aug;43(8):1695-703. https://care.diabetesjournals.org/content/43/8/1695 http://www.ncbi.nlm.nih.gov/pubmed/32546593?tool=bestpractice.com
Advise your patient to test their blood for ketones even if their blood glucose is not elevated.[793]National Inpatient Diabetes COVID-19 Response Group. Concise advice on inpatient diabetes during COVID-19: front door guidance. 2020 [internet publication]. https://abcd.care/resource/concise-advice-inpatient-diabetes-during-covid-19-front-door-guidance
Patients on SGLT-2 inhibitors are at risk of euglycaemic ketoacidosis.[795]Peters AL, Buschur EO, Buse JB, et al. Euglycemic diabetic ketoacidosis: a potential complication of treatment with sodium-glucose cotransporter 2 inhibition. Diabetes Care. 2015 Sep;38(9):1687-93. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4542270/ http://www.ncbi.nlm.nih.gov/pubmed/26078479?tool=bestpractice.com [796]Medicines and Healthcare products Regulatory Agency. SGLT2 inhibitors: updated advice on the risk of diabetic ketoacidosis. 2016 [internet publication]. https://www.gov.uk/drug-safety-update/sglt2-inhibitors-updated-advice-on-the-risk-of-diabetic-ketoacidosis They should test their blood for ketones even after they have stopped their SGLT-2 inhibitor.
People with type 2 diabetes
COVID-19 infection increases insulin resistance and reduces insulin secretion from the pancreatic beta cells. This can precipitate DKA in people with type 2 diabetes and even in people without previous diabetes.
In addition to the general points above, make sure patients with type 2 diabetes are aware of the need to:
Contact their family doctor to get advice on whether to adjust their diabetes medication.
Patients with type 2 diabetes on insulin should monitor their blood glucose at least four times a day and usually continue their insulin, although the dose may need adjusting (based on expert opinion).
Patients who usually take a SGLT-2 inhibitor (e.g., dapagliflozin, canagliflozin, empagliflozin) are recommended, in most COVID-19 consensus statements, to stop this medication during acute illness.[794]Hartmann-Boyce J, Morris E, Goyder C, et al. Diabetes and COVID-19: risks, management, and learnings from other national disasters. Diabetes Care. 2020 Aug;43(8):1695-703. https://care.diabetesjournals.org/content/43/8/1695 http://www.ncbi.nlm.nih.gov/pubmed/32546593?tool=bestpractice.com They are at risk of euglycaemic ketoacidosis with SGLT-2 inhibitors and should check for blood ketones even once the medication is stopped.[795]Peters AL, Buschur EO, Buse JB, et al. Euglycemic diabetic ketoacidosis: a potential complication of treatment with sodium-glucose cotransporter 2 inhibition. Diabetes Care. 2015 Sep;38(9):1687-93. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4542270/ http://www.ncbi.nlm.nih.gov/pubmed/26078479?tool=bestpractice.com [796]Medicines and Healthcare products Regulatory Agency. SGLT2 inhibitors: updated advice on the risk of diabetic ketoacidosis. 2016 [internet publication]. https://www.gov.uk/drug-safety-update/sglt2-inhibitors-updated-advice-on-the-risk-of-diabetic-ketoacidosis [797]Trend Diabetes. Type 2 diabetes: what to do when you’re ill. 2020 [internet publication]. https://trend-uk.org/wp-content/uploads/2020/03/A5_T2Illness_TREND_FINAL.pdf This may be something the patient is not familiar with doing, so organise this to be done urgently.[797]Trend Diabetes. Type 2 diabetes: what to do when you’re ill. 2020 [internet publication]. https://trend-uk.org/wp-content/uploads/2020/03/A5_T2Illness_TREND_FINAL.pdf
Patients who usually take metformin are also advised, in most COVID-related consensus statements, to stop this medication during acute illness.[794]Hartmann-Boyce J, Morris E, Goyder C, et al. Diabetes and COVID-19: risks, management, and learnings from other national disasters. Diabetes Care. 2020 Aug;43(8):1695-703. https://care.diabetesjournals.org/content/43/8/1695 http://www.ncbi.nlm.nih.gov/pubmed/32546593?tool=bestpractice.com In this situation, metformin increases the risk of lactic acidosis.
Be aware that withholding diabetes medications such as SGLT-2 inhibitors or metformin may result in hyperglycaemia so patients should seek diabetes specialist advice on whether further action may be required (based on expert opinion).
Patients who usually take gliclazide may need to reduce or omit a dose if they are not eating and drinking to avoid hypoglycaemia at night (based on expert opinion). On the other hand, during illness, some patients may develop hyperglycaemia so may need to temporarily increase their dose.[797]Trend Diabetes. Type 2 diabetes: what to do when you’re ill. 2020 [internet publication]. https://trend-uk.org/wp-content/uploads/2020/03/A5_T2Illness_TREND_FINAL.pdf Blood glucose monitoring is crucial to guide these decisions.
Sick-day rules from some diabetes organisations also recommend that patients stop glucagon-like peptide-1 (GLP-1) agonists (e.g., dulaglutide, exenatide, liraglutide, lixisenatide).[798]NHS London Clinical Networks. Sick day rules: how to manage type 2 diabetes if you become unwell with coronavirus and what to do with your medication. 2020 [internet publication]. https://www.england.nhs.uk/london/wp-content/uploads/sites/8/2020/04/3.-Covid-19-Type-2-Sick-Day-Rules-Crib-Sheet-06042020.pdf Other guidance recommends that patients who are on GLP-1 agonists should be monitored closely due to serious adverse effects with dehydration.[799]Bornstein SR, Rubino F, Khunti K, et al. Practical recommendations for the management of diabetes in patients with COVID-19. Lancet Diabetes Endocrinol. 2020 Jun;8(6):546-50. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7180013/ http://www.ncbi.nlm.nih.gov/pubmed/32334646?tool=bestpractice.com
Practical tip
Check blood ketones as urinary ketone measurement may be unreliable.
Patients with suspected or confirmed moderate disease (i.e., clinical signs of pneumonia but no signs of severe pneumonia) should be isolated to contain virus transmission.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1
Manage patients in a healthcare facility, in a community facility, or at home. Home isolation, with telemedicine or remote visits as appropriate, can be considered in low-risk patients. Manage patients at high risk of deterioration and pregnant women in a healthcare facility.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1 [3]National Institutes of Health. Coronavirus disease 2019 (COVID-19) treatment guidelines. 2021 [internet publication]. https://covid19treatmentguidelines.nih.gov/
Comorbidities in pregnancy and in children
The information in the BMJ Best Practice comorbidities tool relates to non-pregnant adults.
It is not intended for pregnant patients or for children. In these circumstances, please seek specialist obstetric/gynaecology or paediatric advice on how any comorbidities the patient has may affect your management of COVID-19.
Be aware of any comorbidity-associated risk of clinical deterioration and severe disease
Consider the presence of any comorbidities when deciding the setting for care and levels of monitoring.
The US Centers for Disease Control and Prevention's list of pre-existing conditions that do, or may increase the risk of severe illness with COVID-19 includes among others:[208]Centers for Disease Control and Prevention. Coronavirus disease 2019 (COVID-19): people at increased risk. 2021 [internet publication]. https://www.cdc.gov/coronavirus/2019-ncov/specific-groups/people-at-higher-risk.html
Chronic kidney disease
COPD
Coronary artery disease
Heart failure
Type 1 and type 2 diabetes
Asthma (moderate to severe)
Stroke
Hypertension
Dementia.
The World Health Organization adds that having a mental health disorder increases the risk of severe illness or death.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1
Older people are at increased risk of mortality with COVID-19.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1 [208]Centers for Disease Control and Prevention. Coronavirus disease 2019 (COVID-19): people at increased risk. 2021 [internet publication]. https://www.cdc.gov/coronavirus/2019-ncov/specific-groups/people-at-higher-risk.html
The Office of National Statistics reported that dementia was the most common pre-existing health condition in people whose deaths involved COVID-19 in England and Wales between March and June 2020.[280]Office for National Statistics. Deaths involving COVID-19, England and Wales: deaths occurring in June 2020. 2020 [internet publication]. https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsinvolvingcovid19englandandwales/deathsoccurringinjune2020
A large cohort study in England found that mortality risk was higher in people with type 1 compared with type 2 diabetes, when risk was adjusted for demographic factors and cardiovascular comorbidities.[229]Barron E, Bakhai C, Kar P, et al. Associations of type 1 and type 2 diabetes with COVID-19-related mortality in England: a whole-population study. Lancet Diabetes Endocrinol. 2020 Oct;8(10):813-22. https://www.thelancet.com/journals/landia/article/PIIS2213-8587(20)30272-2/fulltext http://www.ncbi.nlm.nih.gov/pubmed/32798472?tool=bestpractice.com
Monitor patients with risk factors closely, due to the possible risk of deterioration.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1
Consider discussing your patient with the specialist team managing their long-term condition, and/or referring to other healthcare professionals in the multidisciplinary team.
Multidisciplinary collaborative care is recommended for older people with COVID-19 to help ensure all aspects of care (including comorbidities) are adequately addressed.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1
Implement local infection prevention and control procedures when managing patients with COVID-19. For patients in home isolation, advise patients and household members to follow appropriate infection prevention and control measures:
Discontinue transmission-based precautions (including isolation) and release patients from the care pathway 10 days after symptom onset plus at least 3 days without fever and respiratory symptoms.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1 [673]Centers for Disease Control and Prevention. Discontinuation of transmission-based precautions and disposition of patients with SARS-CoV-2 infection in healthcare settings. 2021 [internet publication]. https://www.cdc.gov/coronavirus/2019-ncov/hcp/disposition-hospitalized-patients.html The US Centers for Disease Control and Prevention (CDC) recommends discontinuing isolation once at least 10 days (not severely immunocompromised) or up to 20 days (severely immunocompromised) have passed since symptoms first appeared, and at least 24 hours have passed since last fever without the use of antipyretics, and symptoms have improved, if a symptom-based strategy is used. In asymptomatic people, the CDC recommends discontinuing isolation once at least 10 days (not severely immunocompromised) or up to 20 days (severely immunocompromised) have passed since the date of a positive test. Severely immunocompromised patients may produce replication-competent virus beyond 20 days and require additional testing and consultation with infectious diseases specialists and infection control experts before discontinuing isolation. Alternatively, the CDC recommends at least two negative reverse-transcription polymerase chain reaction (RT-PCR) tests on respiratory specimens collected 24 hours apart before ending isolation if a test-based strategy is used. A symptom-based strategy is preferred; however, a test-based strategy can be considered in severely immunocompromised patients.[673]Centers for Disease Control and Prevention. Discontinuation of transmission-based precautions and disposition of patients with SARS-CoV-2 infection in healthcare settings. 2021 [internet publication]. https://www.cdc.gov/coronavirus/2019-ncov/hcp/disposition-hospitalized-patients.html If the patient is isolated at home, CDC guidance for discontinuing isolation is the same as for mild disease (see above). Guidance on when to stop isolation depends on local recommendations and may differ between countries. For example, in the UK the isolation period is 14 days from a positive test in hospitalised patients, and 10 days in patients with milder disease who are managed in the community. Immunocompetent patients who tested positive on RT-PCR and have completed their 14-day isolation period are exempt from testing prior to hospital discharge if they are within 90 days from their initial illness onset or test, unless they develop new symptoms.[663]Public Health England. Guidance for stepdown of infection control precautions and discharging COVID-19 patients. 2020 [internet publication]. https://www.gov.uk/government/publications/covid-19-guidance-for-stepdown-of-infection-control-precautions-within-hospitals-and-discharging-covid-19-patients-from-hospital-to-home-settings/guidance-for-stepdown-of-infection-control-precautions-and-discharging-covid-19-patients
Treatment recommended for ALL patients in selected patient group
Closely monitor patients for signs or symptoms of disease progression. If the patient is being managed at home, counsel them about signs and symptoms of deterioration or complications that require prompt urgent care (e.g., difficulty breathing, chest pain). Pulse oximetry monitoring at home is recommended in symptomatic patients with risk factors for progression to severe disease who are not hospitalised. Patient education and appropriate follow-up are required. If the patient is being managed in hospital, monitor patients closely for signs of clinical deterioration using medical early warning scores (e.g., National Early Warning Score 2 [NEWS2]), and respond immediately with appropriate supportive care interventions.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1
Check baseline kidney function and monitor closely
Monitor kidney function especially closely if your patient with chronic kidney disease (CKD) or risk factors for CKD becomes ill with an acute condition.[759]National Institute for Health and Care Excellence. Acute kidney injury: prevention, detection and management. 2019 [internet publication]. https://www.nice.org.uk/guidance/ng148
CKD is a significant risk factor for acute kidney injury (AKI).[760]Hsu CY, Ordoñez JD, Chertow GM, et al. The risk of acute renal failure in patients with chronic kidney disease. Kidney Int. 2008 Jul;74(1):101-7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2673528/ http://www.ncbi.nlm.nih.gov/pubmed/18385668?tool=bestpractice.com
AKI in patients with COVID-19 may be common, although exact prevalence is uncertain. AKI is associated with increased mortality.[496]National Institute for Health and Care Excellence. COVID-19 rapid guideline: managing COVID-19. 2021 [internet publication]. https://www.nice.org.uk/guidance/ng191
Patients with CKD and COVID-19 will be at increased risk of AKI, which may be related to, among other factors, fever, dehydration, and use of non-steroidal anti-inflammatory drugs.
Explain to your patient with CKD that they are at increased risk of developing AKI when they become ill. Have mechanisms in place so patients being treated at home can be monitored closely for signs of disease progression.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1
For any patient with COVID-19 admitted to hospital, including those with CKD, check kidney function on admission, and ensure regular monitoring.
For patients with CKD:
Compare kidney function with last available results
Monitor kidney function daily, along with careful volume status monitoring (based on expert opinion).
Monitor for and respond to oliguria.[759]National Institute for Health and Care Excellence. Acute kidney injury: prevention, detection and management. 2019 [internet publication]. https://www.nice.org.uk/guidance/ng148
Treatment recommended for ALL patients in selected patient group
Advise patients to avoid lying on their back as this makes coughing ineffective. Use simple measures first (e.g., a teaspoon of honey in patients aged 1 year and older) to help cough.[496]National Institute for Health and Care Excellence. COVID-19 rapid guideline: managing COVID-19. 2021 [internet publication]. https://www.nice.org.uk/guidance/ng191 A meta-analysis found that honey is superior to usual care (e.g., antitussives) for the improvement of upper respiratory tract infection symptoms, particularly cough frequency and severity.[671]Abuelgasim H, Albury C, Lee J. Effectiveness of honey for symptomatic relief in upper respiratory tract infections: a systematic review and meta-analysis. BMJ Evid Based Med. 2021 Apr;26(2):57-64. https://ebm.bmj.com/content/early/2020/07/28/bmjebm-2020-111336 http://www.ncbi.nlm.nih.gov/pubmed/32817011?tool=bestpractice.com
Advise patients about adequate nutrition and appropriate rehydration. Advise patients to drink fluids regularly to avoid dehydration. Fluid intake needs can be higher than usual because of fever. However, too much fluid can worsen oxygenation.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1 [496]National Institute for Health and Care Excellence. COVID-19 rapid guideline: managing COVID-19. 2021 [internet publication]. https://www.nice.org.uk/guidance/ng191
Continue to monitor fluid balance particularly closely
Maintaining optimal fluid status is critical but it can be hard to achieve in all patients with COVID-19.[496]National Institute for Health and Care Excellence. COVID-19 rapid guideline: managing COVID-19. 2021 [internet publication]. https://www.nice.org.uk/guidance/ng191 Seek senior advice, particularly for complex patients, such as those with heart failure and/or chronic kidney disease (CKD).
There is a risk of pulmonary oedema with fluid resuscitation in patients with heart failure and/or CKD so monitor closely (every hour initially).
Monitoring should include:
Regular clinical assessment of volume status (pulse, BP, jugular venous pressure [JVP], and check for pulmonary and peripheral oedema)
Fluid balance (input/output chart) and daily weight
Kidney function check, at least daily.
Consider bladder catheterisation if urinary output is difficult to measure, but be aware of increased risk of infection and trauma.
Central venous pressure or pulmonary artery catheterisation monitoring may be needed in complex patients.[800]Verbrugge FH, Grieten L, Mullens W. Management of the cardiorenal syndrome in decompensated heart failure. Cardiorenal Med. 2014 Dec;4(3-4):176-88. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4299260/ http://www.ncbi.nlm.nih.gov/pubmed/25737682?tool=bestpractice.com
It’s important to know when to de-escalate fluid therapy. Consider early senior input to support this decision.
If the patient has been volume overloaded with fluid (signs include elevated pulse rate, elevated respiratory rate due to pulmonary oedema, and an elevated JVP with peripheral oedema), stop fluid resuscitation, ask for senior help, and consider intravenous diuretics (based on expert opinion).
Unless there are extenuating circumstances, diuretics and intravenous fluids are not generally given together (based on expert opinion).
Specialist input may be required from a cardiologist and/or nephrologist.
Advise patients to improve air circulation by opening a window or door.[496]National Institute for Health and Care Excellence. COVID-19 rapid guideline: managing COVID-19. 2021 [internet publication]. https://www.nice.org.uk/guidance/ng191
Provide basic mental health and psychosocial support for all patients, and manage any symptoms of insomnia, depression, or anxiety as appropriate.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1
Consider treatment for olfactory dysfunction (e.g., olfactory training) if it persists beyond 2 weeks. There is no evidence to support the use of these treatments in patients with COVID-19.[672]Whitcroft KL, Hummel T. Olfactory dysfunction in COVID-19: diagnosis and management. JAMA. 2020 Jun 23;323(24):2512-4. https://jamanetwork.com/journals/jama/fullarticle/2766523 http://www.ncbi.nlm.nih.gov/pubmed/32432682?tool=bestpractice.com
Support patients with known depression
Support patients treated at home who have pre-existing mental health conditions, such as depression. They may be experiencing increased emotional distress.
The US Center for the Study of Traumatic Stress recommends psychiatrists discuss strategies with their patients to reduce distress and the impact of quarantine, and that they identify and provide additional support to high-risk patients.[761]Center for the Study of Traumatic Stress. Taking care of patients during the coronavirus outbreak: a guide for psychiatrists. 2020 [internet publication]. https://www.cstsonline.org/assets/media/documents/CSTS_FS_Taking_Care_of_Patients_During_Coronavirus_Outbreak_A_Guide_for_Psychiatrists_03_03_2020.pdf
Advise your patient on where to find locally relevant information and sources of support, for example:
There is limited evidence on the effect of quarantine due to the COVID-19 pandemic on people with pre-existing mental health conditions, but it is likely that people who have poor mental health may need additional support.[449]Brooks SK, Webster RK, Smith LE, et al. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. Lancet. 2020 Mar 14;395(10227):912-20. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30460-8/fulltext http://www.ncbi.nlm.nih.gov/pubmed/32112714?tool=bestpractice.com
Consider use of telemedicine to facilitate remote consultations.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1 [762]Shore JH, Schneck CD, Mishkind MC. Telepsychiatry and the coronavirus disease 2019 pandemic-current and future outcomes of the rapid virtualization of psychiatric care. JAMA Psychiatry. 2020 May 11 [Epub ahead of print]. https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2765954 http://www.ncbi.nlm.nih.gov/pubmed/32391861?tool=bestpractice.com [763]Hubley S, Lynch SB, Schneck C, et al. Review of key telepsychiatry outcomes. World J Psychiatry. 2016 Jun 22;6(2):269-82. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4919267/ http://www.ncbi.nlm.nih.gov/pubmed/27354970?tool=bestpractice.com
Treatment recommended for ALL patients in selected patient group
In consultation with the patient with dementia and their carers, agree an escalation plan as early as possible, as you would with any patient (based on expert opinion).
This should include:[764]Fritz Z, Slowther AM, Perkins GD. Resuscitation policy should focus on the patient, not the decision. BMJ. 2017 Feb 28;356:j813. https://www.bmj.com/content/356/bmj.j813.long http://www.ncbi.nlm.nih.gov/pubmed/28246084?tool=bestpractice.com
Resuscitation status (i.e., ‘Do Not Attempt Cardiopulmonary Resuscitation’ [DNACPR] decision)
Ceiling of care (e.g., suitability for intubation or intensive care admission).
Escalation plans should take account of advanced care planning, including legally binding advanced directives.[764]Fritz Z, Slowther AM, Perkins GD. Resuscitation policy should focus on the patient, not the decision. BMJ. 2017 Feb 28;356:j813. https://www.bmj.com/content/356/bmj.j813.long http://www.ncbi.nlm.nih.gov/pubmed/28246084?tool=bestpractice.com
In some situations, the patient with dementia will lack the mental capacity to make decisions for the escalation plan.
Assess and document mental capacity (the ability to make decisions at a specific time a decision needs to be made).[765]National Institute for Health and Care Excellence. Decision making and mental capacity. 2018 [internet publication]. https://www.nice.org.uk/guidance/ng108 Follow the appropriate legislation in your region.
In England and Wales, health professionals must comply with the 2005 Mental Capacity Act.[766]Department of Health. Mental Capacity Act 2005 [internet publication]. https://www.legislation.gov.uk/ukpga/2005/9/contents Assessments should follow the principles in the Act.[766]Department of Health. Mental Capacity Act 2005 [internet publication]. https://www.legislation.gov.uk/ukpga/2005/9/contents
If a patient is assessed to lack mental capacity, ensure decisions are made in the best interests of the patient.[765]National Institute for Health and Care Excellence. Decision making and mental capacity. 2018 [internet publication]. https://www.nice.org.uk/guidance/ng108 [766]Department of Health. Mental Capacity Act 2005 [internet publication]. https://www.legislation.gov.uk/ukpga/2005/9/contents
If the patient is assessed to lack mental capacity, consult with next of kin to make ‘best interests’ decisions.[766]Department of Health. Mental Capacity Act 2005 [internet publication]. https://www.legislation.gov.uk/ukpga/2005/9/contents
According to the 2005 Mental Capacity Act in England and Wales, if a patient is unbefriended and a decision is not time-critical, an independent mental capacity advocate (IMCA) should be sought to perform this role.[767]Social Care Institute for Excellence. Independent mental capacity advocate (IMCA). 2011 [internet publication]. https://www.scie.org.uk/mca/imca/do
Check the appropriate legislation for your territory.
Treatment recommended for ALL patients in selected patient group
Management in the community setting
If your patient with diabetes and moderate COVID-19 is self managing in the community, ensure they are familiar with sick-day rules and know when to seek medical help (see ‘advise patients on self-management of their diabetes’ in the Mild COVID-19 patient group for more details).
Management in the hospital setting
If your patient with diabetes and moderate COVID-19 is admitted to hospital, do not stop insulin in any patients with type 1 diabetes and see information on diabetes as a comorbidity in the Severe COVID-19 patient group for more details.
Treatment recommended for SOME patients in selected patient group
Consider empirical antibiotics only if there is clinical suspicion of secondary bacterial infection. Start treatment as soon as possible, and refer to local guidelines for choice of regimen.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1 [3]National Institutes of Health. Coronavirus disease 2019 (COVID-19) treatment guidelines. 2021 [internet publication]. https://covid19treatmentguidelines.nih.gov/ [496]National Institute for Health and Care Excellence. COVID-19 rapid guideline: managing COVID-19. 2021 [internet publication]. https://www.nice.org.uk/guidance/ng191 The regimen should be based on the clinical diagnosis, local epidemiology and susceptibility data, and local treatment guidelines.
Antibiotics may also be considered in older people (particularly those in long-term care facilities) and children <5 years of age to provide empirical antibiotic treatment for possible pneumonia.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1
Do not offer an antibiotic for preventing secondary bacterial pneumonia in people with COVID-19.[496]National Institute for Health and Care Excellence. COVID-19 rapid guideline: managing COVID-19. 2021 [internet publication]. https://www.nice.org.uk/guidance/ng191
Advise patients to seek medical help without delay if their symptoms do not improve, or worsen rapidly or significantly. Reconsider whether the person has signs and symptoms of more severe disease on reassessment, and whether to refer them to hospital, other acute community support services, or palliative care services.[496]National Institute for Health and Care Excellence. COVID-19 rapid guideline: managing COVID-19. 2021 [internet publication]. https://www.nice.org.uk/guidance/ng191
Treatment recommended for SOME patients in selected patient group
Paracetamol or ibuprofen are recommended.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1 [496]National Institute for Health and Care Excellence. COVID-19 rapid guideline: managing COVID-19. 2021 [internet publication]. https://www.nice.org.uk/guidance/ng191 There is no evidence at present of severe adverse events in COVID-19 patients taking non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, or of effects as a result of the use of NSAIDs on acute healthcare utilisation, long-term survival, or quality of life in patients with COVID-19.[664]European Medicines Agency. EMA gives advice on the use of non-steroidal anti-inflammatories for COVID-19. 2020 [internet publication]. https://www.ema.europa.eu/en/news/ema-gives-advice-use-non-steroidal-anti-inflammatories-covid-19 [665]US Food and Drug Administration. FDA advises patients on use of non-steroidal anti-inflammatory drugs (NSAIDs) for COVID-19. 2020 [internet publication]. https://www.fda.gov/drugs/drug-safety-and-availability/fda-advises-patients-use-non-steroidal-anti-inflammatory-drugs-nsaids-covid-19 [666]Little P. Non-steroidal anti-inflammatory drugs and covid-19. BMJ. 2020 Mar 27;368:m1185. https://www.bmj.com/content/368/bmj.m1185 http://www.ncbi.nlm.nih.gov/pubmed/32220865?tool=bestpractice.com [667]Medicines and Healthcare products Regulatory Agency; Commission on Human Medicines. Commission on Human Medicines advice on ibuprofen and coronavirus (COVID-19). 2020 [internet publication]. https://www.gov.uk/government/news/commission-on-human-medicines-advice-on-ibuprofen-and-coronavirus-covid-19 [668]World Health Organization. The use of non-steroidal anti-inflammatory drugs (NSAIDs) in patients with COVID-19: scientific brief. 2020 [internet publication]. https://www.who.int/news-room/commentaries/detail/the-use-of-non-steroidal-anti-inflammatory-drugs-(nsaids)-in-patients-with-covid-19 [669]National Institute for Health and Care Excellence. COVID-19 rapid evidence summary: acute use of non-steroidal anti-inflammatory drugs (NSAIDs) for people with or at risk of COVID-19. 2020 [internet publication]. https://www.nice.org.uk/advice/es23/chapter/Key-messages [670]Wong AY, MacKenna B, Morton CE, et al. Use of non-steroidal anti-inflammatory drugs and risk of death from COVID-19: an OpenSAFELY cohort analysis based on two cohorts. Ann Rheum Dis. 2021 Jan 21 [Epub ahead of print]. https://ard.bmj.com/content/early/2021/01/20/annrheumdis-2020-219517.long http://www.ncbi.nlm.nih.gov/pubmed/33478953?tool=bestpractice.com
Ibuprofen should only be taken at the lowest effective dose for the shortest period needed to control symptoms. It is not recommended in pregnant women (especially in the third trimester) or children <6 months of age (age cut-offs vary by country).
NSAIDs in patients with chronic kidney disease, heart failure, or asthma
Non-steroidal anti-inflammatory drugs (NSAIDs):
Avoid NSAIDs in patients with chronic kidney disease and/or with heart failure (based on expert opinion)
NSAIDs can worsen symptoms in some patients with asthma, so check whether your patient has a known sensitivity.[768]Global Initiative for Asthma. Global strategy for asthma management and prevention. 2020 [internet publication]. https://ginasthma.org/gina-reports/
Primary options
paracetamol: children: consult local drug formulary for guidance on dose; adults: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day
paracetamol open_in_new: children: consult local drug formulary for guidance on dose; adults: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day
paracetamol: children: consult local drug formulary for guidance on dose; adults: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day
OR
ibuprofen: children: consult local drug formulary for guidance on dose; adults: 300-600 mg orally (immediate-release) every 6-8 hours when required, maximum 2400 mg/day
ibuprofen open_in_new: children: consult local drug formulary for guidance on dose; adults: 300-600 mg orally (immediate-release) every 6-8 hours when required, maximum 2400 mg/day
ibuprofen: children: consult local drug formulary for guidance on dose; adults: 300-600 mg orally (immediate-release) every 6-8 hours when required, maximum 2400 mg/day
These drug options and doses relate to a patient with no comorbidities.
Primary options
paracetamol: children: consult local drug formulary for guidance on dose; adults: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day
paracetamol open_in_new: children: consult local drug formulary for guidance on dose; adults: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day
paracetamol: children: consult local drug formulary for guidance on dose; adults: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day
OR
ibuprofen: children: consult local drug formulary for guidance on dose; adults: 300-600 mg orally (immediate-release) every 6-8 hours when required, maximum 2400 mg/day
ibuprofen open_in_new: children: consult local drug formulary for guidance on dose; adults: 300-600 mg orally (immediate-release) every 6-8 hours when required, maximum 2400 mg/day
ibuprofen: children: consult local drug formulary for guidance on dose; adults: 300-600 mg orally (immediate-release) every 6-8 hours when required, maximum 2400 mg/day
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Primary options
OR
The Renal Handbook
Treatment recommended for SOME patients in selected patient group
Consider appropriate experimental or emerging therapies.
Antiviral therapies will have a greater effect early in the course of the disease, whereas immunosuppressive/anti-inflammatory therapies are likely to have a greater effect later in the course of the disease.[3]National Institutes of Health. Coronavirus disease 2019 (COVID-19) treatment guidelines. 2021 [internet publication]. https://covid19treatmentguidelines.nih.gov/
See the Emerging external link opens in a new windowsection for more information.
Take the patient’s comorbidities into account when considering experimental therapies
The World Health Organization (WHO) recommends that you consider potential adverse effects and drug-drug interactions in patients with COVID-19.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1
One example of this is the effect on the QT interval. A patient may be on a drug that prolongs the QT interval. The patient may then receive another drug for COVID-19 that also prolongs the QT interval.
Consider your patient’s comorbidities and current treatments when prescribing any new medication.
Follow local drug protocol guidelines and consult senior colleagues before starting any new treatments.
Treatment recommended for ALL patients in selected patient group
Guidelines from several professional respiratory organisations agree that patients with asthma or COPD should be advised to continue to take their inhalers as prescribed (including inhaled corticosteroids), whether they do or do not also have COVID-19.[769]Global Initiative for Asthma. Recommendations for inhaled asthma controller medications. 2020 [internet publication]. https://ginasthma.org/recommendations-for-inhaled-asthma-controller-medications/ [770]British Thoracic Society. Advice for healthcare professionals treating people with asthma (adults) in relation to COVID-19. 2020 [internet publication]. https://www.brit-thoracic.org.uk/about-us/covid-19-information-for-the-respiratory-community/ [771]Global Initiative for Chronic Obstructive Lung Disease. GOLD COVID-19 guidance. 2020 [internet publication]. https://goldcopd.org/gold-covid-19-guidance/ [772]National Institute for Health and Care Excellence. COVID-19 rapid guideline: community-based care of patients with chronic obstructive pulmonary disease (COPD). 2020 [internet publication]. https://www.nice.org.uk/guidance/ng168 [773]Hasan SS, Capstick T, Zaidi STR, et al. Use of corticosteroids in asthma and COPD patients with or without COVID-19. Respir Med. 2020 Aug-Sep;170:106045. https://www.resmedjournal.com/article/S0954-6111(20)30185-2/fulltext http://www.ncbi.nlm.nih.gov/pubmed/32843175?tool=bestpractice.com
It is still unclear whether infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may trigger an exacerbation of asthma or COPD, but if it were to occur it could further compromise pulmonary reserve.[773]Hasan SS, Capstick T, Zaidi STR, et al. Use of corticosteroids in asthma and COPD patients with or without COVID-19. Respir Med. 2020 Aug-Sep;170:106045. https://www.resmedjournal.com/article/S0954-6111(20)30185-2/fulltext http://www.ncbi.nlm.nih.gov/pubmed/32843175?tool=bestpractice.com
The overall aim for continuing inhaled corticosteroids is to reduce the risk of an exacerbation of asthma or COPD.[773]Hasan SS, Capstick T, Zaidi STR, et al. Use of corticosteroids in asthma and COPD patients with or without COVID-19. Respir Med. 2020 Aug-Sep;170:106045. https://www.resmedjournal.com/article/S0954-6111(20)30185-2/fulltext http://www.ncbi.nlm.nih.gov/pubmed/32843175?tool=bestpractice.com
There is no evidence that inhaled corticosteroids are related to COVID-19 infection in people with asthma.[774]Centre for Evidence-Based Medicine; Hartmann-Boyce J, Hobbs R. Inhaled steroids in asthma during the COVID-19 outbreak. 2020 [internet publication]. https://www.cebm.net/covid-19/inhaled-steroids-in-asthma-during-the-covid-19-outbreak/ There is also no evidence they increase the risks associated with COVID-19 in people with COPD.[772]National Institute for Health and Care Excellence. COVID-19 rapid guideline: community-based care of patients with chronic obstructive pulmonary disease (COPD). 2020 [internet publication]. https://www.nice.org.uk/guidance/ng168
Patients being cared for at home or in hospital with an acute medical condition can forget to tell you about their inhalers prescribed for COPD or asthma. Remember to check and prescribe if appropriate.
Many inhalers contain a combination of medications, so ensure no dual prescribing.
Patients with COPD or asthma who develop acute kidney injury with an estimated GFR <50 mL/minute/1.73 m² may need to temporarily stop their usual inhaled long-acting muscarinic receptor antagonist, depending on which specific drug is used. Check local formulary or seek pharmacist advice.
Other prescribed medication
Patients with severe asthma or COPD who take oral corticosteroids as regular prescribed maintenance therapy should also continue to take these at the lowest dose possible, as their condition may deteriorate if these are stopped.[769]Global Initiative for Asthma. Recommendations for inhaled asthma controller medications. 2020 [internet publication]. https://ginasthma.org/recommendations-for-inhaled-asthma-controller-medications/ [772]National Institute for Health and Care Excellence. COVID-19 rapid guideline: community-based care of patients with chronic obstructive pulmonary disease (COPD). 2020 [internet publication]. https://www.nice.org.uk/guidance/ng168 [775]National Institute for Health and Care Excellence. COVID-19 rapid guideline: severe asthma. 2020 [internet publication]. https://www.nice.org.uk/guidance/ng166
The UK National Institute for Health and Care Excellence rapid guideline on severe asthma recommends that patients who take regular biological therapy for asthma should continue to take this during the COVID-19 pandemic, but if they become ill with COVID-19, patients should contact the specialist team responsible for their care.[775]National Institute for Health and Care Excellence. COVID-19 rapid guideline: severe asthma. 2020 [internet publication]. https://www.nice.org.uk/guidance/ng166
Treatment recommended for ALL patients in selected patient group
The World Health Organization recommends that antihypertensive drugs should not routinely be stopped in patients with COVID-19, but may need adjusting depending on the patient’s clinical condition, particularly their blood pressure and kidney function.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1
Despite concern about possible increased risk of infection or more severe disease in patients prescribed ACE inhibitors or angiotensin-II receptor antagonists, due to upregulation of angiotensin-converting enzyme-2 (ACE2) receptor expression, the UK National Institute for Health and Care Excellence states that the current evidence is insufficient to draw any conclusion.[779]National Institute for Health and Care Excellence. COVID-19 rapid evidence summary: angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) in people with or at risk of COVID-19. 2020 [internet publication]. https://www.nice.org.uk/advice/es24/chapter/Key-messages
Several professional societies have recommended that during the pandemic patients who are already on these medications (e.g., for hypertension, heart failure, coronary artery disease, CKD, or complications of diabetes) continue to take them (if they don’t have COVID-19). If patients become ill with COVID-19, it is recommended they receive a full clinical assessment by their doctor before making any decisions to stop these medications.[780]American Heart Association; Heart Failure Society of America; American College of Cardiology. Patients taking ACE-i and ARBs who contract COVID-19 should continue treatment, unless otherwise advised by their physician. 2020 [internet publication]. https://newsroom.heart.org/news/patients-taking-ace-i-and-arbs-who-contract-covid-19-should-continue-treatment-unless-otherwise-advised-by-their-physician [781]European Society of Cardiology Council on Hypertension. Position statement of the ESC Council on Hypertension on ACE-inhibitors and angiotensin receptor blockers. 2020 [internet publication]. https://www.escardio.org/Councils/Council-on-Hypertension-(CHT)/News/position-statement-of-the-esc-council-on-hypertension-on-ace-inhibitors-and-ang [782]British Cardiovascular Society; British Society for Heart Failure. BSH & BCS joint statement on ACEi or ARB in relation to COVID-19. 2020 [internet publication]. https://www.britishcardiovascularsociety.org/news/ACEi-or-ARB-and-COVID-19 [783]The Renal Association. The Renal Association, UK position statement on COVID-19 and ACE inhibitor/angiotensin receptor blocker use. 2020 [internet publication]. https://renal.org/health-professionals/covid-19/ra-resources/renal-association-uk-position-statement-covid-19-and-ace
The UK Renal Association and the British Cardiovascular Society recommend following standard current guidance for patients with any intercurrent acute illness when weighing up benefit versus risk of these medications in patients ill with suspected COVID-19.[782]British Cardiovascular Society; British Society for Heart Failure. BSH & BCS joint statement on ACEi or ARB in relation to COVID-19. 2020 [internet publication]. https://www.britishcardiovascularsociety.org/news/ACEi-or-ARB-and-COVID-19 [783]The Renal Association. The Renal Association, UK position statement on COVID-19 and ACE inhibitor/angiotensin receptor blocker use. 2020 [internet publication]. https://renal.org/health-professionals/covid-19/ra-resources/renal-association-uk-position-statement-covid-19-and-ace [784]Clark AL, Kalra PR, Petrie MC, et al. Change in renal function associated with drug treatment in heart failure: national guidance. Heart. 2019 Jun;105(12):904-10. https://heart.bmj.com/content/105/12/904.long http://www.ncbi.nlm.nih.gov/pubmed/31118203?tool=bestpractice.com These include to:
Do an individual clinical assessment
Consider the original indication for any renin-angiotensin-aldosterone system (RAAS) inhibitors (ACE inhibitors, angiotensin-II receptor antagonists, mineralocorticoid receptor/aldosterone antagonists) and degree of prognostic benefit
If medication is temporarily withheld, consider when to re-introduce again once health improves.
Consider calculating a frailty score as patients with higher frailty scores may be more likely to experience medication-related harm when acutely unwell (based on expert opinion).
Consider the benefit versus risk of stopping other medications associated with an increased risk of acute kidney injury during intercurrent illness, such as other antihypertensives and diuretics.
If your patient with chronic kidney disease has been taking non-steroidal anti-inflammatory drugs, advise them to stop taking these when they are ill.
Patients who self-manage their heart failure in a community setting may wish to reduce their dose of diuretics during an intercurrent illness that may result in dehydration (based on expert opinion).
Seek advice from the patient’s cardiology or nephrology team if they have complex conditions (e.g., on renal replacement therapy or immunosuppressive therapy).
Treatment recommended for ALL patients in selected patient group
Do a baseline neurological assessment at the earliest appropriate opportunity in patients who have a history of stroke and are admitted to hospital with an acute medical condition, including COVID-19.
Generally a patient with an acute condition (e.g., an infection and illness-related hypotension) is at increased risk of stroke (both ischaemic and haemorrhagic).[801]Grau AJ, Urbanek C, Palm F. Common infections and the risk of stroke. Nat Rev Neurol. 2010 Dec;6(12):681-94. http://www.ncbi.nlm.nih.gov/pubmed/21060340?tool=bestpractice.com [802]Eigenbrodt ML, Rose KM, Couper DJ, et al. Orthostatic hypotension as a risk factor for stroke: the atherosclerosis risk in communities (ARIC) study, 1987-1996. Stroke. 2000 Oct;31(10):2307-13. https://www.ahajournals.org/doi/10.1161/01.str.31.10.2307 http://www.ncbi.nlm.nih.gov/pubmed/11022055?tool=bestpractice.com This risk is even higher in anyone with a history of stroke.
Compare the baseline assessment results with the patient’s known pre-COVID-19 neurological status. This could be done by asking the patient, family, and carers about the patient’s functional ability before becoming ill (based on expert opinion).
This should reduce the risk of misattributing neurological signs on admission to the previous diagnosis of stroke.
If there is a change in neurological status during admission, repeat the neurological assessment in case of a new stroke.
Following assessment, ensure the right level of patient supervision (e.g., relating to the risk of confusion at night and the risk of falls associated with frailty). A patient with a history of stroke is at increased risk of falling and injury.[803]Winstein CJ, Stein J, Arena R, et al. Guidelines for adult stroke rehabilitation and recovery: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2016 Jun;47(6):e98-169. https://www.ahajournals.org/doi/10.1161/STR.0000000000000098 http://www.ncbi.nlm.nih.gov/pubmed/27145936?tool=bestpractice.com
The World Health Organization recommends that patients in hospital with COVID-19 are monitored closely for signs of clinical deterioration, including for signs or symptoms of stroke.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1
Reported neurological manifestations associated with COVID-19 have included acute ischaemic and haemorrhagic stroke.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1
Treatment recommended for ALL patients in selected patient group
Do a baseline cognitive assessment at the earliest opportunity in any patient admitted to hospital with an acute condition and with a history of dementia. Take a collateral history from family, friends, or carers.[804]Pendlebury ST, Klaus SP, Mather M, et al. Routine cognitive screening in older patients admitted to acute medicine: abbreviated mental test score (AMTS) and subjective memory complaint versus Montreal Cognitive Assessment and IQCODE. Age Ageing. 2015 Nov;44(6):1000-5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4621235/ http://www.ncbi.nlm.nih.gov/pubmed/26464420?tool=bestpractice.com
Use a validated scoring system that is feasible in the acute setting, such as:[804]Pendlebury ST, Klaus SP, Mather M, et al. Routine cognitive screening in older patients admitted to acute medicine: abbreviated mental test score (AMTS) and subjective memory complaint versus Montreal Cognitive Assessment and IQCODE. Age Ageing. 2015 Nov;44(6):1000-5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4621235/ http://www.ncbi.nlm.nih.gov/pubmed/26464420?tool=bestpractice.com
The abbreviated mental test score/10 (AMTS/10).[805]Hodkinson HM. Evaluation of a mental test score for assessment of mental impairment in the elderly. Age Ageing. 1972 Nov;1(4):233-8. http://www.ncbi.nlm.nih.gov/pubmed/4669880?tool=bestpractice.com British Geriatrics Society: Abbreviated Mental Test Score external link opens in a new window
The collateral history establishes whether the patient’s cognition is stable, or if any decline in cognition and function has been gradual or acute.
A standardised cognitive assessment score is useful for monitoring for any clinical improvement, and for establishing needs on discharge. This score is often best interpreted alongside a functional assessment, usually performed by a trained occupational therapist.
Assess for delirium whenever a patient with dementia presents with acute illness.[806]National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management. 2019 [internet publication]. https://www.nice.org.uk/guidance/CG103 The World Health Organization recommends that patients with COVID-19 are assessed for delirium using standardised protocols.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1
People living with dementia are at increased risk of delirium when they are admitted to hospital and throughout their admission.[807]National Institute for Health and Clinical Excellence. Dementia: assessment, management and support for people living with dementia and their carers. 2018 [internet publication]. https://www.nice.org.uk/guidance/ng97 [808]Scottish Intercollegiate Guidelines Network. Risk reduction and management of delirium: a national clinical guideline. 2019 [internet publication]. https://www.sign.ac.uk/our-guidelines/risk-reduction-and-management-of-delirium/
Delirium is not the same as dementia.[809]Nova Scotia Health Authority. This is not my Mom. 2012 [internet publication]. https://www.thisisnotmymom.ca [810]Inouye SK, Schlesinger MJ, Lydon TJ. Delirium: a symptom of how hospital care is failing older persons and a window to improve quality of hospital care. Am J Med. 1999 May;106(5):565-73. http://www.ncbi.nlm.nih.gov/pubmed/10335730?tool=bestpractice.com
Use a screening tool to detect probable delirium, such as:
The 4-AT.[808]Scottish Intercollegiate Guidelines Network. Risk reduction and management of delirium: a national clinical guideline. 2019 [internet publication]. https://www.sign.ac.uk/our-guidelines/risk-reduction-and-management-of-delirium/ [811]Bellelli G, Morandi A, Davis DH, et al. Validation of the 4AT, a new instrument for rapid delirium screening: a study in 234 hospitalised older people. Age Ageing. 2014 Jul;43(4):496-502. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4066613/ http://www.ncbi.nlm.nih.gov/pubmed/24590568?tool=bestpractice.com [812]MacLullich AM, Shenkin SD, Goodacre S, et al. The 4 'A's test for detecting delirium in acute medical patients: a diagnostic accuracy study. Health Technol Assess. 2019 Aug;23(40):1-194. https://www.journalslibrary.nihr.ac.uk/hta/hta23400#/abstract http://www.ncbi.nlm.nih.gov/pubmed/31397263?tool=bestpractice.com
People with dementia may have communication difficulties, making it more difficult for them to report symptoms related to COVID-19. Their initial presentation may be with signs of delirium.[813]Public Health England. Coronavirus (COVID-19): admission and care of people in care homes. 2020 [internet publication]. https://www.gov.uk/government/publications/coronavirus-covid-19-admission-and-care-of-people-in-care-homes
Consider the following actions as part of multicomponent care intervention to reduce the risk of delirium during a hospital admission in people with dementia with any acute condition:[808]Scottish Intercollegiate Guidelines Network. Risk reduction and management of delirium: a national clinical guideline. 2019 [internet publication]. https://www.sign.ac.uk/our-guidelines/risk-reduction-and-management-of-delirium/ [814]British Geriatrics Society. Coronavirus: managing delirium in confirmed and suspected cases. 2020 [internet publication]. https://www.bgs.org.uk/resources/coronavirus-managing-delirium-in-confirmed-and-suspected-cases
Help with orientation; make sure patients have their own glasses and/or hearing aids
Get patients mobilised as soon as possible
Control pain adequately
Identify and treat superadded infections promptly
Keep well hydrated and help patients to eat adequately
Monitor and maintain regular bowel and bladder function
Use supplementary oxygen according to guideline recommendations.
Arrange a medication review with an experienced healthcare professional.[808]Scottish Intercollegiate Guidelines Network. Risk reduction and management of delirium: a national clinical guideline. 2019 [internet publication]. https://www.sign.ac.uk/our-guidelines/risk-reduction-and-management-of-delirium/
Challenges specifically related to COVID-19 include:[814]British Geriatrics Society. Coronavirus: managing delirium in confirmed and suspected cases. 2020 [internet publication]. https://www.bgs.org.uk/resources/coronavirus-managing-delirium-in-confirmed-and-suspected-cases
The need for isolation, which may exacerbate delirium in some patients
The ability to regularly monitor patients for delirium, which may be affected by staffing and time resources available.
Initial investigations for a patient with delirium
If a patient has delirium, check for and treat life-threatening causes:[808]Scottish Intercollegiate Guidelines Network. Risk reduction and management of delirium: a national clinical guideline. 2019 [internet publication]. https://www.sign.ac.uk/our-guidelines/risk-reduction-and-management-of-delirium/
Low blood glucose
Hypotension
Drug intoxication or withdrawal, including alcohol withdrawal.
Other investigations include (based on expert opinion):
Full blood count, electrolytes, renal function, thyroid function tests, liver function tests, calcium, glucose, CRP, folate, and vitamin B12
Blood cultures (if bacteraemia is suspected)
Urine culture
Chest x-ray.
Advanced non-routine investigations such as CT head may be needed, depending on specific clinical findings. Discuss with your senior.[808]Scottish Intercollegiate Guidelines Network. Risk reduction and management of delirium: a national clinical guideline. 2019 [internet publication]. https://www.sign.ac.uk/our-guidelines/risk-reduction-and-management-of-delirium/
Check for and treat any reversible causes of delirium.[806]National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management. 2019 [internet publication]. https://www.nice.org.uk/guidance/CG103 These include:
Infection
Pain
Dehydration
Constipation
Immobility
Poor sleep
Sensory impairment (e.g., ear wax or loss of glasses)
Medications
Ask about recently prescribed medications, especially opioid analgesics, anxiolytics, sedatives, antipsychotics, or medicines with strong anticholinergic properties
Consider calculating a total anticholinergic burden score.
Management of a patient with delirium
Manage patients with delirium initially, if possible with non-pharmacological treatment as recommended in management of delirium in a non-COVID-19 context.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1 [806]National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management. 2019 [internet publication]. https://www.nice.org.uk/guidance/CG103
Reduce disorientation by providing a well-lit room, with a clock and calendar visible (e.g., on the wall).
Encourage and facilitate family, friends, and carers to visit the patient, within restrictions of your visiting policy as determined by current levels of community COVID-19 transmission.
Use verbal and non-verbal techniques to de-escalate conflict and distress.
Where non-pharmacological treatments are ineffective, and the patient is distressed or considered a risk to themselves or others, short-term (often only 1-2 days is required) antipsychotic or sedative drugs may be considered, but only as a last resort. Any new antipsychotic prescribed for this purpose must be regularly reviewed, and discontinued as soon as practical (based on expert opinion).
The British Geriatrics Society has stated that in the context of management of a patient with COVID-19, it may be necessary to progress to pharmacological management earlier than would normally be considered in other circumstances because the risk of transmission of infection causing harm to others may be considered to be greater than potential harm to the individual.[814]British Geriatrics Society. Coronavirus: managing delirium in confirmed and suspected cases. 2020 [internet publication]. https://www.bgs.org.uk/resources/coronavirus-managing-delirium-in-confirmed-and-suspected-cases
The UK National Institute for Health and Care Excellence guideline on delirium (non-COVID-19 setting) recommends short-term use of haloperidol (usually for less than 1 week), but it is not suitable in all patients and must never be used in patients with Parkinson’s disease or in patients with dementia with Lewy bodies.[806]National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management. 2019 [internet publication]. https://www.nice.org.uk/guidance/CG103
The NICE rapid guideline on managing COVID-19 also recommends haloperidol as an option for the pharmacological management of delirium in patients with COVID-19 who can swallow.[496]National Institute for Health and Care Excellence. COVID-19 rapid guideline: managing COVID-19. 2021 [internet publication]. https://www.nice.org.uk/guidance/ng191
The evidence on the efficacy of antipsychotics for delirium is inconclusive, and hospital protocols may vary.[808]Scottish Intercollegiate Guidelines Network. Risk reduction and management of delirium: a national clinical guideline. 2019 [internet publication]. https://www.sign.ac.uk/our-guidelines/risk-reduction-and-management-of-delirium/ Follow your local hospital protocol for choice of medication.
Always start at the lowest dose for antipsychotic drugs and titrate carefully according to symptoms.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1 [806]National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management. 2019 [internet publication]. https://www.nice.org.uk/guidance/CG103 Only ever use oral or intramuscular medication (never intravenous) for this purpose (based on expert opinion).
Provide the family/carers with information so they understand what is happening and how they can work together with the clinical team to help the patient get back to their usual self.[808]Scottish Intercollegiate Guidelines Network. Risk reduction and management of delirium: a national clinical guideline. 2019 [internet publication]. https://www.sign.ac.uk/our-guidelines/risk-reduction-and-management-of-delirium/ Provide locally available information resources.[814]British Geriatrics Society. Coronavirus: managing delirium in confirmed and suspected cases. 2020 [internet publication]. https://www.bgs.org.uk/resources/coronavirus-managing-delirium-in-confirmed-and-suspected-cases
Antipsychotics are associated with increased mortality in people with dementia.
Short-term antipsychotics may sometimes be needed in people with dementia to enable safe care. However, antipsychotics have various adverse effects in older people and are associated with an increased risk of death in people with dementia.
A meta-analysis found that people with dementia who take atypical antipsychotics have an increased mortality risk compared with people taking placebo.[815]Ma H, Huang Y, Cong Z, et al. The efficacy and safety of atypical antipsychotics for the treatment of dementia: a meta-analysis of randomized placebo-controlled trials. J Alzheimers Dis. 2014;42(3):915-37. http://www.ncbi.nlm.nih.gov/pubmed/25024323?tool=bestpractice.com
A large cohort study of older people found that higher doses of antipsychotics are generally associated with greater risk. Of all the antipsychotics studied, haloperidol had the highest risk associated with its use.[816]Huybrechts KF, Gerhard T, Crystal S, et al. Differential risk of death in older residents in nursing homes prescribed specific antipsychotic drugs: population based cohort study. BMJ. 2012 Feb 23;344:e977. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3285717/ http://www.ncbi.nlm.nih.gov/pubmed/22362541?tool=bestpractice.com
Contrary to popular belief, long-term antipsychotic prescriptions can be safely withdrawn in most people with dementia once behaviour has settled.[817]Van Leeuwen E, Petrovic M, van Driel ML, et al. Withdrawal versus continuation of long-term antipsychotic drug use for behavioural and psychological symptoms in older people with dementia. Cochrane Database Syst Rev. 2018 Mar 30;(3):CD007726. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007726.pub3/full http://www.ncbi.nlm.nih.gov/pubmed/29605970?tool=bestpractice.com
If delirium is not responding to initial treatment within 48 hours, refer to a healthcare professional trained and skilled at diagnosing delirium to confirm the diagnosis and treatment plan (based on expert opinion).
Document the diagnosis of delirium clearly.[806]National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management. 2019 [internet publication]. https://www.nice.org.uk/guidance/CG103 [808]Scottish Intercollegiate Guidelines Network. Risk reduction and management of delirium: a national clinical guideline. 2019 [internet publication]. https://www.sign.ac.uk/our-guidelines/risk-reduction-and-management-of-delirium/
Treatment recommended for ALL patients in selected patient group
Practical tip
Asthma exacerbation and COVID-19 may be difficult to differentiate clinically, and they may present together. Cough and shortness of breath are features of both; however, additional symptoms such as fever, fatigue, and change in taste or smell are more likely to suggest COVID-19 infection.[770]British Thoracic Society. Advice for healthcare professionals treating people with asthma (adults) in relation to COVID-19. 2020 [internet publication]. https://www.brit-thoracic.org.uk/about-us/covid-19-information-for-the-respiratory-community/
Monitor for acute worsening of respiratory symptoms and be aware that this may suggest a patient with comorbid asthma is having an acute exacerbation of their asthma.
Seek senior advice.
Follow standard guideline recommendations on assessing severity and managing an acute exacerbation of asthma in adults, even if COVID-19 is suspected as the trigger.[777]British Thoracic Society; Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma: a national clinical guideline. 2019 [internet publication]. https://www.sign.ac.uk/media/1048/sign158.pdf [818]Centers for Disease Control and Prevention. Clinical questions about COVID-19: questions and answers – patients with asthma. 2020 [internet publication]. https://www.cdc.gov/coronavirus/2019-ncov/hcp/faq.html#Patients-with-Asthma
See our topic Acute exacerbation of asthma in adults.
Temporarily stop any long-acting muscarinic receptor antagonist (LAMA) the patient may be on for maintenance therapy (e.g., tiotropium, aclidinium, glycopyrronium, umeclidinium) if you prescribe a nebulised short-acting muscarinic antagonist (e.g., ipratropium) (based on expert opinion). This is due to concern over possible additive anticholinergic adverse effects.
Ensure to re-prescribe the LAMA once the nebuliser treatment has been stopped.
Practical tip
There are currently differences of opinion between organisations in different countries on whether use of a nebuliser is an aerosol-generating procedure and therefore the specific personal protective equipment required.[769]Global Initiative for Asthma. Recommendations for inhaled asthma controller medications. 2020 [internet publication]. https://ginasthma.org/recommendations-for-inhaled-asthma-controller-medications/ [775]National Institute for Health and Care Excellence. COVID-19 rapid guideline: severe asthma. 2020 [internet publication]. https://www.nice.org.uk/guidance/ng166 Follow your local guidance and protocols. Consider whether it may be clinically appropriate to use a metered-dose inhaler delivered via a spacer device as an alternative delivery mechanism.[819]Global Initiative for Asthma. COVID-19: GINA answers to frequently asked questions on asthma management. 2020 [internet publication]. https://ginasthma.org/covid-19-gina-answers-to-frequently-asked-questions-on-asthma-management/
Treatment recommended for ALL patients in selected patient group
If an exacerbation of COPD is suspected in a patient with COVID-19 and pre-existing COPD, follow the patient’s personalised action plan.
Based on the limited evidence available, the Global Initiative for Chronic Obstructive Lung Disease recommends to follow established guidelines on the management of an exacerbation of COPD, including prescription of short-term oral corticosteroids if clinically indicated.[773]Hasan SS, Capstick T, Zaidi STR, et al. Use of corticosteroids in asthma and COPD patients with or without COVID-19. Respir Med. 2020 Aug-Sep;170:106045. https://www.resmedjournal.com/article/S0954-6111(20)30185-2/fulltext http://www.ncbi.nlm.nih.gov/pubmed/32843175?tool=bestpractice.com [778]Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease. 2021 [internet publication]. https://goldcopd.org/2021-gold-reports/
See our topic Acute exacerbation of COPD.
Seek senior or specialist advice.
Differentiate from other conditions, such as acute coronary syndrome, acute heart failure, and pneumonia, as well as from complications of COVID-19.
Practical tip
There are currently differences of opinion between organisations in different countries on whether use of a nebuliser is an aerosol-generating procedure and therefore the specific personal protective equipment required.[775]National Institute for Health and Care Excellence. COVID-19 rapid guideline: severe asthma. 2020 [internet publication]. https://www.nice.org.uk/guidance/ng166 [778]Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease. 2021 [internet publication]. https://goldcopd.org/2021-gold-reports/ Follow your local guidance and protocols.
If a nebuliser is used, bronchodilator therapy via a nebuliser should only be used for 24 to 48 hours and then the patient should be switched back onto their usual inhaler(s).
Temporarily stop any long-acting muscarinic receptor antagonist (LAMA) the patient may be on for maintenance therapy (e.g., tiotropium, aclidinium, glycopyrronium, umeclidinium) if you prescribe a nebulised short-acting muscarinic antagonist (e.g., ipratropium) (based on expert opinion). This is due to concern over possible additive anticholinergic adverse effects.
Ensure to re-prescribe the LAMA once the nebuliser treatment has been stopped.
Treatment recommended for ALL patients in selected patient group
Monitor blood glucose levels at least four times a day (pre-meal and before bedtime if eating) in any acutely unwell patient with diabetes mellitus.[820]American Diabetes Association. Diabetes care in the hospital: standards of medical care in diabetes - 2020. Diabetes Care. 2020 Jan;43(suppl 1):S193-202. https://care.diabetesjournals.org/content/43/Supplement_1/S193 http://www.ncbi.nlm.nih.gov/pubmed/31862758?tool=bestpractice.com
Follow your local protocol on blood glucose monitoring for inpatients with COVID-19 who have diabetes.
There is no consensus on target blood glucose levels for people with diabetes in hospital with an acute medical condition.
The UK Joint British Diabetes Societies for Inpatient Care (JBDS-IP) recommends an ideal range of 6 to 10 mmol/L (108-180 mg/dL), and an acceptable upper level of 12 mmol/L (216 mg/dL).[821]Joint British Diabetes Societies for inpatient care. The use of variable rate intravenous insulin infusion (VRIII) in medical inpatients. 2014 [internet publication]. https://abcd.care/sites/abcd.care/files/resources/JBDS_IP_VRIII.pdf A more liberal blood glucose target is considered appropriate if your patient is at high risk of falls, is frail, or has dementia.[821]Joint British Diabetes Societies for inpatient care. The use of variable rate intravenous insulin infusion (VRIII) in medical inpatients. 2014 [internet publication]. https://abcd.care/sites/abcd.care/files/resources/JBDS_IP_VRIII.pdf
The UK-based National Inpatient Diabetes COVID-19 Response Group makes the same recommendation for patients in hospital with COVID-19.[822]National Inpatient Diabetes COVID-19 Response Group. Concise advice on inpatient diabetes during COVID-19 (COVID:Diabetes): guidance for managing inpatient hyperglycaemia. 2020 [internet publication]. https://abcd.care/sites/abcd.care/files/resources/COvID_Hyper_v4.2.pdf
Consensus guidance from an international group of experts recommends aiming for levels of between 4 and 10 mmol/L (72 and 180 mg/dL) in patients with COVID-19, but to adjust the lower level to 5 mmol/L (90 mg/dL) in patients who are frail.[799]Bornstein SR, Rubino F, Khunti K, et al. Practical recommendations for the management of diabetes in patients with COVID-19. Lancet Diabetes Endocrinol. 2020 Jun;8(6):546-50. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7180013/ http://www.ncbi.nlm.nih.gov/pubmed/32334646?tool=bestpractice.com
The American Diabetes Association recommends a target range of 7.8 to 10 mmol/L (140-180 mg/dL) for most critically and non-critically ill patients (not specifically with COVID-19).[820]American Diabetes Association. Diabetes care in the hospital: standards of medical care in diabetes - 2020. Diabetes Care. 2020 Jan;43(suppl 1):S193-202. https://care.diabetesjournals.org/content/43/Supplement_1/S193 http://www.ncbi.nlm.nih.gov/pubmed/31862758?tool=bestpractice.com
Data are still limited on blood glucose control and its association with outcomes for patients with COVID-19.[794]Hartmann-Boyce J, Morris E, Goyder C, et al. Diabetes and COVID-19: risks, management, and learnings from other national disasters. Diabetes Care. 2020 Aug;43(8):1695-703. https://care.diabetesjournals.org/content/43/8/1695 http://www.ncbi.nlm.nih.gov/pubmed/32546593?tool=bestpractice.com
Hyperglycaemia during the ongoing hospital admission
Treat hyperglycaemia to avoid diabetic ketoacidosis (DKA) and hyperosmolar hyperglycaemic state (HHS), which are medical emergencies.
Follow your local hospital protocol if your patient’s capillary blood glucose is ≥12 mmol/L (≥216 mg/dL).
COVID-19 guidance generally emphasises the importance of managing hyperglycaemia.[794]Hartmann-Boyce J, Morris E, Goyder C, et al. Diabetes and COVID-19: risks, management, and learnings from other national disasters. Diabetes Care. 2020 Aug;43(8):1695-703. https://care.diabetesjournals.org/content/43/8/1695 http://www.ncbi.nlm.nih.gov/pubmed/32546593?tool=bestpractice.com
Exclude DKA or HHS, both of which require specific urgent management.
Consider other conditions associated with hyperglycaemia, such as sepsis.[793]National Inpatient Diabetes COVID-19 Response Group. Concise advice on inpatient diabetes during COVID-19: front door guidance. 2020 [internet publication]. https://abcd.care/resource/concise-advice-inpatient-diabetes-during-covid-19-front-door-guidance
Be aware that the following medications may be associated with hyperglycaemia and may need to be reviewed:[823]Rehman A, Setter SM, Vue MH. Drug-induced glucose alterations part 2: drug-induced hyperglycemia. Diabetes Spect. 2011 Nov;24(4):234-8. https://spectrum.diabetesjournals.org/content/24/4/234
Corticosteroids (e.g., dexamethasone)
Some beta-blockers (e.g., propranolol, atenolol)
Thiazide diuretics (e.g., hydrochlorothiazide)
Some second-generation antipsychotics (e.g., olanzapine, clozapine)
Certain fluoroquinolone antibiotics (e.g., ciprofloxacin)
Calcineurin inhibitors (e.g., ciclosporin, tacrolimus)
Protease inhibitors (e.g., as a component in antiretroviral therapy, lopinavir/ritonavir may be used to treat some patients with COVID-19).
Some experimental drugs used in the management of COVID-19 may be associated with (or cause) hyperglycaemia. Check local drug formularies for further information before prescribing these therapies in patients with diabetes.
If your patient has persistently elevated blood glucose, they may need insulin therapy (intravenous or subcutaneous protocols). Follow your local protocols on management of hyperglycaemia in patients with COVID-19.
Infusion pump devices may not be available outside of intensive care unit (ICU) settings, depending on the need for these devices elsewhere. In this situation, some protocols recommend alternative subcutaneous regimens when managing hyperglycaemia and mild DKA.[822]National Inpatient Diabetes COVID-19 Response Group. Concise advice on inpatient diabetes during COVID-19 (COVID:Diabetes): guidance for managing inpatient hyperglycaemia. 2020 [internet publication]. https://abcd.care/sites/abcd.care/files/resources/COvID_Hyper_v4.2.pdf [824]National Inpatient Diabetes COVID-19 Response Group. Concise advice on inpatient diabetes during COVID-19 (COVID:Diabetes): guideline for managing DKA using subcutaneous insulin. 2020 [internet publication]. https://abcd.care/sites/abcd.care/files/resources/COvID_DKA_SC_v3.3.pdf
Be aware that patients with type 2 diabetes in ICU may have significant degrees of insulin resistance.[822]National Inpatient Diabetes COVID-19 Response Group. Concise advice on inpatient diabetes during COVID-19 (COVID:Diabetes): guidance for managing inpatient hyperglycaemia. 2020 [internet publication]. https://abcd.care/sites/abcd.care/files/resources/COvID_Hyper_v4.2.pdf
Practical tip
Ask for expert advice from the inpatient diabetes team.
Hypoglycaemia during the ongoing hospital admission
Monitor blood glucose and adjust medication in response to illness and hospital meal times, to reduce the risk of hypoglycaemic episodes.
1 in 5 inpatients with diabetes in England and Wales have a hypoglycaemic episode during their hospital stay.[825]NHS Digital. National Diabetes Inpatient Audit (NaDIA) - 2017. 2018 [internet publication]. https://digital.nhs.uk/data-and-information/publications/statistical/national-diabetes-inpatient-audit/national-diabetes-inpatient-audit-nadia-2017
Causes of hypoglycaemia include:[826]Joint British Diabetes Societies for inpatient care. The hospital management of hypoglycaemia in adults with diabetes mellitus. 4th ed. 2020 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_HypoGuideline_4th_edition_FINAL.pdf
Recovery from an acute illness
Patients recovering from COVID-19 may have a rapid change in insulin requirements, so monitor and adjust insulin regimens carefully[822]National Inpatient Diabetes COVID-19 Response Group. Concise advice on inpatient diabetes during COVID-19 (COVID:Diabetes): guidance for managing inpatient hyperglycaemia. 2020 [internet publication]. https://abcd.care/sites/abcd.care/files/resources/COvID_Hyper_v4.2.pdf
Accidental interruptions to patient feeding, which may occur especially when patients with COVID-19 are nursed in the prone position[822]National Inpatient Diabetes COVID-19 Response Group. Concise advice on inpatient diabetes during COVID-19 (COVID:Diabetes): guidance for managing inpatient hyperglycaemia. 2020 [internet publication]. https://abcd.care/sites/abcd.care/files/resources/COvID_Hyper_v4.2.pdf
Reducing doses of corticosteroids, particularly dexamethasone in patients with COVID-19[822]National Inpatient Diabetes COVID-19 Response Group. Concise advice on inpatient diabetes during COVID-19 (COVID:Diabetes): guidance for managing inpatient hyperglycaemia. 2020 [internet publication]. https://abcd.care/sites/abcd.care/files/resources/COvID_Hyper_v4.2.pdf
Insulin or oral hypoglycaemic medication error
Wrong timing of insulin in relation to meals
Patients eating less but taking the same amount of diabetes medication
No bedtime snacks
Reduced appetite or vomiting.
Some experimental drugs used in the management of COVID-19 may be associated with (or cause) hypoglycaemia (e.g., hydroxychloroquine). Check local drug formularies for further information before prescribing these therapies in patients with diabetes.
Be aware that hypoglycaemia as an adverse effect of sulfonylurea medication (e.g., glibenclamide, gliclazide, glimepiride, glipizide) is more likely if meals are skipped or doses are excessive.
In the acute hospital setting, meal times may be interrupted or may not always be at exactly the same time each day.
Give sulfonylurea medication before or with food. Check local drug formulary for more specific guidance on timing of dose in relation to food for specific sulfonylurea.
Never give sulfonylurea medication at bedtime and, if the patient is taking a dose with their evening meal, consider reducing the evening dose to reduce the risk of nocturnal hypoglycaemia (based on expert opinion).
Practical tip
Bedtime snacks can reduce the risk of early morning hypoglycaemia.[825]NHS Digital. National Diabetes Inpatient Audit (NaDIA) - 2017. 2018 [internet publication]. https://digital.nhs.uk/data-and-information/publications/statistical/national-diabetes-inpatient-audit/national-diabetes-inpatient-audit-nadia-2017
Treat hypoglycaemia actively if the blood glucose falls below 4 mmol/L (72 mg/dL).[826]Joint British Diabetes Societies for inpatient care. The hospital management of hypoglycaemia in adults with diabetes mellitus. 4th ed. 2020 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_HypoGuideline_4th_edition_FINAL.pdf Follow hospital protocol. The JBDS-IP guidelines recommend that you:[826]Joint British Diabetes Societies for inpatient care. The hospital management of hypoglycaemia in adults with diabetes mellitus. 4th ed. 2020 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_HypoGuideline_4th_edition_FINAL.pdf
Retest blood glucose at 15 minutes to determine response to treatment
Never stop the next scheduled dose of insulin if the hypoglycaemia has been corrected. This can cause rebound hyperglycaemia and DKA in people with type 1 diabetes.
Follow local protocols and guidance on self-monitoring of blood glucose by patients in hospital.
These may have been adapted in the context of patients with COVID-19. For instance, some hospitals in the US have been utilising ‘virtual’ formats, including expanding self-management protocols, to reduce need for personal protective equipment, where it is safe to do so.[794]Hartmann-Boyce J, Morris E, Goyder C, et al. Diabetes and COVID-19: risks, management, and learnings from other national disasters. Diabetes Care. 2020 Aug;43(8):1695-703. https://care.diabetesjournals.org/content/43/8/1695 http://www.ncbi.nlm.nih.gov/pubmed/32546593?tool=bestpractice.com
Treatment recommended for ALL patients in selected patient group
Check the feet of any adult with diabetes on admission to hospital and whenever they seem more unwell.[827]National Institute for Health and Care Excellence. Diabetic foot problems: prevention and management. 2019 [internet publication]. https://www.nice.org.uk/guidance/ng19 This is still a recommendation for adults with diabetes admitted to hospital with COVID-19.[793]National Inpatient Diabetes COVID-19 Response Group. Concise advice on inpatient diabetes during COVID-19: front door guidance. 2020 [internet publication]. https://abcd.care/resource/concise-advice-inpatient-diabetes-during-covid-19-front-door-guidance
A foot check is needed to detect new ulceration or infection, which may be unnoticed by the patient. It may even be the cause of their acute illness (e.g., patient presenting with sepsis, or endocarditis where the original focus of infection is the foot lesion).
Inspect the foot for lesions and examine for loss of protective sensation.
Follow your local guidelines, but a quick simple test is the Ipswich Touch Test©️, which involves lightly touching/resting the tip of the index finger for 1 to 2 seconds on the tips of the first, third, and fifth toes.[828]Rayman G, Vas PR, Baker N, et al. The Ipswich Touch Test: a simple and novel method to identify inpatients with diabetes at risk of foot ulceration. Diabetes Care. 2011 Jul;34(7):1517-8. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3120164/ http://www.ncbi.nlm.nih.gov/pubmed/21593300?tool=bestpractice.com
If your patient is unable to feel at two or more of these six sites, they have reduced protective sensation.
If your patient has reduced sensation, they are at high risk of pressure ulceration. Inform the nursing staff and provide pressure relieving devices.
A daily heel check for signs of pressure trauma should be done by nursing or healthcare assistant staff.
There is a debate about whether compression stockings should or should not be used in people with diabetes – do not use them if there is vascular disease.
Treatment recommended for ALL patients in selected patient group
Do a mental state examination as the clinical situation allows and if the patient is responsive (based on expert opinion).
The mental state examination is one of the main clinical tools routinely used in psychiatric practice, aiding diagnosis and guiding further management. Mood is one of the assessed domains.
Consider assessing depression by using the PHQ-9 questionnaire.[829]Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001 Sep;16(9):606-13. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1495268/ http://www.ncbi.nlm.nih.gov/pubmed/11556941?tool=bestpractice.com
This is self-administered and takes less than 3 minutes to complete.
Results indicate severity of depressive symptoms.
A score of 5 or above should trigger a referral to your liaison psychiatry service (based on expert opinion).
While data continue to emerge on the psychiatric impact of COVID-19, it is interesting to note that other severe coronavirus infections (severe acute respiratory syndrome [SARS] and Middle East respiratory syndrome [MERS]) have been found to be associated with low mood both in the acute phase of the illness as well as at follow-up.[830]Rogers JP, Chesney E, Oliver D, et al. Psychiatric and neuropsychiatric presentations associated with severe coronavirus infections: a systematic review and meta-analysis with comparison to the COVID-19 pandemic. Lancet Psychiatry. 2020 Jul;7(7):611-27. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7234781/ http://www.ncbi.nlm.nih.gov/pubmed/32437679?tool=bestpractice.com [831]National Institute for Health Research. High rates of delirium, persistent fatigue and post-traumatic stress disorder were common after severe infection in previous coronavirus outbreaks. 2020 [internet publication]. https://evidence.nihr.ac.uk/alert/high-rates-of-delirium-persistent-fatigue-and-post-traumatic-stress-disorder-were-common-after-severe-infection-in-previous-coronavirus-outbreaks/
Consider other factors that may be influencing the patient’s mental state (e.g., the effect of any illicit drug use or alcohol).[832]Boden JM, Fergusson DM. Alcohol and depression. Addiction. 2011 May;106(5):906-14. http://www.ncbi.nlm.nih.gov/pubmed/21382111?tool=bestpractice.com
Treatment recommended for ALL patients in selected patient group
The World Health Organization recommends that potential adverse effects and drug-drug interactions are considered when treating patients with COVID-19.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1 With this in mind, if possible ask the patient which medications they are taking for their depression. Alternatively, review their primary care records for relevant information (if available).
Prescribe the patient’s usual antidepressant medication, unless there are good reasons not to (based on expert opinion).
If antidepressants are stopped abruptly, the patient may develop discontinuation symptoms.[833]Cleare A, Pariante CM, Young AH, et al. Evidence-based guidelines for treating depressive disorders with antidepressants: a revision of the 2008 British Association for Psychopharmacology guidelines. J Psychopharmacol. 2015 May;29(5):459-525. https://www.bap.org.uk/pdfs/BAP_Guidelines-Antidepressants.pdf http://www.ncbi.nlm.nih.gov/pubmed/25969470?tool=bestpractice.com
The severity of symptoms of discontinuation may vary, but it may be unpleasant and may complicate the management of the acute medical condition.[834]National Institute for Health and Care Excellence. Depression in adults with a chronic physical health problem: recognition and management. 2009 [internet publication]. https://www.nice.org.uk/guidance/cg91
When reviewing current medication, look out for:
Perceived current and previous adverse effects
Recent changes in dose
Recent switches from a different class of medication
Pharmacological nuances of specific depression subtypes (e.g., it is likely that patients suffering from psychotic depression would be co-prescribed an antipsychotic)
Augmenting strategies that may be in use in treating resistant depression (e.g., lithium or quetiapine augmentation of a selective serotonin-reuptake inhibitor [SSRI]).
Consider drug-drug interactions.
Antidepressant medications may cause pharmacokinetic (by inhibiting the CYP450 pathway) and pharmacodynamic interactions with medications used for other conditions.[833]Cleare A, Pariante CM, Young AH, et al. Evidence-based guidelines for treating depressive disorders with antidepressants: a revision of the 2008 British Association for Psychopharmacology guidelines. J Psychopharmacol. 2015 May;29(5):459-525. https://www.bap.org.uk/pdfs/BAP_Guidelines-Antidepressants.pdf http://www.ncbi.nlm.nih.gov/pubmed/25969470?tool=bestpractice.com [835]Taylor DM, Barnes TRE, Young AH. The Maudsley prescribing guidelines in psychiatry. 13th edition. Chichester: Wiley-Blackwell; 2018. Consider this issue for all medications prescribed in patients with COVID-19 as well as any experimental therapies (see the Emerging section).
Drug-drug interactions and their associated adverse effects of particular relevance to patients with COVID-19 include sedation, cardiotoxicity (QT prolongation), and respiratory depression.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1
Practical tip
Be aware that smoking cessation or switching from tobacco smoking to any other alternatives (including nicotine replacement therapy) may result in a change to the plasma concentration of any psychotropic medication the patient may be taking (e.g., for depression). This is because nicotine replacement therapy does not impact hepatic enzyme activity like tobacco smoking.[836]Flowers L. Nicotine replacement therapy. Am J Psychiatry Resid J. 2016 Jun;11(6):4-7. https://psychiatryonline.org/doi/10.1176/appi.ajp-rj.2016.110602 [837]Desai HD, Seabolt J, Jann MW. Smoking in patients receiving psychotropic medications: a pharmacokinetic perspective. CNS Drugs. 2001;15(6):469-94. http://www.ncbi.nlm.nih.gov/pubmed/11524025?tool=bestpractice.com [838]Oliveira P, Ribeiro J, Donato H, et al. Smoking and antidepressants pharmacokinetics: a systematic review. Ann Gen Psychiatry. 2017 Mar 6;16:17. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5340025/ http://www.ncbi.nlm.nih.gov/pubmed/28286537?tool=bestpractice.com [839]National Centre for Smoking Cessation and Training. Smoking cessation and mental health: a briefing for front-line staff. 2014 [internet publication]. https://www.ncsct.co.uk/usr/pub/mental%20health%20briefing%20A4.pdf Seek advice on whether any adjustment to the dose of psychotropic medication is appropriate.
Consider psychiatric complications when prescribing non-psychotropic drugs.
Take particular care when prescribing corticosteroids, anticonvulsants, and antiparkinsonian medication.
Consider adverse effects, which may include the following.
Respiratory depression. Be aware that certain antidepressants may precipitate respiratory depression, especially when co-prescribed with other sedative drugs. Particular caution is needed with tricyclic antidepressants and mirtazapine.
QT prolongation, arrhythmias, increased heart rate, or postural hypotension with tricyclic antidepressants. Check ECG, especially in people at risk of arrhythmias.
Hyponatraemia, caused by antidepressants, especially SSRIs, and compounded by other co-prescribed drugs (e.g., diuretics). Check the patient’s serum electrolytes.
Serotonin syndrome (altered mental state, agitation, tremor, hyper-reflexia, clonus, muscle rigidity, diaphoresis, tachycardia, increased bowel sounds, temperature >38℃), especially with polypharmacy and/or overdose of a serotonergic agent.[840]Boyer EW, Shannon M. The serotonin syndrome. N Engl J Med. 2005 Mar 17;352(11):1112-20. https://www.doi.org/10.1056/NEJMra041867 http://www.ncbi.nlm.nih.gov/pubmed/15784664?tool=bestpractice.com
Be particularly aware of increased risk of serotonin syndrome in patients with end-stage renal disease on SSRIs. Treating depression in patients with renal impairment requires a multidisciplinary approach and demands extra caution.
Hepatotoxicity. Adjust doses of antidepressants in patients with hepatic impairment if necessary and avoid drugs that are known to be hepatotoxic.
This list of adverse effects and drug-drug interactions is not exhaustive – consult local formulary for further information. Consult your liaison psychiatry colleagues and/or a pharmacist for advice.
If possible, ask the patient about non-pharmacological treatments for their depression and check current level of support in the community.
This may include other health professionals involved in their care, charities, family and social networks, and psychological therapy.
Treatment recommended for ALL patients in selected patient group
Consider a referral to the liaison psychiatry team/service for any patient with established or suspected depression who is admitted to hospital with an acute condition.[841]National Institute for Health and Care Excellence. Liaison psychiatry. In: Emergency acute medical care in over 16s: service delivery and organisation. 2018 [internet publication]. https://www.nice.org.uk/guidance/ng94/evidence/23.liaison-psychiatry-pdf-172397464636 [842]National Confidential Enquiry into Patient Outcome and Death. Treat as one: bridging the gap between mental and physical healthcare in general hospitals. 2017 [internet publication]. https://www.ncepod.org.uk/2017report1/downloads/TreatAsOne_Summary.pdf
Follow your local protocols/referral pathways in your hospital during the COVID-19 pandemic.
COVID-19 is associated with psychiatric and neurological manifestations including depression.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1
Comorbid depression is linked to poor adherence with recommended physical health treatments, from medication to rehabilitation.[843]DiMatteo MR, Lepper HS, Croghan TW. Depression is a risk factor for noncompliance with medical treatment: meta-analysis of the effects of anxiety and depression on patient adherence. Arch Intern Med. 2000 Jul 24;160(14):2101-7. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/485411 http://www.ncbi.nlm.nih.gov/pubmed/10904452?tool=bestpractice.com
This may lead to worse clinical outcomes, including longer hospital stays.[834]National Institute for Health and Care Excellence. Depression in adults with a chronic physical health problem: recognition and management. 2009 [internet publication]. https://www.nice.org.uk/guidance/cg91 [844]Prina AM, Cosco TD, Dening T, et al. The association between depressive symptoms in the community, non-psychiatric hospital admission and hospital outcomes: a systematic review. J Psychosom Res. 2015 Jan;78(1):25-33. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4292984/ http://www.ncbi.nlm.nih.gov/pubmed/25466985?tool=bestpractice.com [845]Clarke DM, Currie KC. Depression, anxiety and their relationship with chronic diseases: a review of the epidemiology, risk and treatment evidence. Med J Aust. 2009 Apr 6;190(s7):S54-60. http://www.ncbi.nlm.nih.gov/pubmed/19351294?tool=bestpractice.com
Most importantly, depression is linked with excess mortality.[846]World Health Organization. Excess mortality in persons with severe mental disorders. 2016 [internet publication]. https://www.who.int/mental_health/evidence/excess_mortality_report/en/
Treatment recommended for ALL patients in selected patient group
Consider prescribing nicotine replacement therapy to current smokers admitted with an acute condition. This is regardless of intention to quit smoking. However, because there is an increased risk for severe COVID-19 associated with tobacco smoking, in addition to the well-recognised harms, the World Health Organization does recommend smoking cessation using evidence-based methods.[253]World Health Organization. Smoking and COVID-19: scientific brief. 2020 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-Sci_Brief-Smoking-2020.2 [847]Patanavanich R, Glantz SA. Smoking is associated with COVID-19 progression: a meta-analysis. Nicotine Tob Res. 2020 Aug 24;22(9):1653-6. https://academic.oup.com/ntr/advance-article/doi/10.1093/ntr/ntaa082/5835834 http://www.ncbi.nlm.nih.gov/pubmed/32399563?tool=bestpractice.com [848]National Institute for Health and Care Excellence. Smoking: acute, maternity and mental health services. 2020 [internet publication]. https://www.nice.org.uk/guidance/ph48
Nicotine replacement therapy prevents rapid withdrawal during admission, which can be distressing and uncomfortable.
Preparations include transdermal patches or, for patients with skin allergies, inhalators, lozenges, gum, or sprays. Dose depends on how many cigarettes are smoked/day and the formulation chosen.
Use with caution in haemodynamically unstable patients hospitalised with acute stroke, myocardial infarction, and/or uncontrolled hypertension and in patients with severe renal impairment.
Monitor blood glucose closely if starting nicotine replacement therapy in patients with diabetes.
Consult your local drug formulary and hospital guidance for more comprehensive details.
Practical tip
Be aware that switching from tobacco smoking to any other alternatives (including nicotine replacement therapy) may result in a change to the plasma concentration of any psychotropic medication the patient may be taking (e.g., for depression). This is because nicotine replacement therapy does not impact hepatic enzyme activity like tobacco smoking.[836]Flowers L. Nicotine replacement therapy. Am J Psychiatry Resid J. 2016 Jun;11(6):4-7. https://psychiatryonline.org/doi/10.1176/appi.ajp-rj.2016.110602 Seek advice on whether any adjustment to the dose of psychotropic medication is appropriate.
Patients with suspected or confirmed severe disease are at risk of rapid clinical deterioration and should be admitted to an appropriate healthcare facility under the guidance of a specialist team. Severe disease in adults is defined as having clinical signs of pneumonia plus at least one of the following: respiratory rate >30 breaths/minute, severe respiratory distress, or SpO₂ <90% on room air. Severe disease in children is defined as having clinical signs of pneumonia plus at least one of the following: central cyanosis or SpO₂ <90%, severe respiratory distress, general danger signs (inability to breastfeed or drink, lethargy or unconsciousness, or convulsions), or fast breathing (<2 months: ≥60 breaths per minute; 2-11 months: ≥50 breaths per minute; 1-5 years: ≥40 breaths per minute).[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1
Comorbidities in pregnancy and in children
The information in the BMJ Best Practice comorbidities tool relates to non-pregnant adults.
It is not intended for pregnant patients or for children. In these circumstances, please seek specialist obstetric/gynaecology or paediatric advice on how any comorbidities the patient has may affect your management of COVID-19.
Use the Clinical Frailty Scale (CFS) to assess baseline health and inform discussions on treatment expectations when appropriate and within an individualised assessment of frailty. Clinical Frailty Scale external link opens in a new window Do not use the CFS for younger people, people with stable long-term disabilities (e.g., cerebral palsy), learning disabilities, or autism. Make an individualised assessment of frailty in these people, using clinical assessment and alternative scoring methods.[496]National Institute for Health and Care Excellence. COVID-19 rapid guideline: managing COVID-19. 2021 [internet publication]. https://www.nice.org.uk/guidance/ng191 A meta-analysis found that an increase in CFS was associated with an increase in mortality (each 1-point increase in CFS was associated with a 12% increase in mortality).[675]Pranata R, Henrina J, Lim MA, et al. Clinical frailty scale and mortality in COVID-19: a systematic review and dose-response meta-analysis. Arch Gerontol Geriatr. 2021 Mar-Apr;93:104324. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7832565/ http://www.ncbi.nlm.nih.gov/pubmed/33352430?tool=bestpractice.com However, some studies suggest that a more nuanced understanding of frailty and outcomes is needed, and you should exercise caution in placing too much emphasis on the influence of frailty alone when discussing prognosis in older people.[676]Cosco TD, Best J, Davis D, et al. What is the relationship between validated frailty scores and mortality for adults with COVID-19 in acute hospital care? A systematic review. Age Ageing. 2021 Jan 14 [Epub ahead of print]. https://academic.oup.com/ageing/advance-article/doi/10.1093/ageing/afab008/6097011 http://www.ncbi.nlm.nih.gov/pubmed/33448278?tool=bestpractice.com
Be aware of any comorbidity-associated risk of clinical deterioration and severe disease
Consider the presence of any comorbidities when deciding the setting for care and levels of monitoring.
The US Centers for Disease Control and Prevention's list of pre-existing conditions that do, or may increase the risk of severe illness with COVID-19 includes among others:[208]Centers for Disease Control and Prevention. Coronavirus disease 2019 (COVID-19): people at increased risk. 2021 [internet publication]. https://www.cdc.gov/coronavirus/2019-ncov/specific-groups/people-at-higher-risk.html
Chronic kidney disease
COPD
Coronary artery disease
Heart failure
Type 1 and type 2 diabetes
Asthma (moderate to severe)
Stroke
Hypertension
Dementia.
The World Health Organization adds that having a mental health disorder increases the risk of severe illness or death.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1
Older people are at increased risk of mortality with COVID-19.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1 [208]Centers for Disease Control and Prevention. Coronavirus disease 2019 (COVID-19): people at increased risk. 2021 [internet publication]. https://www.cdc.gov/coronavirus/2019-ncov/specific-groups/people-at-higher-risk.html
The Office of National Statistics reported that dementia was the most common pre-existing health condition in people whose deaths involved COVID-19 in England and Wales between March and June 2020.[280]Office for National Statistics. Deaths involving COVID-19, England and Wales: deaths occurring in June 2020. 2020 [internet publication]. https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsinvolvingcovid19englandandwales/deathsoccurringinjune2020
A large cohort study in England found that mortality risk was higher in people with type 1 compared with type 2 diabetes, when risk was adjusted for demographic factors and cardiovascular comorbidities.[229]Barron E, Bakhai C, Kar P, et al. Associations of type 1 and type 2 diabetes with COVID-19-related mortality in England: a whole-population study. Lancet Diabetes Endocrinol. 2020 Oct;8(10):813-22. https://www.thelancet.com/journals/landia/article/PIIS2213-8587(20)30272-2/fulltext http://www.ncbi.nlm.nih.gov/pubmed/32798472?tool=bestpractice.com
Monitor patients with risk factors closely, due to the possible risk of deterioration.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1
Consider discussing your patient with the specialist team managing their long-term condition, and/or referring to other healthcare professionals in the multidisciplinary team.
Multidisciplinary collaborative care is recommended for older people with COVID-19 to help ensure all aspects of care (including comorbidities) are adequately addressed.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1
Baseline neurological assessment
Do a baseline neurological assessment at the earliest appropriate opportunity in patients who have a history of stroke and are admitted to hospital with an acute medical condition, including COVID-19.
Generally a patient with an acute condition (e.g., an infection and illness-related hypotension) is at increased risk of stroke (both ischaemic and haemorrhagic).[801]Grau AJ, Urbanek C, Palm F. Common infections and the risk of stroke. Nat Rev Neurol. 2010 Dec;6(12):681-94. http://www.ncbi.nlm.nih.gov/pubmed/21060340?tool=bestpractice.com [802]Eigenbrodt ML, Rose KM, Couper DJ, et al. Orthostatic hypotension as a risk factor for stroke: the atherosclerosis risk in communities (ARIC) study, 1987-1996. Stroke. 2000 Oct;31(10):2307-13. https://www.ahajournals.org/doi/10.1161/01.str.31.10.2307 http://www.ncbi.nlm.nih.gov/pubmed/11022055?tool=bestpractice.com This risk is even higher in anyone with a history of stroke.
Compare the baseline assessment results with the patient’s known pre-COVID-19 neurological status. This could be done by asking the patient, family, and carers about the patient’s functional ability before becoming ill (based on expert opinion).
This should reduce the risk of misattributing neurological signs on admission to the previous diagnosis of stroke.
If there is a change in neurological status during admission, repeat the neurological assessment in case of a new stroke.
Following assessment, ensure the right level of patient supervision (e.g., relating to the risk of confusion at night and the risk of falls associated with frailty). A patient with a history of stroke is at increased risk of falling and injury.[803]Winstein CJ, Stein J, Arena R, et al. Guidelines for adult stroke rehabilitation and recovery: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2016 Jun;47(6):e98-169. https://www.ahajournals.org/doi/10.1161/STR.0000000000000098 http://www.ncbi.nlm.nih.gov/pubmed/27145936?tool=bestpractice.com
The World Health Organization recommends that patients in hospital with COVID-19 are monitored closely for signs of clinical deterioration, including for signs or symptoms of stroke.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1
Reported neurological manifestations associated with COVID-19 have included acute ischaemic and haemorrhagic stroke.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1
Implement local infection prevention and control procedures when managing patients with COVID-19.
Pregnant women should be managed by a multidisciplinary team, including obstetric, perinatal, neonatal, and intensive care specialists, as well as midwifery and mental health and psychosocial support. A woman-centred, respectful, skilled approach to care is recommended.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1 The multidisciplinary team should be organised as soon as possible after maternal hypoxemia occurs in order to assess fetal maturity, disease progression, and the best options for delivery.[744]Chen L, Jiang H, Zhao Y. Pregnancy with Covid-19: management considerations for care of severe and critically ill cases. Am J Reprod Immunol. 2020 Jul 4:e13299. https://onlinelibrary.wiley.com/doi/10.1111/aji.13299 http://www.ncbi.nlm.nih.gov/pubmed/32623810?tool=bestpractice.com
Discontinue transmission-based precautions (including isolation) and release patients from the care pathway 10 days after symptom onset plus at least 3 days without fever and respiratory symptoms.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1 The US Centers for Disease Control and Prevention (CDC) recommends discontinuing isolation once at least 10 days and up to 20 days have passed since symptoms first appeared, and at least 24 hours have passed since last fever without the use of antipyretics, and symptoms have improved, if a symptom-based strategy is used. Consider consultation with infection control experts before discontinuing isolation. Severely immunocompromised patients may produce replication-competent virus beyond 20 days and require additional testing and consultation with infectious diseases specialists and infection control experts before discontinuing isolation. Alternatively, the CDC recommends at least two negative reverse-transcription polymerase chain reaction (RT-PCR) tests on respiratory specimens collected 24 hours apart before ending isolation if a test-based strategy is used. A symptom-based strategy is preferred; however, a test-based strategy can be considered in severely immunocompromised patients.[673]Centers for Disease Control and Prevention. Discontinuation of transmission-based precautions and disposition of patients with SARS-CoV-2 infection in healthcare settings. 2021 [internet publication]. https://www.cdc.gov/coronavirus/2019-ncov/hcp/disposition-hospitalized-patients.html Guidance on when to stop isolation depends on local recommendations and may differ between countries. For example, in the UK the isolation period is 14 days from a positive test in hospitalised patients. Immunocompetent patients who tested positive on RT-PCR and have completed their 14-day isolation period are exempt from testing prior to hospital discharge if they are within 90 days from their initial illness onset or test, unless they develop new symptoms.[663]Public Health England. Guidance for stepdown of infection control precautions and discharging COVID-19 patients. 2020 [internet publication]. https://www.gov.uk/government/publications/covid-19-guidance-for-stepdown-of-infection-control-precautions-within-hospitals-and-discharging-covid-19-patients-from-hospital-to-home-settings/guidance-for-stepdown-of-infection-control-precautions-and-discharging-covid-19-patients
Treatment recommended for ALL patients in selected patient group
In consultation with the patient with dementia and their carers, agree an escalation plan as early as possible, as you would with any patient (based on expert opinion).
This should include:[764]Fritz Z, Slowther AM, Perkins GD. Resuscitation policy should focus on the patient, not the decision. BMJ. 2017 Feb 28;356:j813. https://www.bmj.com/content/356/bmj.j813.long http://www.ncbi.nlm.nih.gov/pubmed/28246084?tool=bestpractice.com
Resuscitation status (i.e., ‘Do Not Attempt Cardiopulmonary Resuscitation’ [DNACPR] decision)
Ceiling of care (e.g., suitability for intubation or intensive care admission).
Escalation plans should take account of advanced care planning, including legally binding advanced directives.[764]Fritz Z, Slowther AM, Perkins GD. Resuscitation policy should focus on the patient, not the decision. BMJ. 2017 Feb 28;356:j813. https://www.bmj.com/content/356/bmj.j813.long http://www.ncbi.nlm.nih.gov/pubmed/28246084?tool=bestpractice.com
In some situations, the patient with dementia will lack the mental capacity to make decisions for the escalation plan.
Assess and document mental capacity (the ability to make decisions at a specific time a decision needs to be made).[765]National Institute for Health and Care Excellence. Decision making and mental capacity. 2018 [internet publication]. https://www.nice.org.uk/guidance/ng108 Follow the appropriate legislation in your region.
In England and Wales, health professionals must comply with the 2005 Mental Capacity Act.[766]Department of Health. Mental Capacity Act 2005 [internet publication]. https://www.legislation.gov.uk/ukpga/2005/9/contents Assessments should follow the principles in the Act.[766]Department of Health. Mental Capacity Act 2005 [internet publication]. https://www.legislation.gov.uk/ukpga/2005/9/contents
If a patient is assessed to lack mental capacity, ensure decisions are made in the best interests of the patient.[765]National Institute for Health and Care Excellence. Decision making and mental capacity. 2018 [internet publication]. https://www.nice.org.uk/guidance/ng108 [766]Department of Health. Mental Capacity Act 2005 [internet publication]. https://www.legislation.gov.uk/ukpga/2005/9/contents
If the patient is assessed to lack mental capacity, consult with next of kin to make ‘best interests’ decisions.[766]Department of Health. Mental Capacity Act 2005 [internet publication]. https://www.legislation.gov.uk/ukpga/2005/9/contents
According to the 2005 Mental Capacity Act in England and Wales, if a patient is unbefriended and a decision is not time-critical, an independent mental capacity advocate (IMCA) should be sought to perform this role.[767]Social Care Institute for Excellence. Independent mental capacity advocate (IMCA). 2011 [internet publication]. https://www.scie.org.uk/mca/imca/do
Check the appropriate legislation for your territory.
Treatment recommended for ALL patients in selected patient group
Start supplemental oxygen therapy immediately in any patient with emergency signs (i.e., obstructed or absent breathing, severe respiratory distress, central cyanosis, shock, coma and/or convulsions), or any patient without emergency signs and SpO₂ <90%.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1 [3]National Institutes of Health. Coronavirus disease 2019 (COVID-19) treatment guidelines. 2021 [internet publication]. https://covid19treatmentguidelines.nih.gov/
Target SpO₂ to ≥94% during resuscitation in adults and children with emergency signs who require emergency airway management and oxygen therapy. Once the patient is stable, a target SpO₂ >90% in children and non-pregnant adults, and ≥92% to 95% in pregnant women, is recommended. Nasal prongs or a nasal cannula are preferred in young children.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1 Some guidelines recommend that SpO₂ should be maintained no higher than 96%.[678]Alhazzani W, Evans L, Alshamsi F, et al. Surviving Sepsis Campaign guidelines on the management of adults with coronavirus disease 2019 (COVID-19) in the ICU: first update. Crit Care Med. 2021 Mar 1;49(3):e219-34. https://journals.lww.com/ccmjournal/Abstract/9000/Surviving_Sepsis_Campaign_Guidelines_on_the.95371.aspx http://www.ncbi.nlm.nih.gov/pubmed/33555780?tool=bestpractice.com
Some centres may recommend different SpO₂ targets in order to support prioritisation of oxygen flow for the most severely ill patients in hospital. NHS England recommends a target of 92% to 96% (or 90% to 94% if clinically appropriate), for example.[679]NHS England. Clinical guide for the optimal use of oxygen therapy during the coronavirus pandemic. 2020 [internet publication]. https://www.nice.org.uk/Media/Default/About/COVID-19/Specialty-guides/specialty-guide-oxygen-therapy.pdf
Consider positioning techniques (e.g., high supported sitting), and airway clearance management to optimise oxygenation and assist with secretion clearance in adults. Consider awake prone positioning (for 8-12 hours/day, broken into shorter periods over the day) in severely ill patients who require supplemental oxygen.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1 [3]National Institutes of Health. Coronavirus disease 2019 (COVID-19) treatment guidelines. 2021 [internet publication]. https://covid19treatmentguidelines.nih.gov/ Early self-proning of awake, non-intubated patients has been shown to improve oxygen saturation and may delay or reduce the need for intensive care.[680]Caputo ND, Strayer RJ, Levitan R. Early self-proning in awake, non-intubated patients in the emergency department: a single ED's experience during the COVID-19 pandemic. Acad Emerg Med. 2020 May;27(5):375-8. https://onlinelibrary.wiley.com/doi/abs/10.1111/acem.13994 http://www.ncbi.nlm.nih.gov/pubmed/32320506?tool=bestpractice.com [681]Ng Z, Tay WC, Ho CHB. Awake prone positioning for non-intubated oxygen dependent COVID-19 pneumonia patients. Eur Respir J. 2020 Jul 23;56(1):2001198. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7251246/ http://www.ncbi.nlm.nih.gov/pubmed/32457195?tool=bestpractice.com [682]Golestani-Eraghi M, Mahmoodpoor A. Early application of prone position for management of Covid-19 patients. J Clin Anesth. 2020 May 26;66:109917. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7247987/ http://www.ncbi.nlm.nih.gov/pubmed/32473503?tool=bestpractice.com [683]Thompson AE, Ranard BL, Wei Y, et al. Prone positioning in awake, nonintubated patients with COVID-19 hypoxemic respiratory failure. JAMA Intern Med. 2020 Jun 17;180(11):1537-9. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7301298/ http://www.ncbi.nlm.nih.gov/pubmed/32584946?tool=bestpractice.com [684]Coppo A, Bellani G, Winterton D, et al. Feasibility and physiological effects of prone positioning in non-intubated patients with acute respiratory failure due to COVID-19 (PRON-COVID): a prospective cohort study. Lancet Respir Med. 2020 Aug;8(8):765-74. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7304954/ http://www.ncbi.nlm.nih.gov/pubmed/32569585?tool=bestpractice.com
Monitor patients closely for signs of progressive acute hypoxaemic respiratory failure.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1 [3]National Institutes of Health. Coronavirus disease 2019 (COVID-19) treatment guidelines. 2021 [internet publication]. https://covid19treatmentguidelines.nih.gov/
Oxygen therapy in patients with asthma
If the patient’s asthma is stable, follow guideline recommendations for oxygen saturation target for the presenting acute condition (i.e., COVID-19).[849]O'Driscoll BR, Howard LS, Earis J, et al. BTS guideline for oxygen use in adults in healthcare and emergency settings. Thorax. 2017 Jun;72(suppl 1):ii1-90. https://thorax.bmj.com/content/72/Suppl_1/ii1.long http://www.ncbi.nlm.nih.gov/pubmed/28507176?tool=bestpractice.com
Measure resting oxygen saturation in all patients with asthma with any acute illness.[849]O'Driscoll BR, Howard LS, Earis J, et al. BTS guideline for oxygen use in adults in healthcare and emergency settings. Thorax. 2017 Jun;72(suppl 1):ii1-90. https://thorax.bmj.com/content/72/Suppl_1/ii1.long http://www.ncbi.nlm.nih.gov/pubmed/28507176?tool=bestpractice.com This is routine practice in patients with COVID-19.
If COVID-19 triggers an acute exacerbation of the patient’s asthma, current opinion is to follow standard guideline recommendations for managing an acute exacerbation of asthma in adults.[777]British Thoracic Society; Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma: a national clinical guideline. 2019 [internet publication]. https://www.sign.ac.uk/media/1048/sign158.pdf [818]Centers for Disease Control and Prevention. Clinical questions about COVID-19: questions and answers – patients with asthma. 2020 [internet publication]. https://www.cdc.gov/coronavirus/2019-ncov/hcp/faq.html#Patients-with-Asthma
Follow your local hospital protocol on target oxygen saturations recommended in your hospital during the COVID-19 pandemic for acutely ill patients.
Hypercapnia in asthma is a near fatal sign showing a patient is tiring and needs ventilatory support.[777]British Thoracic Society; Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma: a national clinical guideline. 2019 [internet publication]. https://www.sign.ac.uk/media/1048/sign158.pdf Intensive care support is needed immediately.[777]British Thoracic Society; Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma: a national clinical guideline. 2019 [internet publication]. https://www.sign.ac.uk/media/1048/sign158.pdf
Oxygen therapy in patients with COPD
If your patient with comorbid COPD is suitable for full escalation of care, refer for consideration of ventilation support if they are:
Severely hypoxaemic (PaO2 <7.3 kPa [54.8 mmHg]) despite oxygen therapy (based on expert opinion)
Hypercapnic (PaCO2 >6 kPa [45 mmHg]) with respiratory acidosis (pH <7.35)[849]O'Driscoll BR, Howard LS, Earis J, et al. BTS guideline for oxygen use in adults in healthcare and emergency settings. Thorax. 2017 Jun;72(suppl 1):ii1-90. https://thorax.bmj.com/content/72/Suppl_1/ii1.long http://www.ncbi.nlm.nih.gov/pubmed/28507176?tool=bestpractice.com
AND/OR
Exhibiting changes in mental status (confusion, coma).
If your patient with comorbid COPD develops type 2 respiratory failure and it has been agreed that they are not suitable for full escalation of care involving intensive care unit admission:
Follow the guidance on oxygen as below
Discuss with your senior or respiratory expert whether ward-based non-invasive ventilation is suitable.
Practical tip
Take the same care when prescribing any supplemental oxygen in patients at risk of type 2 respiratory failure with COVID-19 as you would for patients with any other acute medical condition. Oxygen therapy for these patients should almost always be controlled. High-flow nasal oxygen (HFNO) is therefore not suitable for these patients. HFNO may be considered in patients not at risk of type 2 respiratory failure, but with severe hypoxaemia. Be aware that this should be prescribed by a senior decision-maker and should only ever be used with careful observation and repeat ABG measurements (based on expert opinion).
Measure resting oxygen saturations and be aware of additional factors to consider when prescribing oxygen therapy in a patient with COPD who is hypoxic.
Guidelines on emergency oxygen use (not specifically for COVID-19) from the British Thoracic Society recommend that any patient with COPD requiring oxygen supplementation needs an arterial blood gas (ABG) measurement.[849]O'Driscoll BR, Howard LS, Earis J, et al. BTS guideline for oxygen use in adults in healthcare and emergency settings. Thorax. 2017 Jun;72(suppl 1):ii1-90. https://thorax.bmj.com/content/72/Suppl_1/ii1.long http://www.ncbi.nlm.nih.gov/pubmed/28507176?tool=bestpractice.com
Re-check ABG after 30 to 60 minutes in all patients.[849]O'Driscoll BR, Howard LS, Earis J, et al. BTS guideline for oxygen use in adults in healthcare and emergency settings. Thorax. 2017 Jun;72(suppl 1):ii1-90. https://thorax.bmj.com/content/72/Suppl_1/ii1.long http://www.ncbi.nlm.nih.gov/pubmed/28507176?tool=bestpractice.com
The British Thoracic Society recommends that standard protocols should be followed in patients admitted to hospital with COVID-19 who also have COPD and evidence of acute on chronic type 2 respiratory failure, as detailed in the sections below.[850]British Thoracic Society. BTS guidance: respiratory support of patients on medical wards. 2020 [internet publication]. https://www.brit-thoracic.org.uk/about-us/covid-19-information-for-the-respiratory-community/
If a patient with comorbid COPD is critically ill (e.g., shock, sepsis, major head injury, status epilepticus, anaphylaxis, major trauma) and needs high levels of oxygen:
The British Thoracic Society (BTS) recommends an initial target oxygen saturation of 94% to 98%, although more recent evidence suggests an upper target of 96% may be preferred in most cases.[849]O'Driscoll BR, Howard LS, Earis J, et al. BTS guideline for oxygen use in adults in healthcare and emergency settings. Thorax. 2017 Jun;72(suppl 1):ii1-90. https://thorax.bmj.com/content/72/Suppl_1/ii1.long http://www.ncbi.nlm.nih.gov/pubmed/28507176?tool=bestpractice.com [851]Chu DK, Kim LH, Young PJ, et al. Mortality and morbidity in acutely ill adults treated with liberal versus conservative oxygen therapy (IOTA): a systematic review and meta-analysis. Lancet. 2018 Apr 28;391(10131):1693-705. http://www.ncbi.nlm.nih.gov/pubmed/29726345?tool=bestpractice.com [852]Siemieniuk RAC, Chu DK, Kim LH, et al. Oxygen therapy for acutely ill medical patients: a clinical practice guideline. BMJ. 2018 Oct 24;363:k4169. http://www.ncbi.nlm.nih.gov/pubmed/30355567?tool=bestpractice.com Follow your local hospital protocol on target oxygen saturations recommended in your hospital during the COVID-19 pandemic for acutely ill patients
Subsequently, you may need to adjust to controlled oxygen therapy with a target oxygen saturation range of 88% to 92% depending on the ABG results.[849]O'Driscoll BR, Howard LS, Earis J, et al. BTS guideline for oxygen use in adults in healthcare and emergency settings. Thorax. 2017 Jun;72(suppl 1):ii1-90. https://thorax.bmj.com/content/72/Suppl_1/ii1.long http://www.ncbi.nlm.nih.gov/pubmed/28507176?tool=bestpractice.com
If a patient with comorbid COPD is acutely but not critically ill and is at risk of hypercapnic failure (including any patient with moderate or severe COPD, particularly if on long-term oxygen therapy, or with an alert card, or with a previous history of hypercapnic respiratory failure):[849]O'Driscoll BR, Howard LS, Earis J, et al. BTS guideline for oxygen use in adults in healthcare and emergency settings. Thorax. 2017 Jun;72(suppl 1):ii1-90. https://thorax.bmj.com/content/72/Suppl_1/ii1.long http://www.ncbi.nlm.nih.gov/pubmed/28507176?tool=bestpractice.com
Use an initial target oxygen saturation of 88% to 92%
Check ABG and recheck after 30 to 60 minutes.
If a patient with comorbid COPD is acutely but not critically ill and is NOT at risk of hypercapnic respiratory failure (e.g., stable, mild COPD with minimal symptoms):
Use an initial target oxygen saturation as recommended by guidelines for the presenting acute condition.
The BTS recommends a target oxygen saturation of between 94% and 98% pending ABG results for most acutely ill patients, although more recent evidence suggests an upper target of 96% may be preferred.[849]O'Driscoll BR, Howard LS, Earis J, et al. BTS guideline for oxygen use in adults in healthcare and emergency settings. Thorax. 2017 Jun;72(suppl 1):ii1-90. https://thorax.bmj.com/content/72/Suppl_1/ii1.long http://www.ncbi.nlm.nih.gov/pubmed/28507176?tool=bestpractice.com [851]Chu DK, Kim LH, Young PJ, et al. Mortality and morbidity in acutely ill adults treated with liberal versus conservative oxygen therapy (IOTA): a systematic review and meta-analysis. Lancet. 2018 Apr 28;391(10131):1693-705. http://www.ncbi.nlm.nih.gov/pubmed/29726345?tool=bestpractice.com [852]Siemieniuk RAC, Chu DK, Kim LH, et al. Oxygen therapy for acutely ill medical patients: a clinical practice guideline. BMJ. 2018 Oct 24;363:k4169. http://www.ncbi.nlm.nih.gov/pubmed/30355567?tool=bestpractice.com This target saturation level may be lower depending on local hospital oxygen supplies (follow your local protocol)
Measure ABG as soon as possible[849]O'Driscoll BR, Howard LS, Earis J, et al. BTS guideline for oxygen use in adults in healthcare and emergency settings. Thorax. 2017 Jun;72(suppl 1):ii1-90. https://thorax.bmj.com/content/72/Suppl_1/ii1.long http://www.ncbi.nlm.nih.gov/pubmed/28507176?tool=bestpractice.com
Subsequently, you may need to adjust to controlled oxygen therapy with a target oxygen saturation range of 88% to 92% depending on the ABG results.[849]O'Driscoll BR, Howard LS, Earis J, et al. BTS guideline for oxygen use in adults in healthcare and emergency settings. Thorax. 2017 Jun;72(suppl 1):ii1-90. https://thorax.bmj.com/content/72/Suppl_1/ii1.long http://www.ncbi.nlm.nih.gov/pubmed/28507176?tool=bestpractice.com
Treatment recommended for ALL patients in selected patient group
Fluids and electrolytes: use cautious fluid management in adults and children without tissue hypoperfusion and fluid responsiveness as aggressive fluid resuscitation may worsen oxygenation.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1 Correct any electrolyte or metabolic abnormalities, such as hyperglycaemia or metabolic acidosis, according to local protocols.[685]Mojoli F, Mongodi S, Orlando A, et al. Our recommendations for acute management of COVID-19. Crit Care. 2020 May 8;24(1):207. https://ccforum.biomedcentral.com/articles/10.1186/s13054-020-02930-6 http://www.ncbi.nlm.nih.gov/pubmed/32384909?tool=bestpractice.com
Assess fluid status and manage fluid balance particularly closely
It can be difficult to assess hypotension, low organ perfusion, and shock in a patient with heart failure and/or chronic kidney disease (CKD).
Hypovolaemia may be difficult to assess in a person with heart failure and/or CKD.[853]National Institute for Health and Care Excellence. Intravenous fluid therapy in adults in hospital. 2017 [internet publication]. https://www.nice.org.uk/guidance/cg174
Assess:[853]National Institute for Health and Care Excellence. Intravenous fluid therapy in adults in hospital. 2017 [internet publication]. https://www.nice.org.uk/guidance/cg174
Pulse
Blood pressure
For postural hypotension
Peripheral perfusion
Capillary refill
Jugular venous pressure
For presence of pulmonary and peripheral oedema.
Establish the patient’s baseline blood pressure as the fall from baseline is more significant than absolute systolic blood pressure (SBP). An SBP of <90 mmHg may suggest hypotension, but a patient on medication for chronic heart failure can have a baseline SBP of <90 mmHg (based on expert opinion).
A patient with CKD who is hypotensive, particularly if in shock, needs immediate fluid resuscitation.
Reassess the patient after initial fluid challenge and get senior input if the patient does not rapidly stabilise. Consider transfer to a more intensive level of care.
A patient with heart failure may need fluid resuscitation but seek senior review to assess volume status and the risk of volume overload. Consider transferring the patient to a more intensive level of care before initiating fluid resuscitation.
Cough: advise patients to avoid lying on their back as this makes coughing ineffective. Use simple measures first (e.g., a teaspoon of honey in patients aged 1 year and older) to help cough. Short-term use of a cough suppressant may be considered in select patients (e.g., if the cough is distressing to the patient) provided there are no contraindications.[496]National Institute for Health and Care Excellence. COVID-19 rapid guideline: managing COVID-19. 2021 [internet publication]. https://www.nice.org.uk/guidance/ng191 A meta-analysis found that honey is superior to usual care (e.g., antitussives) for the improvement of upper respiratory tract infection symptoms, particularly cough frequency and severity.[671]Abuelgasim H, Albury C, Lee J. Effectiveness of honey for symptomatic relief in upper respiratory tract infections: a systematic review and meta-analysis. BMJ Evid Based Med. 2021 Apr;26(2):57-64. https://ebm.bmj.com/content/early/2020/07/28/bmjebm-2020-111336 http://www.ncbi.nlm.nih.gov/pubmed/32817011?tool=bestpractice.com
Breathlessness: keep the room cool, and encourage relaxation, breathing techniques, and changing body positions. Identify and treat any reversible causes of breathlessness (e.g., pulmonary oedema, pulmonary embolism, COPD, asthma). Consider a trial of oxygen, if available.[496]National Institute for Health and Care Excellence. COVID-19 rapid guideline: managing COVID-19. 2021 [internet publication]. https://www.nice.org.uk/guidance/ng191
Anxiety, delirium, and agitation: identify and treat any underlying or reversible causes (e.g., offer reassurance, treat hypoxia, correct metabolic or endocrine abnormalities, address co-infections, minimise use of drugs that may cause or worsen delirium, treat substance withdrawal, maintain normal sleep cycles, treat pain or breathlessness).[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1 [496]National Institute for Health and Care Excellence. COVID-19 rapid guideline: managing COVID-19. 2021 [internet publication]. https://www.nice.org.uk/guidance/ng191 Low doses of haloperidol (or another suitable antipsychotic) can be considered for agitation.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1 Non-pharmacological interventions are the mainstay for the management of delirium when possible, and prevention is key.[686]Centre for Evidence-Based Medicine; Jones L, Candy B, Roberts N, et al. How can healthcare workers adapt non-pharmacological treatment – whilst maintaining safety – when treating people with COVID-19 and delirium? 2020 [internet publication]. https://www.cebm.net/covid-19/how-can-healthcare-workers-adapt-non-pharmacological-treatment-whilst-maintaining-safety-when-treating-people-with-covid-19-and-delirium/
Baseline cognitive and delirium assessments with collateral history
Do a baseline cognitive assessment at the earliest opportunity in any patient admitted to hospital with an acute condition and with a history of dementia. Take a collateral history from family, friends, or carers.[804]Pendlebury ST, Klaus SP, Mather M, et al. Routine cognitive screening in older patients admitted to acute medicine: abbreviated mental test score (AMTS) and subjective memory complaint versus Montreal Cognitive Assessment and IQCODE. Age Ageing. 2015 Nov;44(6):1000-5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4621235/ http://www.ncbi.nlm.nih.gov/pubmed/26464420?tool=bestpractice.com
Use a validated scoring system that is feasible in the acute setting, such as:[804]Pendlebury ST, Klaus SP, Mather M, et al. Routine cognitive screening in older patients admitted to acute medicine: abbreviated mental test score (AMTS) and subjective memory complaint versus Montreal Cognitive Assessment and IQCODE. Age Ageing. 2015 Nov;44(6):1000-5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4621235/ http://www.ncbi.nlm.nih.gov/pubmed/26464420?tool=bestpractice.com
The abbreviated mental test score/10 (AMTS/10).[805]Hodkinson HM. Evaluation of a mental test score for assessment of mental impairment in the elderly. Age Ageing. 1972 Nov;1(4):233-8. http://www.ncbi.nlm.nih.gov/pubmed/4669880?tool=bestpractice.com British Geriatrics Society: Abbreviated Mental Test Score external link opens in a new window
The collateral history establishes whether the patient’s cognition is stable, or if any decline in cognition and function has been gradual or acute.
A standardised cognitive assessment score is useful for monitoring for any clinical improvement, and for establishing needs on discharge. This score is often best interpreted alongside a functional assessment, usually performed by a trained occupational therapist.
Assess for delirium whenever a patient with dementia presents with acute illness.[806]National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management. 2019 [internet publication]. https://www.nice.org.uk/guidance/CG103 The World Health Organization recommends that patients with COVID-19 are assessed for delirium using standardised protocols.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1
People living with dementia are at increased risk of delirium when they are admitted to hospital and throughout their admission.[807]National Institute for Health and Clinical Excellence. Dementia: assessment, management and support for people living with dementia and their carers. 2018 [internet publication]. https://www.nice.org.uk/guidance/ng97 [808]Scottish Intercollegiate Guidelines Network. Risk reduction and management of delirium: a national clinical guideline. 2019 [internet publication]. https://www.sign.ac.uk/our-guidelines/risk-reduction-and-management-of-delirium/
Delirium is not the same as dementia.[809]Nova Scotia Health Authority. This is not my Mom. 2012 [internet publication]. https://www.thisisnotmymom.ca It is a potentially life-threatening acute, fluctuating change in mental functioning, with inattention, disorganised thinking, and altered levels of consciousness.[810]Inouye SK, Schlesinger MJ, Lydon TJ. Delirium: a symptom of how hospital care is failing older persons and a window to improve quality of hospital care. Am J Med. 1999 May;106(5):565-73. http://www.ncbi.nlm.nih.gov/pubmed/10335730?tool=bestpractice.com
Use a screening tool to detect probable delirium, such as:
The 4-AT.[808]Scottish Intercollegiate Guidelines Network. Risk reduction and management of delirium: a national clinical guideline. 2019 [internet publication]. https://www.sign.ac.uk/our-guidelines/risk-reduction-and-management-of-delirium/ [811]Bellelli G, Morandi A, Davis DH, et al. Validation of the 4AT, a new instrument for rapid delirium screening: a study in 234 hospitalised older people. Age Ageing. 2014 Jul;43(4):496-502. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4066613/ http://www.ncbi.nlm.nih.gov/pubmed/24590568?tool=bestpractice.com [812]MacLullich AM, Shenkin SD, Goodacre S, et al. The 4 'A's test for detecting delirium in acute medical patients: a diagnostic accuracy study. Health Technol Assess. 2019 Aug;23(40):1-194. https://www.journalslibrary.nihr.ac.uk/hta/hta23400#/abstract http://www.ncbi.nlm.nih.gov/pubmed/31397263?tool=bestpractice.com
People with dementia may have communication difficulties, making it more difficult for them to report symptoms related to COVID-19. Their initial presentation may be with signs of delirium.[813]Public Health England. Coronavirus (COVID-19): admission and care of people in care homes. 2020 [internet publication]. https://www.gov.uk/government/publications/coronavirus-covid-19-admission-and-care-of-people-in-care-homes
Consider the following actions as part of multicomponent care intervention to reduce the risk of delirium during a hospital admission in people with dementia with any acute condition:[808]Scottish Intercollegiate Guidelines Network. Risk reduction and management of delirium: a national clinical guideline. 2019 [internet publication]. https://www.sign.ac.uk/our-guidelines/risk-reduction-and-management-of-delirium/ [814]British Geriatrics Society. Coronavirus: managing delirium in confirmed and suspected cases. 2020 [internet publication]. https://www.bgs.org.uk/resources/coronavirus-managing-delirium-in-confirmed-and-suspected-cases
Help with orientation; make sure patients have their own glasses and/or hearing aids
Get patients mobilised as soon as possible
Control pain adequately
Identify and treat superadded infections promptly
Keep well hydrated and help patients to eat adequately
Monitor and maintain regular bowel and bladder function
Use supplementary oxygen according to guideline recommendations.
Arrange a medication review with an experienced healthcare professional.[808]Scottish Intercollegiate Guidelines Network. Risk reduction and management of delirium: a national clinical guideline. 2019 [internet publication]. https://www.sign.ac.uk/our-guidelines/risk-reduction-and-management-of-delirium/
Challenges specifically related to COVID-19 include:[814]British Geriatrics Society. Coronavirus: managing delirium in confirmed and suspected cases. 2020 [internet publication]. https://www.bgs.org.uk/resources/coronavirus-managing-delirium-in-confirmed-and-suspected-cases
The need for isolation, which may exacerbate delirium in some patients
The ability to regularly monitor patients for delirium, which may be affected by staffing and time resources available.
Initial investigations for a patient with delirium
If a patient has delirium, check for and treat life-threatening causes:[808]Scottish Intercollegiate Guidelines Network. Risk reduction and management of delirium: a national clinical guideline. 2019 [internet publication]. https://www.sign.ac.uk/our-guidelines/risk-reduction-and-management-of-delirium/
Low blood glucose
Hypotension
Drug intoxication or withdrawal, including alcohol withdrawal.
Other investigations include (based on expert opinion):
Full blood count, electrolytes, renal function, thyroid function tests, liver function tests, calcium, glucose, CRP, folate, and vitamin B12
Blood cultures (if bacteraemia is suspected)
Urine culture
Chest x-ray.
Advanced non-routine investigations such as CT head may be needed, depending on specific clinical findings. Discuss with your senior.[808]Scottish Intercollegiate Guidelines Network. Risk reduction and management of delirium: a national clinical guideline. 2019 [internet publication]. https://www.sign.ac.uk/our-guidelines/risk-reduction-and-management-of-delirium/
Check for and treat any reversible causes of delirium.[806]National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management. 2019 [internet publication]. https://www.nice.org.uk/guidance/CG103 These include:
Infection
Pain
Dehydration
Constipation
Immobility
Poor sleep
Sensory impairment (e.g., ear wax or loss of glasses)
Medications
Ask about recently prescribed medications, especially opioid analgesics, anxiolytics, sedatives, antipsychotics, or medicines with strong anticholinergic properties
Consider calculating a total anticholinergic burden score.
Management of a patient with delirium
Manage patients with delirium initially, if possible with non-pharmacological treatment as recommended in management of delirium in a non-COVID-19 context.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1 [806]National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management. 2019 [internet publication]. https://www.nice.org.uk/guidance/CG103
Reduce disorientation by providing a well-lit room, with a clock and calendar visible (e.g., on the wall).
Encourage and facilitate family, friends, and carers to visit the patient, within restrictions of your visiting policy as determined by current levels of community COVID-19 transmission.
Use verbal and non-verbal techniques to de-escalate conflict and distress.
Where non-pharmacological treatments are ineffective, and the patient is distressed or considered a risk to themselves or others, short-term (often only 1-2 days is required) antipsychotic or sedative drugs may be considered, but only as a last resort. Any new antipsychotic prescribed for this purpose must be regularly reviewed, and discontinued as soon as practical (based on expert opinion).
The British Geriatrics Society has stated that in the context of management of a patient with COVID-19, it may be necessary to progress to pharmacological management earlier than would normally be considered in other circumstances because the risk of transmission of infection causing harm to others may be considered to be greater than potential harm to the individual.[814]British Geriatrics Society. Coronavirus: managing delirium in confirmed and suspected cases. 2020 [internet publication]. https://www.bgs.org.uk/resources/coronavirus-managing-delirium-in-confirmed-and-suspected-cases
The UK National Institute for Health and Care Excellence guideline on delirium (non-COVID-19 setting) recommends short-term use of haloperidol (usually for less than 1 week), but it is not suitable in all patients and must never be used in patients with Parkinson’s disease or in patients with dementia with Lewy bodies.[806]National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management. 2019 [internet publication]. https://www.nice.org.uk/guidance/CG103
The NICE rapid guideline on managing COVID-19 also recommends haloperidol as an option for the pharmacological management of delirium in patients with COVID-19 who can swallow.[496]National Institute for Health and Care Excellence. COVID-19 rapid guideline: managing COVID-19. 2021 [internet publication]. https://www.nice.org.uk/guidance/ng191
The evidence on the efficacy of antipsychotics for delirium is inconclusive, and hospital protocols may vary.[808]Scottish Intercollegiate Guidelines Network. Risk reduction and management of delirium: a national clinical guideline. 2019 [internet publication]. https://www.sign.ac.uk/our-guidelines/risk-reduction-and-management-of-delirium/ Follow your local hospital protocol for choice of medication.
Always start at the lowest dose for antipsychotic drugs and titrate carefully according to symptoms.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1 [806]National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management. 2019 [internet publication]. https://www.nice.org.uk/guidance/CG103 Only ever use oral or intramuscular medication (never intravenous) for this purpose (based on expert opinion).
Provide the family/carers with information so they understand what is happening and how they can work together with the clinical team to help the patient get back to their usual self.[808]Scottish Intercollegiate Guidelines Network. Risk reduction and management of delirium: a national clinical guideline. 2019 [internet publication]. https://www.sign.ac.uk/our-guidelines/risk-reduction-and-management-of-delirium/ Provide locally available information resources.[814]British Geriatrics Society. Coronavirus: managing delirium in confirmed and suspected cases. 2020 [internet publication]. https://www.bgs.org.uk/resources/coronavirus-managing-delirium-in-confirmed-and-suspected-cases
Antipsychotics are associated with increased mortality in people with dementia.
Short-term antipsychotics may sometimes be needed in people with dementia to enable safe care. However, antipsychotics have various adverse effects in older people and are associated with an increased risk of death in people with dementia.
A meta-analysis found that people with dementia who take atypical antipsychotics have an increased mortality risk compared with people taking placebo.[815]Ma H, Huang Y, Cong Z, et al. The efficacy and safety of atypical antipsychotics for the treatment of dementia: a meta-analysis of randomized placebo-controlled trials. J Alzheimers Dis. 2014;42(3):915-37. http://www.ncbi.nlm.nih.gov/pubmed/25024323?tool=bestpractice.com
A large cohort study of older people found that higher doses of antipsychotics are generally associated with greater risk. Of all the antipsychotics studied, haloperidol had the highest risk associated with its use.[816]Huybrechts KF, Gerhard T, Crystal S, et al. Differential risk of death in older residents in nursing homes prescribed specific antipsychotic drugs: population based cohort study. BMJ. 2012 Feb 23;344:e977. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3285717/ http://www.ncbi.nlm.nih.gov/pubmed/22362541?tool=bestpractice.com
Contrary to popular belief, long-term antipsychotic prescriptions can be safely withdrawn in most people with dementia once behaviour has settled.[817]Van Leeuwen E, Petrovic M, van Driel ML, et al. Withdrawal versus continuation of long-term antipsychotic drug use for behavioural and psychological symptoms in older people with dementia. Cochrane Database Syst Rev. 2018 Mar 30;(3):CD007726. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007726.pub3/full http://www.ncbi.nlm.nih.gov/pubmed/29605970?tool=bestpractice.com
If delirium is not responding to initial treatment within 48 hours, refer to a healthcare professional trained and skilled at diagnosing delirium to confirm the diagnosis and treatment plan (based on expert opinion).
Document the diagnosis of delirium clearly.[806]National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management. 2019 [internet publication]. https://www.nice.org.uk/guidance/CG103 [808]Scottish Intercollegiate Guidelines Network. Risk reduction and management of delirium: a national clinical guideline. 2019 [internet publication]. https://www.sign.ac.uk/our-guidelines/risk-reduction-and-management-of-delirium/
Mouth care: an important part of overall patient care in hospitalised patients who are ventilated or non-ventilated and those undergoing step-down or end-of-life care.[687]Public Health England. Mouth care for hospitalised patients with confirmed or suspected COVID-19. 2020 [internet publication]. https://www.gov.uk/government/publications/covid-19-mouth-care-for-patients-with-a-confirmed-or-suspected-case/mouth-care-for-hospitalised-patients-with-confirmed-or-suspected-covid-19
Mental health symptoms: provide basic mental health and psychosocial support for all patients, and manage any symptoms of insomnia or depression as appropriate.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1
Mental state examination
Do a mental state examination as the clinical situation allows and if the patient is responsive (based on expert opinion).
The mental state examination is one of the main clinical tools routinely used in psychiatric practice, aiding diagnosis and guiding further management. Mood is one of the assessed domains.
Consider assessing depression by using the PHQ-9 questionnaire.[829]Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001 Sep;16(9):606-13. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1495268/ http://www.ncbi.nlm.nih.gov/pubmed/11556941?tool=bestpractice.com
This is self-administered and takes less than 3 minutes to complete.
Results indicate severity of depressive symptoms.
A score of 5 or above should trigger a referral to your liaison psychiatry service (based on expert opinion).
While data continue to emerge on the psychiatric impact of COVID-19, it is interesting to note that other severe coronavirus infections (severe acute respiratory syndrome [SARS] and Middle East respiratory syndrome [MERS]) have been found to be associated with low mood both in the acute phase of the illness as well as at follow-up.[830]Rogers JP, Chesney E, Oliver D, et al. Psychiatric and neuropsychiatric presentations associated with severe coronavirus infections: a systematic review and meta-analysis with comparison to the COVID-19 pandemic. Lancet Psychiatry. 2020 Jul;7(7):611-27. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7234781/ http://www.ncbi.nlm.nih.gov/pubmed/32437679?tool=bestpractice.com [831]National Institute for Health Research. High rates of delirium, persistent fatigue and post-traumatic stress disorder were common after severe infection in previous coronavirus outbreaks. 2020 [internet publication]. https://evidence.nihr.ac.uk/alert/high-rates-of-delirium-persistent-fatigue-and-post-traumatic-stress-disorder-were-common-after-severe-infection-in-previous-coronavirus-outbreaks/
Consider other factors that may be influencing the patient’s mental state (e.g., the effect of any illicit drug use or alcohol).[832]Boden JM, Fergusson DM. Alcohol and depression. Addiction. 2011 May;106(5):906-14. http://www.ncbi.nlm.nih.gov/pubmed/21382111?tool=bestpractice.com
Treatment recommended for ALL patients in selected patient group
Practical tip
Contact your hospital’s diabetes specialist team for support in managing any patients with COVID-19 and diabetes.
Never stop basal insulin (long-acting/background insulin [e.g., determir, glargine, or degludec]) in a patient with type 1 diabetes who presents with an acute illness, including COVID-19.[799]Bornstein SR, Rubino F, Khunti K, et al. Practical recommendations for the management of diabetes in patients with COVID-19. Lancet Diabetes Endocrinol. 2020 Jun;8(6):546-50. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7180013/ http://www.ncbi.nlm.nih.gov/pubmed/32334646?tool=bestpractice.com [854]Chowdhury TA, Cheston H, Claydon A. Managing adults with diabetes in hospital during an acute illness. BMJ. 2017 Jun 22;357:j2551. http://www.ncbi.nlm.nih.gov/pubmed/28642274?tool=bestpractice.com
Insulin deficiency (e.g., due to delayed or missed doses) will rapidly cause ketoacidosis.[854]Chowdhury TA, Cheston H, Claydon A. Managing adults with diabetes in hospital during an acute illness. BMJ. 2017 Jun 22;357:j2551. http://www.ncbi.nlm.nih.gov/pubmed/28642274?tool=bestpractice.com
Generally, any patient with type 2 diabetes who is on basal insulin should continue to receive it, but this may not always be the case so check with senior and/or diabetes specialist team (based on expert opinion).
Be aware that COVID-19 appears to increase the risk of potentially life-threatening emergencies including:[793]National Inpatient Diabetes COVID-19 Response Group. Concise advice on inpatient diabetes during COVID-19: front door guidance. 2020 [internet publication]. https://abcd.care/resource/concise-advice-inpatient-diabetes-during-covid-19-front-door-guidance [799]Bornstein SR, Rubino F, Khunti K, et al. Practical recommendations for the management of diabetes in patients with COVID-19. Lancet Diabetes Endocrinol. 2020 Jun;8(6):546-50. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7180013/ http://www.ncbi.nlm.nih.gov/pubmed/32334646?tool=bestpractice.com
Hyperglycaemia with ketones
Diabetic ketoacidosis (DKA)
Hyperosmolar hyperglycaemic state (HHS)
This is the case in patients with COVID-19 with and without known diabetes.
Check the following on admission to hospital:[793]National Inpatient Diabetes COVID-19 Response Group. Concise advice on inpatient diabetes during COVID-19: front door guidance. 2020 [internet publication]. https://abcd.care/resource/concise-advice-inpatient-diabetes-during-covid-19-front-door-guidance
Blood glucose, in all patients
Blood ketones in all patients with diabetes (type 1 and type 2) and any patient who has a blood glucose on admission >12 mmol/L (>216 mg/dL).
Diagnose DKA in your patient with known diabetes if:[793]National Inpatient Diabetes COVID-19 Response Group. Concise advice on inpatient diabetes during COVID-19: front door guidance. 2020 [internet publication]. https://abcd.care/resource/concise-advice-inpatient-diabetes-during-covid-19-front-door-guidance
Blood ketone level is ≥3 mmol/L (≥54 mg/dL) and
Blood pH <7.3 or bicarbonate <15 mmol/L (<270 mg/dL).
Note that the American Diabetes Association and the American Association of Clinical Endocrinologists/American College of Endocrinology each recommend using different criteria for diagnosing DKA compared with the criteria above.[855]Karslioglu French E, Donihi AC, Korytkowski MT. Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients. BMJ. 2019 May 29;365:l1114. https://www.bmj.com/content/365/bmj.l1114.long http://www.ncbi.nlm.nih.gov/pubmed/31142480?tool=bestpractice.com
Practical tip
In euglycaemic ketoacidosis, the glucose level may not be significantly elevated.
The diagnosis of HHS is highly likely in the presence of:[793]National Inpatient Diabetes COVID-19 Response Group. Concise advice on inpatient diabetes during COVID-19: front door guidance. 2020 [internet publication]. https://abcd.care/resource/concise-advice-inpatient-diabetes-during-covid-19-front-door-guidance
Blood glucose ≥30 mmol/L and
Serum osmolality ([(2 x Na) + glucose + urea]) >320 mOsm/kg and
pH >7.3.
Note that the American Diabetes Association recommends using different criteria for diagnosing HHS compared with the criteria above.[855]Karslioglu French E, Donihi AC, Korytkowski MT. Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients. BMJ. 2019 May 29;365:l1114. https://www.bmj.com/content/365/bmj.l1114.long http://www.ncbi.nlm.nih.gov/pubmed/31142480?tool=bestpractice.com
Contact the diabetes specialist team and follow your local guidelines for management of DKA or HHS in patients with COVID-19, or if you suspect mixed DKA/HHS.
Diagnose hypoglycaemia if blood glucose <4 mmol/L (<72 mg/dL).
Follow your local protocol for management of hypoglycaemia.
Stop the following medication:[793]National Inpatient Diabetes COVID-19 Response Group. Concise advice on inpatient diabetes during COVID-19: front door guidance. 2020 [internet publication]. https://abcd.care/resource/concise-advice-inpatient-diabetes-during-covid-19-front-door-guidance
Sodium-glucose cotransporter-2 (SGLT-2) inhibitors (e.g., dapagliflozin, canagliflozin, empagliflozin)
SGLT-2 inhibitors reduce blood glucose reabsorption in the kidneys (independently of insulin metabolism of glucose).[795]Peters AL, Buschur EO, Buse JB, et al. Euglycemic diabetic ketoacidosis: a potential complication of treatment with sodium-glucose cotransporter 2 inhibition. Diabetes Care. 2015 Sep;38(9):1687-93. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4542270/ http://www.ncbi.nlm.nih.gov/pubmed/26078479?tool=bestpractice.com
They can mask underlying ketoacidosis as the patient may have a normal (or near normal) serum glucose level (euglycaemic ketoacidosis).
Metformin
Metformin is contraindicated in patients with significant renal impairment (estimated GFR <30 mL/minute/1.73 m2), or metabolic acidosis (including lactic acidosis and DKA).
It is also contraindicated if the patient is at risk of lactic acidosis: for example, with acute kidney injury or tissue hypoxia, including dehydration, or if they are to be fasted for a prolonged period.
Consider re-starting metformin depending on results of the patient’s blood lactate, kidney function, and arterial blood gases.
The patient may need medication adjustment or to start insulin as a temporary measure if their usual SGLT-2 inhibitor or metformin is stopped. Seek diabetes specialist team advice.
Treatment recommended for ALL patients in selected patient group
Assess the risk of bleeding as soon as possible after admission, or by the time of the first consultant review, using a suitable risk assessment tool.[496]National Institute for Health and Care Excellence. COVID-19 rapid guideline: managing COVID-19. 2021 [internet publication]. https://www.nice.org.uk/guidance/ng191
Start venous thromboembolism (VTE) prophylaxis in acutely ill hospitalised adults and adolescents, provided there are no contraindications.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1 [3]National Institutes of Health. Coronavirus disease 2019 (COVID-19) treatment guidelines. 2021 [internet publication]. https://covid19treatmentguidelines.nih.gov/ [688]Barnes GD, Burnett A, Allen A, et al. Thromboembolism and anticoagulant therapy during the COVID-19 pandemic: interim clinical guidance from the Anticoagulation Forum. J Thromb Thrombolysis. 2020 Jul;50(1):72-81. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7241581/ http://www.ncbi.nlm.nih.gov/pubmed/32440883?tool=bestpractice.com [689]Moores LK, Tritschler T, Brosnahan S, et al. Prevention, diagnosis, and treatment of VTE in patients with coronavirus disease 2019: CHEST guideline and expert panel report. Chest. 2020 Sep;158(3):1143-63. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7265858/ http://www.ncbi.nlm.nih.gov/pubmed/32502594?tool=bestpractice.com The UK National Institute for Health and Care Excellence (NICE) recommends starting as soon as possible and within 14 hours of admission, and continuing for a minimum of 14 days or until discharge.[496]National Institute for Health and Care Excellence. COVID-19 rapid guideline: managing COVID-19. 2021 [internet publication]. https://www.nice.org.uk/guidance/ng191 For hospitalised children, indications for VTE prophylaxis should be the same as those for children without COVID-19.[3]National Institutes of Health. Coronavirus disease 2019 (COVID-19) treatment guidelines. 2021 [internet publication]. https://covid19treatmentguidelines.nih.gov/
Low molecular weight heparin, unfractionated heparin, or fondaparinux are the recommended options for standard thromboprophylaxis.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1 NICE recommends low molecular weight heparin first-line, with fondaparinux or unfractionated heparin reserved for patients who cannot have low molecular weight heparin.[496]National Institute for Health and Care Excellence. COVID-19 rapid guideline: managing COVID-19. 2021 [internet publication]. https://www.nice.org.uk/guidance/ng191 Unfractionated heparin is contraindicated in patients with severe thrombocytopenia. Fondaparinux is recommended in patients with a history of heparin-induced thrombocytopenia. Mechanical thromboprophylaxis (e.g., intermittent pneumatic compression devices) is recommended if anticoagulation is contraindicated or not available.[689]Moores LK, Tritschler T, Brosnahan S, et al. Prevention, diagnosis, and treatment of VTE in patients with coronavirus disease 2019: CHEST guideline and expert panel report. Chest. 2020 Sep;158(3):1143-63. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7265858/ http://www.ncbi.nlm.nih.gov/pubmed/32502594?tool=bestpractice.com [691]American Society Of Hematology. COVID-19 and VTE/anticoagulation: frequently asked questions. 2020 [internet publication]. https://www.hematology.org/covid-19/covid-19-and-vte-anticoagulation
The optimal dose is yet to be determined. Standard prophylaxis doses are generally recommended over intermediate- or full treatment-dose regimens in patients without an established indication for higher-dose anticoagulation. However, this recommendation varies and you should consult your local guidelines. The World Health Organization recommends standard thromboprophylaxis dosing of anticoagulation rather than therapeutic or intermediate dosing in patients without an established indication for higher-dose anticoagulation.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1 NICE recommends clinicians consider a treatment dose of a low molecular weight heparin in young people and adults who are likely to be in hospital for at least 3 days and need supplemental oxygen (but who are not yet receiving high-flow oxygen, continuous positive airway pressure, non-invasive ventilation, or invasive mechanical ventilation), unless contraindicated. This is because of fewer deaths and less likelihood of needing intensive care with this dose compared with a standard prophylaxis dose without a notable increase in major bleeding, although the evidence for this recommendation is weak. Treatment should be for a minimum of 14 days or until discharge, and the dose may need to be reduced if the clinical circumstances change (such as a need for advanced respiratory support). For those who do not need supplemental oxygen, follow standard VTE prophylaxis guidelines.[496]National Institute for Health and Care Excellence. COVID-19 rapid guideline: managing COVID-19. 2021 [internet publication]. https://www.nice.org.uk/guidance/ng191 The National Institutes of Health guidelines panel recommends prophylactic-dose anticoagulation, and states that there are insufficient data to recommend increased anticoagulant doses for VTE prophylaxis in COVID-19 patients outside the setting of a clinical trial.[3]National Institutes of Health. Coronavirus disease 2019 (COVID-19) treatment guidelines. 2021 [internet publication]. https://covid19treatmentguidelines.nih.gov/
Dose adjustments may be required in patients with extremes of body weight or renal impairment.[496]National Institute for Health and Care Excellence. COVID-19 rapid guideline: managing COVID-19. 2021 [internet publication]. https://www.nice.org.uk/guidance/ng191
For patients who are already on an anticoagulant for another condition, continue the patient’s current therapeutic dose unless contraindicated by a change in clinical circumstances. Consider switching to low molecular weight heparin as the preferred option for venous thromboembolism prophylaxis if the patient’s clinical condition is deteriorating and the patient is not currently on low molecular weight heparin.[496]National Institute for Health and Care Excellence. COVID-19 rapid guideline: managing COVID-19. 2021 [internet publication]. https://www.nice.org.uk/guidance/ng191
Monitor patients for signs and symptoms suggestive of thromboembolism and proceed with appropriate diagnostic and management pathways if clinically suspected.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1 If the patient’s clinical condition changes, assess the risk of VTE, reassess the bleeding risk, and review VTE prophylaxis.[496]National Institute for Health and Care Excellence. COVID-19 rapid guideline: managing COVID-19. 2021 [internet publication]. https://www.nice.org.uk/guidance/ng191
Continue until hospital discharge.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1 Routine post-discharge VTE prophylaxis is not generally recommended, except in certain high-risk patients.[3]National Institutes of Health. Coronavirus disease 2019 (COVID-19) treatment guidelines. 2021 [internet publication]. https://covid19treatmentguidelines.nih.gov/ [688]Barnes GD, Burnett A, Allen A, et al. Thromboembolism and anticoagulant therapy during the COVID-19 pandemic: interim clinical guidance from the Anticoagulation Forum. J Thromb Thrombolysis. 2020 Jul;50(1):72-81. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7241581/ http://www.ncbi.nlm.nih.gov/pubmed/32440883?tool=bestpractice.com [689]Moores LK, Tritschler T, Brosnahan S, et al. Prevention, diagnosis, and treatment of VTE in patients with coronavirus disease 2019: CHEST guideline and expert panel report. Chest. 2020 Sep;158(3):1143-63. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7265858/ http://www.ncbi.nlm.nih.gov/pubmed/32502594?tool=bestpractice.com Ensure patients who require VTE prophylaxis after discharge are able to use it correctly or have arrangements made for someone to help them.[496]National Institute for Health and Care Excellence. COVID-19 rapid guideline: managing COVID-19. 2021 [internet publication]. https://www.nice.org.uk/guidance/ng191
There is currently insufficient evidence to determine the risks and benefits of prophylactic anticoagulation in hospitalised patients with COVID-19.[692]Flumignan RL, Tinôco JDS, Pascoal PI, et al. Prophylactic anticoagulants for people hospitalised with COVID-19. Cochrane Database Syst Rev. 2020 Oct 2;(10):CD013739. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD013739/full http://www.ncbi.nlm.nih.gov/pubmed/33502773?tool=bestpractice.com A retrospective analysis of over 4000 patients found that anticoagulation was associated with lower mortality and intubation among hospitalised COVID-19 patients. Therapeutic anticoagulation was associated with lower mortality compared with prophylactic anticoagulation, but the difference was not statistically significant.[693]Nadkarni GN, Lala A, Bagiella E, et al. Anticoagulation, mortality, bleeding and pathology among patients hospitalized with COVID-19: a single health system study. J Am Coll Cardiol. 2020 Oct 20;76(16):1815-26. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7449655/ http://www.ncbi.nlm.nih.gov/pubmed/32860872?tool=bestpractice.com An observational cohort study of over 4000 patients found that early initiation of prophylactic anticoagulation in hospitalised patients was associated with a decreased risk of 30-day mortality and no increased risk of serious bleeding events compared with no anticoagulation.[694]Rentsch CT, Beckman JA, Tomlinson L, et al. Early initiation of prophylactic anticoagulation for prevention of coronavirus disease 2019 mortality in patients admitted to hospital in the United States: cohort study. BMJ. 2021 Feb 11;372:n311. https://www.bmj.com/content/372/bmj.n311 http://www.ncbi.nlm.nih.gov/pubmed/33574135?tool=bestpractice.com Clinicians should rely on pre-COVID-19 evidence-based principles of anticoagulation management combined with rational approaches to address clinical challenges.[688]Barnes GD, Burnett A, Allen A, et al. Thromboembolism and anticoagulant therapy during the COVID-19 pandemic: interim clinical guidance from the Anticoagulation Forum. J Thromb Thrombolysis. 2020 Jul;50(1):72-81. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7241581/ http://www.ncbi.nlm.nih.gov/pubmed/32440883?tool=bestpractice.com
Anticoagulation in patients with chronic kidney disease
Check your local drug formulary/renal handbook for details on prescribing anticoagulants for venous thromboembolism prophylaxis in patients with reduced kidney function (chronic kidney disease, acute kidney injury).
Patients with impairment of kidney function may have an increased risk of bleeding with certain anticoagulants and careful patient monitoring is needed.[856]Law JP, Pickup L, Townend JN, et al. Anticoagulant strategies for the patient with chronic kidney disease. Clin Med (Lond). 2020 Mar;20(2):151-5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7081809/ http://www.ncbi.nlm.nih.gov/pubmed/32188649?tool=bestpractice.com
Depending on the degree of impairment of your patient’s kidney function, you may need to:
Adjust the dose
Avoid certain anticoagulants.
Follow local drug formulary guidance on recommended monitoring of anti-factor Xa activity.
Seek a nephrologist’s advice if the patient is on renal replacement therapy.
Primary options
enoxaparin: consult specialist for guidance on dose
enoxaparin open_in_new: consult specialist for guidance on dose
enoxaparin: consult specialist for guidance on dose
OR
dalteparin: consult specialist for guidance on dose
dalteparin open_in_new: consult specialist for guidance on dose
dalteparin: consult specialist for guidance on dose
Secondary options
fondaparinux: consult specialist for guidance on dose
fondaparinux open_in_new: consult specialist for guidance on dose
fondaparinux: consult specialist for guidance on dose
OR
These drug options and doses relate to a patient with no comorbidities.
Primary options
enoxaparin: consult specialist for guidance on dose
enoxaparin open_in_new: consult specialist for guidance on dose
enoxaparin: consult specialist for guidance on dose
OR
dalteparin: consult specialist for guidance on dose
dalteparin open_in_new: consult specialist for guidance on dose
dalteparin: consult specialist for guidance on dose
Secondary options
fondaparinux: consult specialist for guidance on dose
fondaparinux open_in_new: consult specialist for guidance on dose
fondaparinux: consult specialist for guidance on dose
OR
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Primary options
OR
Secondary options
OR
The Renal Handbook
Treatment recommended for ALL patients in selected patient group
Monitor patients closely for signs of clinical deterioration, and respond immediately with appropriate supportive care interventions.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1
Check baseline kidney function and monitor closely
Monitor kidney function especially closely if your patient with chronic kidney disease (CKD) or risk factors for CKD becomes ill with an acute condition.[759]National Institute for Health and Care Excellence. Acute kidney injury: prevention, detection and management. 2019 [internet publication]. https://www.nice.org.uk/guidance/ng148
CKD is a significant risk factor for acute kidney injury (AKI).[760]Hsu CY, Ordoñez JD, Chertow GM, et al. The risk of acute renal failure in patients with chronic kidney disease. Kidney Int. 2008 Jul;74(1):101-7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2673528/ http://www.ncbi.nlm.nih.gov/pubmed/18385668?tool=bestpractice.com
AKI in patients with COVID-19 may be common, although exact prevalence is uncertain. AKI is associated with increased mortality.[496]National Institute for Health and Care Excellence. COVID-19 rapid guideline: managing COVID-19. 2021 [internet publication]. https://www.nice.org.uk/guidance/ng191
Patients with CKD and COVID-19 will be at increased risk of AKI, which may be related to, among other factors, fever, dehydration, and use of non-steroidal anti-inflammatory drugs.
Explain to your patient with CKD that they are at increased risk of developing AKI when they become ill. Have mechanisms in place so patients being treated at home can be monitored closely for signs of disease progression.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1
For any patient with COVID-19 admitted to hospital, including those with CKD, check kidney function on admission, and ensure regular monitoring.
For patients with CKD:
Compare kidney function with last available results
Monitor kidney function daily, along with careful volume status monitoring (based on expert opinion).
Monitor for and respond to oliguria.[759]National Institute for Health and Care Excellence. Acute kidney injury: prevention, detection and management. 2019 [internet publication]. https://www.nice.org.uk/guidance/ng148
Continue to monitor fluid balance particularly closely
Maintaining optimal fluid status is critical but it can be hard to achieve in all patients with COVID-19.[496]National Institute for Health and Care Excellence. COVID-19 rapid guideline: managing COVID-19. 2021 [internet publication]. https://www.nice.org.uk/guidance/ng191 Seek senior advice, particularly for complex patients, such as those with heart failure and/or chronic kidney disease (CKD).
There is a risk of pulmonary oedema with fluid resuscitation in patients with heart failure and/or CKD so monitor closely (every hour initially).
Monitoring should include:
Regular clinical assessment of volume status (pulse, BP, jugular venous pressure [JVP], and check for pulmonary and peripheral oedema)
Fluid balance (input/output chart) and daily weight
Kidney function check, at least daily.
Consider bladder catheterisation if urinary output is difficult to measure, but be aware of increased risk of infection and trauma.
Central venous pressure or pulmonary artery catheterisation monitoring may be needed in complex patients.[800]Verbrugge FH, Grieten L, Mullens W. Management of the cardiorenal syndrome in decompensated heart failure. Cardiorenal Med. 2014 Dec;4(3-4):176-88. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4299260/ http://www.ncbi.nlm.nih.gov/pubmed/25737682?tool=bestpractice.com
It’s important to know when to de-escalate fluid therapy. Consider early senior input to support this decision.
If the patient has been volume overloaded with fluid (signs include elevated pulse rate, elevated respiratory rate due to pulmonary oedema, and an elevated JVP with peripheral oedema), stop fluid resuscitation, ask for senior help, and consider intravenous diuretics (based on expert opinion).
Unless there are extenuating circumstances, diuretics and intravenous fluids are not generally given together (based on expert opinion).
Specialist input may be required from a cardiologist and/or nephrologist.
Treatment recommended for SOME patients in selected patient group
Consider empirical antibiotics if there is clinical suspicion of secondary bacterial infection. Give within 1 hour of initial assessment for patients with suspected sepsis or if the patient meets high-risk criteria (or within 4 hours of establishing a diagnosis of secondary bacterial pneumonia); do not wait for microbiology results. Base the regimen on the clinical diagnosis (e.g., community-acquired pneumonia, hospital-acquired pneumonia, sepsis), local epidemiology and susceptibility data, and local treatment guidelines.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1 [3]National Institutes of Health. Coronavirus disease 2019 (COVID-19) treatment guidelines. 2021 [internet publication]. https://covid19treatmentguidelines.nih.gov/ [496]National Institute for Health and Care Excellence. COVID-19 rapid guideline: managing COVID-19. 2021 [internet publication]. https://www.nice.org.uk/guidance/ng191
Do not offer antibiotics for preventing or treating pneumonia if SARS-CoV-2, another virus, or a fungal infection is likely to be the cause.[496]National Institute for Health and Care Excellence. COVID-19 rapid guideline: managing COVID-19. 2021 [internet publication]. https://www.nice.org.uk/guidance/ng191 There is insufficient evidence to recommend empirical broad-spectrum antibiotics in the absence of another indication.[3]National Institutes of Health. Coronavirus disease 2019 (COVID-19) treatment guidelines. 2021 [internet publication]. https://covid19treatmentguidelines.nih.gov/
Consider seeking specialist advice for people who: are immunocompromised; have a history of infection with resistant organisms; have a history of repeated infective exacerbations of lung disease; are pregnant; or are receiving advanced respiratory or organ support. Seek specialist advice if there is a suspicion that the person has an infection with multidrug-resistant bacteria and may need a different antibiotic, or there is clinical or microbiological evidence of infection and the person's condition does not improve as expected after 48 to 72 hours of antibiotic treatment.[496]National Institute for Health and Care Excellence. COVID-19 rapid guideline: managing COVID-19. 2021 [internet publication]. https://www.nice.org.uk/guidance/ng191
Reassess antibiotic use daily. De-escalate empirical therapy on the basis of microbiology results and clinical judgement. Regularly review the possibility of switching from intravenous to oral therapy. Duration of treatment should be as short as possible (e.g., 5 to 7 days). Antibiotic stewardship programmes should be in place.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1
Treatment recommended for SOME patients in selected patient group
[Figure caption and citation for the preceding image starts]: Recommendations and evidence for the use of corticosteroids in hospitalised patients with COVID-19BMJ. 2020;370:m3379 [Citation ends].
The World Health Organization (WHO) strongly recommends systemic corticosteroid therapy (low-dose intravenous or oral dexamethasone or hydrocortisone) for 7 to 10 days in adults with severe COVID-19. This recommendation is based on two meta-analyses that pooled data from eight randomised trials (over 7000 patients), including the UK RECOVERY trial. Moderate-quality evidence suggests that systemic corticosteroids probably reduce 28-day mortality in patients with severe and critical COVID-19. They also probably reduce the need for invasive ventilation. There is no evidence directly comparing dexamethasone and hydrocortisone. The harms of treatment in this context are considered to be minor. It is unclear whether these recommendations can be applied to children or those who are immunocompromised.[652]World Health Organization. Therapeutics and COVID-19: living guideline. 2021 [internet publication]. https://www.who.int/publications/i/item/therapeutics-and-covid-19-living-guideline [696]WHO Rapid Evidence Appraisal for COVID-19 Therapies (REACT) Working Group; Sterne JAC, Murthy S, Diaz JV, et al. Association between administration of systemic corticosteroids and mortality among critically ill patients with COVID-19: a meta-analysis. JAMA. 2020 Oct 6;324(13):1330-41. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7489434/ http://www.ncbi.nlm.nih.gov/pubmed/32876694?tool=bestpractice.com [697]Rochwerg B, Siemieniuk RA, Agoritsas T, et al. A living WHO guideline on drugs for covid-19. BMJ. 2020 Sep 4;370:m3379. https://www.bmj.com/content/370/bmj.m3379.long http://www.ncbi.nlm.nih.gov/pubmed/32887691?tool=bestpractice.com [698]Rochwerg B, Siemieniuk RA, Lamontagne R, et al. Update to living WHO guideline on drugs for covid-19. BMJ. 2021 Mar 31;372:n860. https://www.bmj.com/content/372/bmj.n860.long http://www.ncbi.nlm.nih.gov/pubmed/33789884?tool=bestpractice.com [699]RECOVERY Collaborative Group; Horby P, Lim WS, Emberson JR, et al. Dexamethasone in hospitalized patients with Covid-19. N Engl J Med. 2021 Feb 25;384(8):693-704. https://www.nejm.org/doi/full/10.1056/NEJMoa2021436 http://www.ncbi.nlm.nih.gov/pubmed/32678530?tool=bestpractice.com There is also evidence that corticosteroids probably increase ventilator-free days (moderate certainty).[700]Siemieniuk RA, Bartoszko JJ, Ge L, et al. Drug treatments for covid-19: living systematic review and network meta-analysis. BMJ. 2020 Jul 30;370:m2980. https://www.bmj.com/content/370/bmj.m2980 http://www.ncbi.nlm.nih.gov/pubmed/32732190?tool=bestpractice.com [701]Siemieniuk RA, Bartoszko JJ, Ge L, et al. Update to living systematic review on drug treatments for covid-19. BMJ. 2021 Mar 31;372:n858. https://www.bmj.com/content/372/bmj.n858.long http://www.ncbi.nlm.nih.gov/pubmed/33789885?tool=bestpractice.com
In Europe, the European Medicines Agency has endorsed the use of dexamethasone for patients with severe disease who require oxygen therapy or mechanical ventilation.[702]European Medicines Agency. EMA endorses use of dexamethasone in COVID-19 patients on oxygen or mechanical ventilation. 2020 [internet publication]. https://www.ema.europa.eu/en/news/ema-endorses-use-dexamethasone-covid-19-patients-oxygen-mechanical-ventilation
In the US, the National Institutes of Health guidelines panel recommends dexamethasone, either alone or in combination with remdesivir (see the Emerging external link opens in a new windowsection for information on remdesivir), in hospitalized patients who require supplemental oxygen. The panel recommends against using dexamethasone in patients who do not require supplemental oxygen. Alternative corticosteroids may be used in situations where dexamethasone is not available.[3]National Institutes of Health. Coronavirus disease 2019 (COVID-19) treatment guidelines. 2021 [internet publication]. https://covid19treatmentguidelines.nih.gov/ The Infectious Diseases Society of America supports the use of dexamethasone in hospitalised patients with severe disease.[703]Bhimraj A, Morgan RL, Hirsch Shumaker A, et al. Infectious Diseases Society of America guidelines on the treatment and management of patients with COVID-19 infection. 2021 [internet publication]. https://www.idsociety.org/practice-guideline/covid-19-guideline-treatment-and-management/
Monitor patients for adverse effects (e.g., hyperglycaemia, secondary infections, psychiatric effects, reactivation of latent infections) and assess for drug-drug interactions.[3]National Institutes of Health. Coronavirus disease 2019 (COVID-19) treatment guidelines. 2021 [internet publication]. https://covid19treatmentguidelines.nih.gov/
Manage the patient’s diabetes when they are taking corticosteroids
Giving corticosteroids to someone with diabetes will worsen their glycaemic control, so test blood glucose at least four times a day.[857]National Inpatient Diabetes COVID-19 Response Group. Concise advice on inpatient diabetes during COVID-19 (COVID:Diabetes): dexamethasone therapy in covid-19 patients – implications and guidance for the management of blood glucose in people with and without diabetes. 2020 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/Resources/COVID-19/COvID_Dex_v1.4.pdf
For patients with diabetes, use the same doses of corticosteroid as for patients without diabetes but adjust diabetes medication, as their diabetes control will get worse.
Synthetic corticosteroids can cause hyperglycaemia by affecting carbohydrate metabolism and inducing insulin resistance.[858]Joint British Diabetes Societies for inpatient care. Management of hyperglycaemia and steroid (glucocorticosteroid) therapy. 2014 [internet publication]. https://abcd.care/sites/abcd.care/files/resources/JBDS_IP_Steroids.pdf
COVID-19 is also associated with increased insulin resistance as well as reduced insulin secretion from the pancreatic beta cells.[857]National Inpatient Diabetes COVID-19 Response Group. Concise advice on inpatient diabetes during COVID-19 (COVID:Diabetes): dexamethasone therapy in covid-19 patients – implications and guidance for the management of blood glucose in people with and without diabetes. 2020 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/Resources/COVID-19/COvID_Dex_v1.4.pdf
If hyperglycaemia does occur, rule out diabetic ketoacidosis or hyperosmolar hyperglycaemic state and follow your hospital protocol on managing blood glucose in patients with diabetes and COVID-19 taking corticosteroids.[857]National Inpatient Diabetes COVID-19 Response Group. Concise advice on inpatient diabetes during COVID-19 (COVID:Diabetes): dexamethasone therapy in covid-19 patients – implications and guidance for the management of blood glucose in people with and without diabetes. 2020 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/Resources/COVID-19/COvID_Dex_v1.4.pdf
The recommended protocol by the UK-based National Inpatient Diabetes COVID-19 Response Group uses subcutaneous insulin.
The group highlights that sulfonylureas are not recommended in this scenario due to potential impairment of beta cell function and likely severe insulin resistance.[857]National Inpatient Diabetes COVID-19 Response Group. Concise advice on inpatient diabetes during COVID-19 (COVID:Diabetes): dexamethasone therapy in covid-19 patients – implications and guidance for the management of blood glucose in people with and without diabetes. 2020 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/Resources/COVID-19/COvID_Dex_v1.4.pdf
When you stop the corticosteroid dose, glycaemic control will likely improve, although this may occur over a few days.
Follow your local protocol on titrating antidiabetic medication.
Monitor for psychiatric complications of corticosteroids
Check previous response to corticosteroids.
Past incidence of psychiatric complications during corticosteroid therapy increases the risk of recurrence in subsequent treatments.[859]Judd LL, Schettler PJ, Brown ES, et al. Adverse consequences of glucocorticoid medication: psychological, cognitive, and behavioral effects. Am J Psychiatry. 2014 Oct;171(10):1045-51. https://ajp.psychiatryonline.org/doi/10.1176/appi.ajp.2014.13091264 http://www.ncbi.nlm.nih.gov/pubmed/25272344?tool=bestpractice.com
Monitor for psychiatric adverse effects.[860]Kenna HA, Poon AW, de los Angeles CP, et al. Psychiatric complications of treatment with corticosteroids: review with case report. Psychiatry Clin Neurosci. 2011 Oct;65(6):549-60. https://onlinelibrary.wiley.com/doi/full/10.1111/j.1440-1819.2011.02260.x http://www.ncbi.nlm.nih.gov/pubmed/22003987?tool=bestpractice.com
These may vary in severity and include:
Minor changes in temperament
Severe mood changes, including manic states
Cognitive impairment.
Starting corticosteroid treatment is most often linked with manic episodes and delirious states. Chronic corticosteroid therapy most frequently presents with depression.[861]Warrington TP, Bostwick JM. Psychiatric adverse effects of corticosteroids. Mayo Clin Proc. 2006 Oct;81(10):1361-7. https://www.mayoclinicproceedings.org/article/S0025-6196(11)61160-9/fulltext http://www.ncbi.nlm.nih.gov/pubmed/17036562?tool=bestpractice.com
Effects seem to be dose-related and are more common with long-term regimens or long-acting formulations, and in older patients.[859]Judd LL, Schettler PJ, Brown ES, et al. Adverse consequences of glucocorticoid medication: psychological, cognitive, and behavioral effects. Am J Psychiatry. 2014 Oct;171(10):1045-51. https://ajp.psychiatryonline.org/doi/10.1176/appi.ajp.2014.13091264 http://www.ncbi.nlm.nih.gov/pubmed/25272344?tool=bestpractice.com This also stands true for patients who have neuropsychiatric adverse effects related to discontinuing long-term corticosteroid therapy.[862]Fardet L, Nazareth I, Whitaker HJ, et al. Severe neuropsychiatric outcomes following discontinuation of long-term glucocorticoid therapy: a cohort study. J Clin Psychiatry. 2013 Apr;74(4):e281-6. http://www.ncbi.nlm.nih.gov/pubmed/23656853?tool=bestpractice.com
Liaise with the psychiatry team for advice on appropriate management of the patient’s mood-related complications (based on expert opinion).
This may involve:
Adjusting the dose or discontinuing the corticosteroid therapy if clinically indicated.
If discontinuing corticosteroids, being mindful of a possible withdrawal reaction.[862]Fardet L, Nazareth I, Whitaker HJ, et al. Severe neuropsychiatric outcomes following discontinuation of long-term glucocorticoid therapy: a cohort study. J Clin Psychiatry. 2013 Apr;74(4):e281-6. http://www.ncbi.nlm.nih.gov/pubmed/23656853?tool=bestpractice.com This can present with weakness, fatigue, gastrointestinal symptoms, and delirium, as well as with psychiatric complications including depression
Considering prophylactic medication to reduce the risk of psychiatric adverse effects when a patient with a history of mood disorder is started on corticosteroid therapy. Seek expert psychiatric advice.
Primary options
dexamethasone: adults: 6 mg orally/intravenously once daily for 7-10 days
dexamethasone open_in_new: adults: 6 mg orally/intravenously once daily for 7-10 days
dexamethasone: adults: 6 mg orally/intravenously once daily for 7-10 days
OR
hydrocortisone: adults: 50 mg orally/intravenously every 8 hours for 7-10 days
hydrocortisone open_in_new: adults: 50 mg orally/intravenously every 8 hours for 7-10 days
hydrocortisone: adults: 50 mg orally/intravenously every 8 hours for 7-10 days
Secondary options
prednisolone: adults: 40 mg/day orally given in 1-2 divided doses for 7-10 days
prednisolone open_in_new: adults: 40 mg/day orally given in 1-2 divided doses for 7-10 days
prednisolone: adults: 40 mg/day orally given in 1-2 divided doses for 7-10 days
OR
methylprednisolone: adults: 32 mg/day orally/intravenously given in 1-2 divided doses for 7-10 days
methylprednisolone open_in_new: adults: 32 mg/day orally/intravenously given in 1-2 divided doses for 7-10 days
methylprednisolone: adults: 32 mg/day orally/intravenously given in 1-2 divided doses for 7-10 days
These drug options and doses relate to a patient with no comorbidities.
Primary options
dexamethasone: adults: 6 mg orally/intravenously once daily for 7-10 days
dexamethasone open_in_new: adults: 6 mg orally/intravenously once daily for 7-10 days
dexamethasone: adults: 6 mg orally/intravenously once daily for 7-10 days
OR
hydrocortisone: adults: 50 mg orally/intravenously every 8 hours for 7-10 days
hydrocortisone open_in_new: adults: 50 mg orally/intravenously every 8 hours for 7-10 days
hydrocortisone: adults: 50 mg orally/intravenously every 8 hours for 7-10 days
Secondary options
prednisolone: adults: 40 mg/day orally given in 1-2 divided doses for 7-10 days
prednisolone open_in_new: adults: 40 mg/day orally given in 1-2 divided doses for 7-10 days
prednisolone: adults: 40 mg/day orally given in 1-2 divided doses for 7-10 days
OR
methylprednisolone: adults: 32 mg/day orally/intravenously given in 1-2 divided doses for 7-10 days
methylprednisolone open_in_new: adults: 32 mg/day orally/intravenously given in 1-2 divided doses for 7-10 days
methylprednisolone: adults: 32 mg/day orally/intravenously given in 1-2 divided doses for 7-10 days
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Primary options
OR
Secondary options
OR
The Renal Handbook
Treatment recommended for SOME patients in selected patient group
Treat laboratory-confirmed co-infections (e.g., malaria, tuberculosis, influenza) as appropriate according to local protocols.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1 The treatment of influenza is the same in all patients regardless of SARS-CoV-2 co-infection. Start empirical treatment with oseltamivir in hospitalised patients who are suspected of having either or both infections as soon as possible without waiting for influenza test results. Antiviral therapy can be stopped once influenza has been ruled out.[3]National Institutes of Health. Coronavirus disease 2019 (COVID-19) treatment guidelines. 2021 [internet publication]. https://covid19treatmentguidelines.nih.gov/
Treatment recommended for SOME patients in selected patient group
Paracetamol or ibuprofen are recommended.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1 [496]National Institute for Health and Care Excellence. COVID-19 rapid guideline: managing COVID-19. 2021 [internet publication]. https://www.nice.org.uk/guidance/ng191 There is no evidence at present of severe adverse events in COVID-19 patients taking non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, or of effects as a result of the use of NSAIDs on acute healthcare utilisation, long-term survival, or quality of life in patients with COVID-19.[664]European Medicines Agency. EMA gives advice on the use of non-steroidal anti-inflammatories for COVID-19. 2020 [internet publication]. https://www.ema.europa.eu/en/news/ema-gives-advice-use-non-steroidal-anti-inflammatories-covid-19 [665]US Food and Drug Administration. FDA advises patients on use of non-steroidal anti-inflammatory drugs (NSAIDs) for COVID-19. 2020 [internet publication]. https://www.fda.gov/drugs/drug-safety-and-availability/fda-advises-patients-use-non-steroidal-anti-inflammatory-drugs-nsaids-covid-19 [666]Little P. Non-steroidal anti-inflammatory drugs and covid-19. BMJ. 2020 Mar 27;368:m1185. https://www.bmj.com/content/368/bmj.m1185 http://www.ncbi.nlm.nih.gov/pubmed/32220865?tool=bestpractice.com [667]Medicines and Healthcare products Regulatory Agency; Commission on Human Medicines. Commission on Human Medicines advice on ibuprofen and coronavirus (COVID-19). 2020 [internet publication]. https://www.gov.uk/government/news/commission-on-human-medicines-advice-on-ibuprofen-and-coronavirus-covid-19 [668]World Health Organization. The use of non-steroidal anti-inflammatory drugs (NSAIDs) in patients with COVID-19: scientific brief. 2020 [internet publication]. https://www.who.int/news-room/commentaries/detail/the-use-of-non-steroidal-anti-inflammatory-drugs-(nsaids)-in-patients-with-covid-19 [669]National Institute for Health and Care Excellence. COVID-19 rapid evidence summary: acute use of non-steroidal anti-inflammatory drugs (NSAIDs) for people with or at risk of COVID-19. 2020 [internet publication]. https://www.nice.org.uk/advice/es23/chapter/Key-messages [670]Wong AY, MacKenna B, Morton CE, et al. Use of non-steroidal anti-inflammatory drugs and risk of death from COVID-19: an OpenSAFELY cohort analysis based on two cohorts. Ann Rheum Dis. 2021 Jan 21 [Epub ahead of print]. https://ard.bmj.com/content/early/2021/01/20/annrheumdis-2020-219517.long http://www.ncbi.nlm.nih.gov/pubmed/33478953?tool=bestpractice.com
Ibuprofen should only be taken at the lowest effective dose for the shortest period needed to control symptoms. It is not recommended in pregnant women (especially in the third trimester) or children <6 months of age (age cut-offs vary by country).
NSAIDs in patients with chronic kidney disease, heart failure, or asthma
Non-steroidal anti-inflammatory drugs (NSAIDs):
Avoid NSAIDs in patients with chronic kidney disease and/or with heart failure (based on expert opinion)
NSAIDs can worsen symptoms in some patients with asthma, so check whether your patient has a known sensitivity.[768]Global Initiative for Asthma. Global strategy for asthma management and prevention. 2020 [internet publication]. https://ginasthma.org/gina-reports/
Primary options
paracetamol: children: consult local drug formulary for guidance on dose; adults: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day
paracetamol open_in_new: children: consult local drug formulary for guidance on dose; adults: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day
paracetamol: children: consult local drug formulary for guidance on dose; adults: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day
OR
ibuprofen: children: consult local drug formulary for guidance on dose; adults: 300-600 mg orally (immediate-release) every 6-8 hours when required, maximum 2400 mg/day
ibuprofen open_in_new: children: consult local drug formulary for guidance on dose; adults: 300-600 mg orally (immediate-release) every 6-8 hours when required, maximum 2400 mg/day
ibuprofen: children: consult local drug formulary for guidance on dose; adults: 300-600 mg orally (immediate-release) every 6-8 hours when required, maximum 2400 mg/day
These drug options and doses relate to a patient with no comorbidities.
Primary options
paracetamol: children: consult local drug formulary for guidance on dose; adults: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day
paracetamol open_in_new: children: consult local drug formulary for guidance on dose; adults: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day
paracetamol: children: consult local drug formulary for guidance on dose; adults: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day
OR
ibuprofen: children: consult local drug formulary for guidance on dose; adults: 300-600 mg orally (immediate-release) every 6-8 hours when required, maximum 2400 mg/day
ibuprofen open_in_new: children: consult local drug formulary for guidance on dose; adults: 300-600 mg orally (immediate-release) every 6-8 hours when required, maximum 2400 mg/day
ibuprofen: children: consult local drug formulary for guidance on dose; adults: 300-600 mg orally (immediate-release) every 6-8 hours when required, maximum 2400 mg/day
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Primary options
OR
The Renal Handbook
Treatment recommended for ALL patients in selected patient group
Guidelines from several professional respiratory organisations agree that patients with asthma or COPD should be advised to continue to take their inhalers as prescribed (including inhaled corticosteroids), whether they do or do not also have COVID-19.[769]Global Initiative for Asthma. Recommendations for inhaled asthma controller medications. 2020 [internet publication]. https://ginasthma.org/recommendations-for-inhaled-asthma-controller-medications/ [770]British Thoracic Society. Advice for healthcare professionals treating people with asthma (adults) in relation to COVID-19. 2020 [internet publication]. https://www.brit-thoracic.org.uk/about-us/covid-19-information-for-the-respiratory-community/ [771]Global Initiative for Chronic Obstructive Lung Disease. GOLD COVID-19 guidance. 2020 [internet publication]. https://goldcopd.org/gold-covid-19-guidance/ [772]National Institute for Health and Care Excellence. COVID-19 rapid guideline: community-based care of patients with chronic obstructive pulmonary disease (COPD). 2020 [internet publication]. https://www.nice.org.uk/guidance/ng168 [773]Hasan SS, Capstick T, Zaidi STR, et al. Use of corticosteroids in asthma and COPD patients with or without COVID-19. Respir Med. 2020 Aug-Sep;170:106045. https://www.resmedjournal.com/article/S0954-6111(20)30185-2/fulltext http://www.ncbi.nlm.nih.gov/pubmed/32843175?tool=bestpractice.com
It is still unclear whether infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may trigger an exacerbation of asthma or COPD, but if it were to occur it could further compromise pulmonary reserve.[773]Hasan SS, Capstick T, Zaidi STR, et al. Use of corticosteroids in asthma and COPD patients with or without COVID-19. Respir Med. 2020 Aug-Sep;170:106045. https://www.resmedjournal.com/article/S0954-6111(20)30185-2/fulltext http://www.ncbi.nlm.nih.gov/pubmed/32843175?tool=bestpractice.com
The overall aim for continuing inhaled corticosteroids is to reduce the risk of an exacerbation of asthma or COPD.[773]Hasan SS, Capstick T, Zaidi STR, et al. Use of corticosteroids in asthma and COPD patients with or without COVID-19. Respir Med. 2020 Aug-Sep;170:106045. https://www.resmedjournal.com/article/S0954-6111(20)30185-2/fulltext http://www.ncbi.nlm.nih.gov/pubmed/32843175?tool=bestpractice.com
There is no evidence that inhaled corticosteroids are related to COVID-19 infection in people with asthma.[774]Centre for Evidence-Based Medicine; Hartmann-Boyce J, Hobbs R. Inhaled steroids in asthma during the COVID-19 outbreak. 2020 [internet publication]. https://www.cebm.net/covid-19/inhaled-steroids-in-asthma-during-the-covid-19-outbreak/ There is also no evidence they increase the risks associated with COVID-19 in people with COPD.[772]National Institute for Health and Care Excellence. COVID-19 rapid guideline: community-based care of patients with chronic obstructive pulmonary disease (COPD). 2020 [internet publication]. https://www.nice.org.uk/guidance/ng168
Patients being cared for at home or in hospital with an acute medical condition can forget to tell you about their inhalers prescribed for COPD or asthma. Remember to check and prescribe if appropriate.
Many inhalers contain a combination of medications, so ensure no dual prescribing.
Patients with COPD or asthma who develop acute kidney injury with an estimated GFR <50 mL/minute/1.73 m² may need to temporarily stop their usual inhaled long-acting muscarinic receptor antagonist, depending on which specific drug is used. Check local formulary or seek pharmacist advice.
Other prescribed medication
Patients with severe asthma or COPD who take oral corticosteroids as regular prescribed maintenance therapy should also continue to take these at the lowest dose possible, as their condition may deteriorate if these are stopped.[769]Global Initiative for Asthma. Recommendations for inhaled asthma controller medications. 2020 [internet publication]. https://ginasthma.org/recommendations-for-inhaled-asthma-controller-medications/ [772]National Institute for Health and Care Excellence. COVID-19 rapid guideline: community-based care of patients with chronic obstructive pulmonary disease (COPD). 2020 [internet publication]. https://www.nice.org.uk/guidance/ng168 [775]National Institute for Health and Care Excellence. COVID-19 rapid guideline: severe asthma. 2020 [internet publication]. https://www.nice.org.uk/guidance/ng166
The UK National Institute for Health and Care Excellence rapid guideline on severe asthma recommends that patients who take regular biological therapy for asthma should continue to take this during the COVID-19 pandemic, but if they become ill with COVID-19, patients should contact the specialist team responsible for their care.[775]National Institute for Health and Care Excellence. COVID-19 rapid guideline: severe asthma. 2020 [internet publication]. https://www.nice.org.uk/guidance/ng166
Treatment recommended for ALL patients in selected patient group
The World Health Organization recommends that antihypertensive drugs should not routinely be stopped in patients with COVID-19, but may need adjusting depending on the patient’s clinical condition, particularly their blood pressure and kidney function.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1
Despite concern about possible increased risk of infection or more severe disease in patients prescribed ACE inhibitors or angiotensin-II receptor antagonists, due to upregulation of angiotensin-converting enzyme-2 (ACE2) receptor expression, the UK National Institute for Health and Care Excellence states that the current evidence is insufficient to draw any conclusion.[779]National Institute for Health and Care Excellence. COVID-19 rapid evidence summary: angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) in people with or at risk of COVID-19. 2020 [internet publication]. https://www.nice.org.uk/advice/es24/chapter/Key-messages
Several professional societies have recommended that during the pandemic patients who are already on these medications (e.g., for hypertension, heart failure, coronary artery disease, CKD, or complications of diabetes) continue to take them (if they don’t have COVID-19). If patients become ill with COVID-19, it is recommended they receive a full clinical assessment by their doctor before making any decisions to stop these medications.[780]American Heart Association; Heart Failure Society of America; American College of Cardiology. Patients taking ACE-i and ARBs who contract COVID-19 should continue treatment, unless otherwise advised by their physician. 2020 [internet publication]. https://newsroom.heart.org/news/patients-taking-ace-i-and-arbs-who-contract-covid-19-should-continue-treatment-unless-otherwise-advised-by-their-physician [781]European Society of Cardiology Council on Hypertension. Position statement of the ESC Council on Hypertension on ACE-inhibitors and angiotensin receptor blockers. 2020 [internet publication]. https://www.escardio.org/Councils/Council-on-Hypertension-(CHT)/News/position-statement-of-the-esc-council-on-hypertension-on-ace-inhibitors-and-ang [782]British Cardiovascular Society; British Society for Heart Failure. BSH & BCS joint statement on ACEi or ARB in relation to COVID-19. 2020 [internet publication]. https://www.britishcardiovascularsociety.org/news/ACEi-or-ARB-and-COVID-19 [783]The Renal Association. The Renal Association, UK position statement on COVID-19 and ACE inhibitor/angiotensin receptor blocker use. 2020 [internet publication]. https://renal.org/health-professionals/covid-19/ra-resources/renal-association-uk-position-statement-covid-19-and-ace
The UK Renal Association and the British Cardiovascular Society recommend following standard current guidance for patients with any intercurrent acute illness when weighing up benefit versus risk of these medications in patients ill with suspected COVID-19.[782]British Cardiovascular Society; British Society for Heart Failure. BSH & BCS joint statement on ACEi or ARB in relation to COVID-19. 2020 [internet publication]. https://www.britishcardiovascularsociety.org/news/ACEi-or-ARB-and-COVID-19 [783]The Renal Association. The Renal Association, UK position statement on COVID-19 and ACE inhibitor/angiotensin receptor blocker use. 2020 [internet publication]. https://renal.org/health-professionals/covid-19/ra-resources/renal-association-uk-position-statement-covid-19-and-ace [784]Clark AL, Kalra PR, Petrie MC, et al. Change in renal function associated with drug treatment in heart failure: national guidance. Heart. 2019 Jun;105(12):904-10. https://heart.bmj.com/content/105/12/904.long http://www.ncbi.nlm.nih.gov/pubmed/31118203?tool=bestpractice.com These include to:
Do an individual clinical assessment
Consider the original indication for any renin-angiotensin-aldosterone system (RAAS) inhibitors (ACE inhibitors, angiotensin-II receptor antagonists, mineralocorticoid receptor/aldosterone antagonists) and degree of prognostic benefit
If medication is temporarily withheld, consider when to re-introduce again once health improves.
Consider calculating a frailty score as patients with higher frailty scores may be more likely to experience medication-related harm when acutely unwell (based on expert opinion).
Consider the benefit versus risk of stopping other medications associated with an increased risk of acute kidney injury during intercurrent illness, such as other antihypertensives and diuretics.
If your patient with chronic kidney disease has been taking non-steroidal anti-inflammatory drugs, advise them to stop taking these when they are ill.
Patients who self-manage their heart failure in a community setting may wish to reduce their dose of diuretics during an intercurrent illness that may result in dehydration (based on expert opinion).
Seek advice from the patient’s cardiology or nephrology team if they have complex conditions (e.g., on renal replacement therapy or immunosuppressive therapy).
Treatment recommended for SOME patients in selected patient group
Consider appropriate experimental or emerging therapies.
Antiviral therapies will have a greater effect early in the course of the disease, whereas immunosuppressive/anti-inflammatory therapies are likely to have a greater effect later in the course of the disease.[3]National Institutes of Health. Coronavirus disease 2019 (COVID-19) treatment guidelines. 2021 [internet publication]. https://covid19treatmentguidelines.nih.gov/
See the Emerging external link opens in a new windowsection for more information.
Take the patient’s comorbidities into account when considering experimental therapies
The World Health Organization (WHO) recommends that you consider potential adverse effects and drug-drug interactions in patients with COVID-19.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1
One example of this is the effect on the QT interval. A patient may be on a drug that prolongs the QT interval. The patient may then receive another drug for COVID-19 that also prolongs the QT interval.
Consider your patient’s comorbidities and current treatments when prescribing any new medication.
Follow local drug protocol guidelines and consult senior colleagues before starting any new treatments.
Treatment recommended for SOME patients in selected patient group
Routinely assess older patients for mobility, functional swallow, cognitive impairment, and mental health concerns, and based on that assessment determine whether the patient is ready for discharge, and whether the patient has any rehabilitation and follow-up requirements.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1
Ensure plans are in place for follow-up of comorbidities
Ensure the patient has follow-up plans in place concerning any comorbidities as well as discharge and follow-up criteria related to COVID-19.
Knowledge and experience concerning the rehabilitation needs of patients post-hospital discharge is still increasing.[863]Greenhalgh T, Knight M, A’Court C, et al. Management of post-acute covid-19 in primary care. BMJ. 2020 Aug 11;370:m3026. https://www.bmj.com/content/370/bmj.m3026 http://www.ncbi.nlm.nih.gov/pubmed/32784198?tool=bestpractice.com [864]British Geriatrics Society. COVID-19: rehabilitation of older people. 2020 [internet publication]. https://www.bgs.org.uk/resources/covid-19-rehabilitation-of-older-people
COVID-19 may have long-term effects that relate to other comorbidities. UK-based patients with certain comorbidities may find the following sources of information useful:
Follow your local protocols and ask advice from relevant speciality teams.
Consider use of telemedicine to facilitate remote consultations in selected patients.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1 [762]Shore JH, Schneck CD, Mishkind MC. Telepsychiatry and the coronavirus disease 2019 pandemic-current and future outcomes of the rapid virtualization of psychiatric care. JAMA Psychiatry. 2020 May 11 [Epub ahead of print]. https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2765954 http://www.ncbi.nlm.nih.gov/pubmed/32391861?tool=bestpractice.com [763]Hubley S, Lynch SB, Schneck C, et al. Review of key telepsychiatry outcomes. World J Psychiatry. 2016 Jun 22;6(2):269-82. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4919267/ http://www.ncbi.nlm.nih.gov/pubmed/27354970?tool=bestpractice.com
Treatment recommended for SOME patients in selected patient group
Palliative care interventions should be made accessible at each institution that provides care for patients with COVID-19. Identify whether the patient has an advance care plan and respect the patient’s priorities and preferences when formulating the patient’s care plan.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1 Follow local palliative care guidelines.
Treatment recommended for ALL patients in selected patient group
Practical tip
Asthma exacerbation and COVID-19 may be difficult to differentiate clinically, and they may present together. Cough and shortness of breath are features of both; however, additional symptoms such as fever, fatigue, and change in taste or smell are more likely to suggest COVID-19 infection.[770]British Thoracic Society. Advice for healthcare professionals treating people with asthma (adults) in relation to COVID-19. 2020 [internet publication]. https://www.brit-thoracic.org.uk/about-us/covid-19-information-for-the-respiratory-community/
Monitor for acute worsening of respiratory symptoms and be aware that this may suggest a patient with comorbid asthma is having an acute exacerbation of their asthma.
Seek senior advice.
Follow standard guideline recommendations on assessing severity and managing an acute exacerbation of asthma in adults, even if COVID-19 is suspected as the trigger.[777]British Thoracic Society; Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma: a national clinical guideline. 2019 [internet publication]. https://www.sign.ac.uk/media/1048/sign158.pdf [818]Centers for Disease Control and Prevention. Clinical questions about COVID-19: questions and answers – patients with asthma. 2020 [internet publication]. https://www.cdc.gov/coronavirus/2019-ncov/hcp/faq.html#Patients-with-Asthma
See our topic Acute exacerbation of asthma in adults.
Temporarily stop any long-acting muscarinic receptor antagonist (LAMA) the patient may be on for maintenance therapy (e.g., tiotropium, aclidinium, glycopyrronium, umeclidinium) if you prescribe a nebulised short-acting muscarinic antagonist (e.g., ipratropium) (based on expert opinion). This is due to concern over possible additive anticholinergic adverse effects.
Ensure to re-prescribe the LAMA once the nebuliser treatment has been stopped.
Practical tip
There are currently differences of opinion between organisations in different countries on whether use of a nebuliser is an aerosol-generating procedure and therefore the specific personal protective equipment required.[769]Global Initiative for Asthma. Recommendations for inhaled asthma controller medications. 2020 [internet publication]. https://ginasthma.org/recommendations-for-inhaled-asthma-controller-medications/ [775]National Institute for Health and Care Excellence. COVID-19 rapid guideline: severe asthma. 2020 [internet publication]. https://www.nice.org.uk/guidance/ng166 Follow your local guidance and protocols. Consider whether it may be clinically appropriate to use a metered-dose inhaler delivered via a spacer device as an alternative delivery mechanism.[819]Global Initiative for Asthma. COVID-19: GINA answers to frequently asked questions on asthma management. 2020 [internet publication]. https://ginasthma.org/covid-19-gina-answers-to-frequently-asked-questions-on-asthma-management/
Treatment recommended for ALL patients in selected patient group
If an exacerbation of COPD is suspected in a patient with COVID-19 and pre-existing COPD, follow the patient’s personalised action plan.
Based on the limited evidence available, the Global Initiative for Chronic Obstructive Lung Disease recommends to follow established guidelines on the management of an exacerbation of COPD, including prescription of short-term oral corticosteroids if clinically indicated.[773]Hasan SS, Capstick T, Zaidi STR, et al. Use of corticosteroids in asthma and COPD patients with or without COVID-19. Respir Med. 2020 Aug-Sep;170:106045. https://www.resmedjournal.com/article/S0954-6111(20)30185-2/fulltext http://www.ncbi.nlm.nih.gov/pubmed/32843175?tool=bestpractice.com [778]Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease. 2021 [internet publication]. https://goldcopd.org/2021-gold-reports/
See our topic Acute exacerbation of COPD.
Seek senior or specialist advice.
Differentiate from other conditions, such as acute coronary syndrome, acute heart failure, and pneumonia, as well as from complications of COVID-19.
Practical tip
There are currently differences of opinion between organisations in different countries on whether use of a nebuliser is an aerosol-generating procedure and therefore the specific personal protective equipment required.[775]National Institute for Health and Care Excellence. COVID-19 rapid guideline: severe asthma. 2020 [internet publication]. https://www.nice.org.uk/guidance/ng166 [778]Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease. 2021 [internet publication]. https://goldcopd.org/2021-gold-reports/ Follow your local guidance and protocols.
If a nebuliser is used, bronchodilator therapy via a nebuliser should only be used for 24 to 48 hours and then the patient should be switched back onto their usual inhaler(s).
Temporarily stop any long-acting muscarinic receptor antagonist (LAMA) the patient may be on for maintenance therapy (e.g., tiotropium, aclidinium, glycopyrronium, umeclidinium) if you prescribe a nebulised short-acting muscarinic antagonist (e.g., ipratropium) (based on expert opinion). This is due to concern over possible additive anticholinergic adverse effects.
Ensure to re-prescribe the LAMA once the nebuliser treatment has been stopped.
Treatment recommended for ALL patients in selected patient group
Monitor blood glucose levels at least four times a day (pre-meal and before bedtime if eating) in any acutely unwell patient with diabetes mellitus.[820]American Diabetes Association. Diabetes care in the hospital: standards of medical care in diabetes - 2020. Diabetes Care. 2020 Jan;43(suppl 1):S193-202. https://care.diabetesjournals.org/content/43/Supplement_1/S193 http://www.ncbi.nlm.nih.gov/pubmed/31862758?tool=bestpractice.com
Follow your local protocol on blood glucose monitoring for inpatients with COVID-19 who have diabetes.
There is no consensus on target blood glucose levels for people with diabetes in hospital with an acute medical condition.
The UK Joint British Diabetes Societies for Inpatient Care (JBDS-IP) recommends an ideal range of 6 to 10 mmol/L (108-180 mg/dL), and an acceptable upper level of 12 mmol/L (216 mg/dL).[821]Joint British Diabetes Societies for inpatient care. The use of variable rate intravenous insulin infusion (VRIII) in medical inpatients. 2014 [internet publication]. https://abcd.care/sites/abcd.care/files/resources/JBDS_IP_VRIII.pdf A more liberal blood glucose target is considered appropriate if your patient is at high risk of falls, is frail, or has dementia.[821]Joint British Diabetes Societies for inpatient care. The use of variable rate intravenous insulin infusion (VRIII) in medical inpatients. 2014 [internet publication]. https://abcd.care/sites/abcd.care/files/resources/JBDS_IP_VRIII.pdf
The UK-based National Inpatient Diabetes COVID-19 Response Group makes the same recommendation for patients in hospital with COVID-19.[822]National Inpatient Diabetes COVID-19 Response Group. Concise advice on inpatient diabetes during COVID-19 (COVID:Diabetes): guidance for managing inpatient hyperglycaemia. 2020 [internet publication]. https://abcd.care/sites/abcd.care/files/resources/COvID_Hyper_v4.2.pdf
Consensus guidance from an international group of experts recommends aiming for levels of between 4 and 10 mmol/L (72 and 180 mg/dL) in patients with COVID-19, but to adjust the lower level to 5 mmol/L (90 mg/dL) in patients who are frail.[799]Bornstein SR, Rubino F, Khunti K, et al. Practical recommendations for the management of diabetes in patients with COVID-19. Lancet Diabetes Endocrinol. 2020 Jun;8(6):546-50. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7180013/ http://www.ncbi.nlm.nih.gov/pubmed/32334646?tool=bestpractice.com
The American Diabetes Association recommends a target range of 7.8 to 10 mmol/L (140-180 mg/dL) for most critically and non-critically ill patients (not specifically with COVID-19).[820]American Diabetes Association. Diabetes care in the hospital: standards of medical care in diabetes - 2020. Diabetes Care. 2020 Jan;43(suppl 1):S193-202. https://care.diabetesjournals.org/content/43/Supplement_1/S193 http://www.ncbi.nlm.nih.gov/pubmed/31862758?tool=bestpractice.com
Data are still limited on blood glucose control and its association with outcomes for patients with COVID-19.[794]Hartmann-Boyce J, Morris E, Goyder C, et al. Diabetes and COVID-19: risks, management, and learnings from other national disasters. Diabetes Care. 2020 Aug;43(8):1695-703. https://care.diabetesjournals.org/content/43/8/1695 http://www.ncbi.nlm.nih.gov/pubmed/32546593?tool=bestpractice.com
Hyperglycaemia during the ongoing hospital admission
Treat hyperglycaemia to avoid diabetic ketoacidosis (DKA) and hyperosmolar hyperglycaemic state (HHS), which are medical emergencies.
Follow your local hospital protocol if your patient’s capillary blood glucose is ≥12 mmol/L (≥216 mg/dL).
COVID-19 guidance generally emphasises the importance of managing hyperglycaemia.[794]Hartmann-Boyce J, Morris E, Goyder C, et al. Diabetes and COVID-19: risks, management, and learnings from other national disasters. Diabetes Care. 2020 Aug;43(8):1695-703. https://care.diabetesjournals.org/content/43/8/1695 http://www.ncbi.nlm.nih.gov/pubmed/32546593?tool=bestpractice.com
Exclude DKA or HHS, both of which require specific urgent management.
Consider other conditions associated with hyperglycaemia, such as sepsis.[793]National Inpatient Diabetes COVID-19 Response Group. Concise advice on inpatient diabetes during COVID-19: front door guidance. 2020 [internet publication]. https://abcd.care/resource/concise-advice-inpatient-diabetes-during-covid-19-front-door-guidance
Be aware that the following medications may be associated with hyperglycaemia and may need to be reviewed:[823]Rehman A, Setter SM, Vue MH. Drug-induced glucose alterations part 2: drug-induced hyperglycemia. Diabetes Spect. 2011 Nov;24(4):234-8. https://spectrum.diabetesjournals.org/content/24/4/234
Corticosteroids (e.g., dexamethasone)
Some beta-blockers (e.g., propranolol, atenolol)
Thiazide diuretics (e.g., hydrochlorothiazide)
Some second-generation antipsychotics (e.g., olanzapine, clozapine)
Certain fluoroquinolone antibiotics (e.g., ciprofloxacin)
Calcineurin inhibitors (e.g., ciclosporin, tacrolimus)
Protease inhibitors (e.g., as a component in antiretroviral therapy, lopinavir/ritonavir may be used to treat some patients with COVID-19).
Some experimental drugs used in the management of COVID-19 may be associated with (or cause) hyperglycaemia. Check local drug formularies for further information before prescribing these therapies in patients with diabetes.
If your patient has persistently elevated blood glucose, they may need insulin therapy (intravenous or subcutaneous protocols). Follow your local protocols on management of hyperglycaemia in patients with COVID-19.
Infusion pump devices may not be available outside of intensive care unit (ICU) settings, depending on the need for these devices elsewhere. In this situation, some protocols recommend alternative subcutaneous regimens when managing hyperglycaemia and mild DKA.[822]National Inpatient Diabetes COVID-19 Response Group. Concise advice on inpatient diabetes during COVID-19 (COVID:Diabetes): guidance for managing inpatient hyperglycaemia. 2020 [internet publication]. https://abcd.care/sites/abcd.care/files/resources/COvID_Hyper_v4.2.pdf [824]National Inpatient Diabetes COVID-19 Response Group. Concise advice on inpatient diabetes during COVID-19 (COVID:Diabetes): guideline for managing DKA using subcutaneous insulin. 2020 [internet publication]. https://abcd.care/sites/abcd.care/files/resources/COvID_DKA_SC_v3.3.pdf
Be aware that patients with type 2 diabetes in ICU may have significant degrees of insulin resistance.[822]National Inpatient Diabetes COVID-19 Response Group. Concise advice on inpatient diabetes during COVID-19 (COVID:Diabetes): guidance for managing inpatient hyperglycaemia. 2020 [internet publication]. https://abcd.care/sites/abcd.care/files/resources/COvID_Hyper_v4.2.pdf
Practical tip
Ask for expert advice from the inpatient diabetes team.
Hypoglycaemia during the ongoing hospital admission
Monitor blood glucose and adjust medication in response to illness and hospital meal times, to reduce the risk of hypoglycaemic episodes.
1 in 5 inpatients with diabetes in England and Wales have a hypoglycaemic episode during their hospital stay.[825]NHS Digital. National Diabetes Inpatient Audit (NaDIA) - 2017. 2018 [internet publication]. https://digital.nhs.uk/data-and-information/publications/statistical/national-diabetes-inpatient-audit/national-diabetes-inpatient-audit-nadia-2017
Causes of hypoglycaemia include:[826]Joint British Diabetes Societies for inpatient care. The hospital management of hypoglycaemia in adults with diabetes mellitus. 4th ed. 2020 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_HypoGuideline_4th_edition_FINAL.pdf
Recovery from an acute illness
Patients recovering from COVID-19 may have a rapid change in insulin requirements, so monitor and adjust insulin regimens carefully[822]National Inpatient Diabetes COVID-19 Response Group. Concise advice on inpatient diabetes during COVID-19 (COVID:Diabetes): guidance for managing inpatient hyperglycaemia. 2020 [internet publication]. https://abcd.care/sites/abcd.care/files/resources/COvID_Hyper_v4.2.pdf
Accidental interruptions to patient feeding, which may occur especially when patients with COVID-19 are nursed in the prone position[822]National Inpatient Diabetes COVID-19 Response Group. Concise advice on inpatient diabetes during COVID-19 (COVID:Diabetes): guidance for managing inpatient hyperglycaemia. 2020 [internet publication]. https://abcd.care/sites/abcd.care/files/resources/COvID_Hyper_v4.2.pdf
Reducing doses of corticosteroids, particularly dexamethasone in patients with COVID-19[822]National Inpatient Diabetes COVID-19 Response Group. Concise advice on inpatient diabetes during COVID-19 (COVID:Diabetes): guidance for managing inpatient hyperglycaemia. 2020 [internet publication]. https://abcd.care/sites/abcd.care/files/resources/COvID_Hyper_v4.2.pdf
Insulin or oral hypoglycaemic medication error
Wrong timing of insulin in relation to meals
Patients eating less but taking the same amount of diabetes medication
No bedtime snacks
Reduced appetite or vomiting.
Some experimental drugs used in the management of COVID-19 may be associated with (or cause) hypoglycaemia (e.g., hydroxychloroquine). Check local drug formularies for further information before prescribing these therapies in patients with diabetes.
Be aware that hypoglycaemia as an adverse effect of sulfonylurea medication (e.g., glibenclamide, gliclazide, glimepiride, glipizide) is more likely if meals are skipped or doses are excessive.
In the acute hospital setting, meal times may be interrupted or may not always be at exactly the same time each day.
Give sulfonylurea medication before or with food. Check local drug formulary for more specific guidance on timing of dose in relation to food for specific sulfonylurea.
Never give sulfonylurea medication at bedtime and, if the patient is taking a dose with their evening meal, consider reducing the evening dose to reduce the risk of nocturnal hypoglycaemia (based on expert opinion).
Practical tip
Bedtime snacks can reduce the risk of early morning hypoglycaemia.[825]NHS Digital. National Diabetes Inpatient Audit (NaDIA) - 2017. 2018 [internet publication]. https://digital.nhs.uk/data-and-information/publications/statistical/national-diabetes-inpatient-audit/national-diabetes-inpatient-audit-nadia-2017
Treat hypoglycaemia actively if the blood glucose falls below 4 mmol/L (72 mg/dL).[826]Joint British Diabetes Societies for inpatient care. The hospital management of hypoglycaemia in adults with diabetes mellitus. 4th ed. 2020 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_HypoGuideline_4th_edition_FINAL.pdf Follow hospital protocol. The JBDS-IP guidelines recommend that you:[826]Joint British Diabetes Societies for inpatient care. The hospital management of hypoglycaemia in adults with diabetes mellitus. 4th ed. 2020 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_HypoGuideline_4th_edition_FINAL.pdf
Retest blood glucose at 15 minutes to determine response to treatment
Never stop the next scheduled dose of insulin if the hypoglycaemia has been corrected. This can cause rebound hyperglycaemia and DKA in people with type 1 diabetes.
Follow local protocols and guidance on self-monitoring of blood glucose by patients in hospital.
These may have been adapted in the context of patients with COVID-19. For instance, some hospitals in the US have been utilising ‘virtual’ formats, including expanding self-management protocols, to reduce need for personal protective equipment, where it is safe to do so.[794]Hartmann-Boyce J, Morris E, Goyder C, et al. Diabetes and COVID-19: risks, management, and learnings from other national disasters. Diabetes Care. 2020 Aug;43(8):1695-703. https://care.diabetesjournals.org/content/43/8/1695 http://www.ncbi.nlm.nih.gov/pubmed/32546593?tool=bestpractice.com
Treatment recommended for ALL patients in selected patient group
Check the feet of any adult with diabetes on admission to hospital and whenever they seem more unwell.[827]National Institute for Health and Care Excellence. Diabetic foot problems: prevention and management. 2019 [internet publication]. https://www.nice.org.uk/guidance/ng19 This is still a recommendation for adults with diabetes admitted to hospital with COVID-19.[793]National Inpatient Diabetes COVID-19 Response Group. Concise advice on inpatient diabetes during COVID-19: front door guidance. 2020 [internet publication]. https://abcd.care/resource/concise-advice-inpatient-diabetes-during-covid-19-front-door-guidance
A foot check is needed to detect new ulceration or infection, which may be unnoticed by the patient. It may even be the cause of their acute illness (e.g., patient presenting with sepsis, or endocarditis where the original focus of infection is the foot lesion).
Inspect the foot for lesions and examine for loss of protective sensation.
Follow your local guidelines, but a quick simple test is the Ipswich Touch Test©️, which involves lightly touching/resting the tip of the index finger for 1 to 2 seconds on the tips of the first, third, and fifth toes.[828]Rayman G, Vas PR, Baker N, et al. The Ipswich Touch Test: a simple and novel method to identify inpatients with diabetes at risk of foot ulceration. Diabetes Care. 2011 Jul;34(7):1517-8. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3120164/ http://www.ncbi.nlm.nih.gov/pubmed/21593300?tool=bestpractice.com
If your patient is unable to feel at two or more of these six sites, they have reduced protective sensation.
If your patient has reduced sensation, they are at high risk of pressure ulceration. Inform the nursing staff and provide pressure relieving devices.
A daily heel check for signs of pressure trauma should be done by nursing or healthcare assistant staff.
There is a debate about whether compression stockings should or should not be used in people with diabetes – do not use them if there is vascular disease.
Treatment recommended for ALL patients in selected patient group
The World Health Organization recommends that potential adverse effects and drug-drug interactions are considered when treating patients with COVID-19.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1 With this in mind, if possible ask the patient which medications they are taking for their depression. Alternatively, review their primary care records for relevant information (if available).
Prescribe the patient’s usual antidepressant medication, unless there are good reasons not to (based on expert opinion).
If antidepressants are stopped abruptly, the patient may develop discontinuation symptoms.[833]Cleare A, Pariante CM, Young AH, et al. Evidence-based guidelines for treating depressive disorders with antidepressants: a revision of the 2008 British Association for Psychopharmacology guidelines. J Psychopharmacol. 2015 May;29(5):459-525. https://www.bap.org.uk/pdfs/BAP_Guidelines-Antidepressants.pdf http://www.ncbi.nlm.nih.gov/pubmed/25969470?tool=bestpractice.com
The severity of symptoms of discontinuation may vary, but it may be unpleasant and may complicate the management of the acute medical condition.[834]National Institute for Health and Care Excellence. Depression in adults with a chronic physical health problem: recognition and management. 2009 [internet publication]. https://www.nice.org.uk/guidance/cg91
When reviewing current medication, look out for:
Perceived current and previous adverse effects
Recent changes in dose
Recent switches from a different class of medication
Pharmacological nuances of specific depression subtypes (e.g., it is likely that patients suffering from psychotic depression would be co-prescribed an antipsychotic)
Augmenting strategies that may be in use in treating resistant depression (e.g., lithium or quetiapine augmentation of a selective serotonin-reuptake inhibitor [SSRI]).
Consider drug-drug interactions.
Antidepressant medications may cause pharmacokinetic (by inhibiting the CYP450 pathway) and pharmacodynamic interactions with medications used for other conditions.[833]Cleare A, Pariante CM, Young AH, et al. Evidence-based guidelines for treating depressive disorders with antidepressants: a revision of the 2008 British Association for Psychopharmacology guidelines. J Psychopharmacol. 2015 May;29(5):459-525. https://www.bap.org.uk/pdfs/BAP_Guidelines-Antidepressants.pdf http://www.ncbi.nlm.nih.gov/pubmed/25969470?tool=bestpractice.com [835]Taylor DM, Barnes TRE, Young AH. The Maudsley prescribing guidelines in psychiatry. 13th edition. Chichester: Wiley-Blackwell; 2018. Consider this issue for all medications prescribed in patients with COVID-19 as well as any experimental therapies (see the Emerging section).
Drug-drug interactions and their associated adverse effects of particular relevance to patients with COVID-19 include sedation, cardiotoxicity (QT prolongation), and respiratory depression.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1
Practical tip
Be aware that smoking cessation or switching from tobacco smoking to any other alternatives (including nicotine replacement therapy) may result in a change to the plasma concentration of any psychotropic medication the patient may be taking (e.g., for depression). This is because nicotine replacement therapy does not impact hepatic enzyme activity like tobacco smoking.[836]Flowers L. Nicotine replacement therapy. Am J Psychiatry Resid J. 2016 Jun;11(6):4-7. https://psychiatryonline.org/doi/10.1176/appi.ajp-rj.2016.110602 [837]Desai HD, Seabolt J, Jann MW. Smoking in patients receiving psychotropic medications: a pharmacokinetic perspective. CNS Drugs. 2001;15(6):469-94. http://www.ncbi.nlm.nih.gov/pubmed/11524025?tool=bestpractice.com [838]Oliveira P, Ribeiro J, Donato H, et al. Smoking and antidepressants pharmacokinetics: a systematic review. Ann Gen Psychiatry. 2017 Mar 6;16:17. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5340025/ http://www.ncbi.nlm.nih.gov/pubmed/28286537?tool=bestpractice.com [839]National Centre for Smoking Cessation and Training. Smoking cessation and mental health: a briefing for front-line staff. 2014 [internet publication]. https://www.ncsct.co.uk/usr/pub/mental%20health%20briefing%20A4.pdf Seek advice on whether any adjustment to the dose of psychotropic medication is appropriate.
Consider psychiatric complications when prescribing non-psychotropic drugs.
Take particular care when prescribing corticosteroids, anticonvulsants, and antiparkinsonian medication.
Consider adverse effects, which may include the following.
Respiratory depression. Be aware that certain antidepressants may precipitate respiratory depression, especially when co-prescribed with other sedative drugs. Particular caution is needed with tricyclic antidepressants and mirtazapine.
QT prolongation, arrhythmias, increased heart rate, or postural hypotension with tricyclic antidepressants. Check ECG, especially in people at risk of arrhythmias.
Hyponatraemia, caused by antidepressants, especially SSRIs, and compounded by other co-prescribed drugs (e.g., diuretics). Check the patient’s serum electrolytes.
Serotonin syndrome (altered mental state, agitation, tremor, hyper-reflexia, clonus, muscle rigidity, diaphoresis, tachycardia, increased bowel sounds, temperature >38℃), especially with polypharmacy and/or overdose of a serotonergic agent.[840]Boyer EW, Shannon M. The serotonin syndrome. N Engl J Med. 2005 Mar 17;352(11):1112-20. https://www.doi.org/10.1056/NEJMra041867 http://www.ncbi.nlm.nih.gov/pubmed/15784664?tool=bestpractice.com
Be particularly aware of increased risk of serotonin syndrome in patients with end-stage renal disease on SSRIs. Treating depression in patients with renal impairment requires a multidisciplinary approach and demands extra caution.
Hepatotoxicity. Adjust doses of antidepressants in patients with hepatic impairment if necessary and avoid drugs that are known to be hepatotoxic.
This list of adverse effects and drug-drug interactions is not exhaustive – consult local formulary for further information. Consult your liaison psychiatry colleagues and/or a pharmacist for advice.
If possible, ask the patient about non-pharmacological treatments for their depression and check current level of support in the community.
This may include other health professionals involved in their care, charities, family and social networks, and psychological therapy.
Treatment recommended for ALL patients in selected patient group
Consider a referral to the liaison psychiatry team/service for any patient with established or suspected depression who is admitted to hospital with an acute condition.[841]National Institute for Health and Care Excellence. Liaison psychiatry. In: Emergency acute medical care in over 16s: service delivery and organisation. 2018 [internet publication]. https://www.nice.org.uk/guidance/ng94/evidence/23.liaison-psychiatry-pdf-172397464636 [842]National Confidential Enquiry into Patient Outcome and Death. Treat as one: bridging the gap between mental and physical healthcare in general hospitals. 2017 [internet publication]. https://www.ncepod.org.uk/2017report1/downloads/TreatAsOne_Summary.pdf
Follow your local protocols/referral pathways in your hospital during the COVID-19 pandemic.
COVID-19 is associated with psychiatric and neurological manifestations including depression.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1
Comorbid depression is linked to poor adherence with recommended physical health treatments, from medication to rehabilitation.[843]DiMatteo MR, Lepper HS, Croghan TW. Depression is a risk factor for noncompliance with medical treatment: meta-analysis of the effects of anxiety and depression on patient adherence. Arch Intern Med. 2000 Jul 24;160(14):2101-7. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/485411 http://www.ncbi.nlm.nih.gov/pubmed/10904452?tool=bestpractice.com
This may lead to worse clinical outcomes, including longer hospital stays.[834]National Institute for Health and Care Excellence. Depression in adults with a chronic physical health problem: recognition and management. 2009 [internet publication]. https://www.nice.org.uk/guidance/cg91 [844]Prina AM, Cosco TD, Dening T, et al. The association between depressive symptoms in the community, non-psychiatric hospital admission and hospital outcomes: a systematic review. J Psychosom Res. 2015 Jan;78(1):25-33. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4292984/ http://www.ncbi.nlm.nih.gov/pubmed/25466985?tool=bestpractice.com [845]Clarke DM, Currie KC. Depression, anxiety and their relationship with chronic diseases: a review of the epidemiology, risk and treatment evidence. Med J Aust. 2009 Apr 6;190(s7):S54-60. http://www.ncbi.nlm.nih.gov/pubmed/19351294?tool=bestpractice.com
Most importantly, depression is linked with excess mortality.[846]World Health Organization. Excess mortality in persons with severe mental disorders. 2016 [internet publication]. https://www.who.int/mental_health/evidence/excess_mortality_report/en/
Treatment recommended for ALL patients in selected patient group
Consider prescribing nicotine replacement therapy to current smokers admitted with an acute condition. This is regardless of intention to quit smoking. However, because there is an increased risk for severe COVID-19 associated with tobacco smoking, in addition to the well-recognised harms, the World Health Organization does recommend smoking cessation using evidence-based methods.[253]World Health Organization. Smoking and COVID-19: scientific brief. 2020 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-Sci_Brief-Smoking-2020.2 [847]Patanavanich R, Glantz SA. Smoking is associated with COVID-19 progression: a meta-analysis. Nicotine Tob Res. 2020 Aug 24;22(9):1653-6. https://academic.oup.com/ntr/advance-article/doi/10.1093/ntr/ntaa082/5835834 http://www.ncbi.nlm.nih.gov/pubmed/32399563?tool=bestpractice.com [848]National Institute for Health and Care Excellence. Smoking: acute, maternity and mental health services. 2020 [internet publication]. https://www.nice.org.uk/guidance/ph48
Nicotine replacement therapy prevents rapid withdrawal during admission, which can be distressing and uncomfortable.
Preparations include transdermal patches or, for patients with skin allergies, inhalators, lozenges, gum, or sprays. Dose depends on how many cigarettes are smoked/day and the formulation chosen.
Use with caution in haemodynamically unstable patients hospitalised with acute stroke, myocardial infarction, and/or uncontrolled hypertension and in patients with severe renal impairment.
Monitor blood glucose closely if starting nicotine replacement therapy in patients with diabetes.
Consult your local drug formulary and hospital guidance for more comprehensive details.
Practical tip
Be aware that switching from tobacco smoking to any other alternatives (including nicotine replacement therapy) may result in a change to the plasma concentration of any psychotropic medication the patient may be taking (e.g., for depression). This is because nicotine replacement therapy does not impact hepatic enzyme activity like tobacco smoking.[836]Flowers L. Nicotine replacement therapy. Am J Psychiatry Resid J. 2016 Jun;11(6):4-7. https://psychiatryonline.org/doi/10.1176/appi.ajp-rj.2016.110602 Seek advice on whether any adjustment to the dose of psychotropic medication is appropriate.
Patients with critical disease (i.e., presence of acute respiratory distress syndrome, sepsis, or septic shock) should be admitted or transferred to an intensive/critical care unit under the guidance of a specialist team.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1
Withhold antihypertensives and/or diuretics if hypotensive
Consider withholding antihypertensives and/or diuretics in a patient with a history of hypertension, coronary heart disease, heart failure, stroke, or CKD if:
The patient is shocked or hypotensive[865]Ponikowski P, Voors AA, Anker SD, et al. 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2016 Jul 14;37(27):2129-200. https://academic.oup.com/eurheartj/article/37/27/2129/1748921 http://www.ncbi.nlm.nih.gov/pubmed/27206819?tool=bestpractice.com
The patient has a blood pressure ≥40 mmHg lower than baseline, has developed orthostatic hypotension (defined, by consensus, as a fall in systolic blood pressure ≥20 mmHg and/or a fall in diastolic blood pressure ≥10 mmHg within 3 minutes of standing[866]Freeman R, Wieling W, Axelrod FB, et al. Consensus statement on the definition of orthostatic hypotension, neurally mediated syncope and the postural tachycardia syndrome. Clin Auton Res. 2011 Apr;21(2):69-72. http://www.ncbi.nlm.nih.gov/pubmed/21431947?tool=bestpractice.com ), or has developed postural symptoms (based on expert opinion)
Establish the patient’s baseline blood pressure and assess volume status
Patients with treated heart failure may have chronically low blood pressure (e.g., systolic BP ≤90 mmHg). If their systolic blood pressure falls by >10 to 15 mmHg, it may be appropriate to withhold medication that may lower blood pressure. You may need expert review.
If diuretics are withheld in a patient with heart failure and/or CKD,close monitoring is needed as fluid can quickly accumulate.
If antihypertensives or diuretics have been withheld during the acute illness, consider restarting them before discharge if clinically appropriate (based on expert opinion).
Most patients won’t tolerate restarting all medications at the original doses in one go.
Restart one at a time at a lower dose and ask the patient's general practitioner to titrate back to normal dose.
If it is not clinically appropriate to restart these medicines before discharge, make sure the patient/carers understand the need to arrange a clinical review with the patient’s general practitioner to decide when the medications can be re-introduced. Ensure you have communicated clearly to the patient’s general practitioner.
Discuss the risks, benefits, and potential outcomes of treatment options with patients and their families, and allow them to express preferences about their management. Take their wishes and expectations into account when considering the ceiling of treatment. Use decision support tools if available. Put treatment escalation plans in place, and discuss any existing advance care plans or advance decisions to refuse treatment with patients who have pre-existing advanced comorbidities.[496]National Institute for Health and Care Excellence. COVID-19 rapid guideline: managing COVID-19. 2021 [internet publication]. https://www.nice.org.uk/guidance/ng191
Set an escalation plan
In consultation with the patient with dementia and their carers, agree an escalation plan as early as possible, as you would with any patient (based on expert opinion).
This should include:[764]Fritz Z, Slowther AM, Perkins GD. Resuscitation policy should focus on the patient, not the decision. BMJ. 2017 Feb 28;356:j813. https://www.bmj.com/content/356/bmj.j813.long http://www.ncbi.nlm.nih.gov/pubmed/28246084?tool=bestpractice.com
Resuscitation status (i.e., ‘Do Not Attempt Cardiopulmonary Resuscitation’ [DNACPR] decision)
Ceiling of care (e.g., suitability for intubation or intensive care admission).
Escalation plans should take account of advanced care planning, including legally binding advanced directives.[764]Fritz Z, Slowther AM, Perkins GD. Resuscitation policy should focus on the patient, not the decision. BMJ. 2017 Feb 28;356:j813. https://www.bmj.com/content/356/bmj.j813.long http://www.ncbi.nlm.nih.gov/pubmed/28246084?tool=bestpractice.com
In some situations, the patient with dementia will lack the mental capacity to make decisions for the escalation plan.
Assess and document mental capacity (the ability to make decisions at a specific time a decision needs to be made).[765]National Institute for Health and Care Excellence. Decision making and mental capacity. 2018 [internet publication]. https://www.nice.org.uk/guidance/ng108 Follow the appropriate legislation in your region.
In England and Wales, health professionals must comply with the 2005 Mental Capacity Act.[766]Department of Health. Mental Capacity Act 2005 [internet publication]. https://www.legislation.gov.uk/ukpga/2005/9/contents Assessments should follow the principles in the Act.[766]Department of Health. Mental Capacity Act 2005 [internet publication]. https://www.legislation.gov.uk/ukpga/2005/9/contents
If a patient is assessed to lack mental capacity, ensure decisions are made in the best interests of the patient.[765]National Institute for Health and Care Excellence. Decision making and mental capacity. 2018 [internet publication]. https://www.nice.org.uk/guidance/ng108 [766]Department of Health. Mental Capacity Act 2005 [internet publication]. https://www.legislation.gov.uk/ukpga/2005/9/contents
If the patient is assessed to lack mental capacity, consult with next of kin to make ‘best interests’ decisions.[766]Department of Health. Mental Capacity Act 2005 [internet publication]. https://www.legislation.gov.uk/ukpga/2005/9/contents
According to the 2005 Mental Capacity Act in England and Wales, if a patient is unbefriended and a decision is not time-critical, an independent mental capacity advocate (IMCA) should be sought to perform this role.[767]Social Care Institute for Excellence. Independent mental capacity advocate (IMCA). 2011 [internet publication]. https://www.scie.org.uk/mca/imca/do
Check the appropriate legislation for your territory.
Implement local infection prevention and control procedures when managing patients with COVID-19.
Pregnant women should be managed by a multidisciplinary team, including obstetric, perinatal, neonatal, and intensive care specialists, as well as midwifery and mental health and psychosocial support. A woman-centred, respectful, skilled approach to care is recommended.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1 The multidisciplinary team should be organised as soon as possible after maternal hypoxemia occurs in order to assess fetal maturity, disease progression, and the best options for delivery.[744]Chen L, Jiang H, Zhao Y. Pregnancy with Covid-19: management considerations for care of severe and critically ill cases. Am J Reprod Immunol. 2020 Jul 4:e13299. https://onlinelibrary.wiley.com/doi/10.1111/aji.13299 http://www.ncbi.nlm.nih.gov/pubmed/32623810?tool=bestpractice.com
Comorbidities in pregnancy and in children
The information in the BMJ Best Practice comorbidities tool relates to non-pregnant adults.
It is not intended for pregnant patients or for children. In these circumstances, please seek specialist obstetric/gynaecology or paediatric advice on how any comorbidities the patient has may affect your management of COVID-19.
Discontinue transmission-based precautions (including isolation) and release patients from the care pathway 10 days after symptom onset plus at least 3 days without fever and respiratory symptoms.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1 The US Centers for Disease Control and Prevention (CDC) recommends discontinuing isolation once at least 10 days and up to 20 days have passed since symptoms first appeared, and at least 24 hours have passed since last fever without the use of antipyretics, and symptoms have improved, if a symptom-based strategy is used. Consider consultation with infection control experts before discontinuing isolation. Severely immunocompromised patients may produce replication-competent virus beyond 20 days and require additional testing and consultation with infectious diseases specialists and infection control experts before discontinuing isolation. Alternatively, the CDC recommends at least two negative reverse-transcription polymerase chain reaction (RT-PCR) tests on respiratory specimens collected 24 hours apart before ending isolation if a test-based strategy is used. A symptom-based strategy is preferred; however, a test-based strategy can be considered in severely immunocompromised patients.[673]Centers for Disease Control and Prevention. Discontinuation of transmission-based precautions and disposition of patients with SARS-CoV-2 infection in healthcare settings. 2021 [internet publication]. https://www.cdc.gov/coronavirus/2019-ncov/hcp/disposition-hospitalized-patients.html Guidance on when to stop isolation depends on local recommendations and may differ between countries. For example, in the UK the isolation period is 14 days from a positive test in hospitalised patients. Immunocompetent patients who tested positive on RT-PCR and have completed their 14-day isolation period are exempt from testing prior to hospital discharge if they are within 90 days from their initial illness onset or test, unless they develop new symptoms.[663]Public Health England. Guidance for stepdown of infection control precautions and discharging COVID-19 patients. 2020 [internet publication]. https://www.gov.uk/government/publications/covid-19-guidance-for-stepdown-of-infection-control-precautions-within-hospitals-and-discharging-covid-19-patients-from-hospital-to-home-settings/guidance-for-stepdown-of-infection-control-precautions-and-discharging-covid-19-patients
Treatment recommended for ALL patients in selected patient group
Consider fluid and electrolyte management, antimicrobial treatment, and symptom management as appropriate. See Severe COVID-19 above for more detailed information.
Follow local guidelines for the management of pain, sedation, and delirium.[3]National Institutes of Health. Coronavirus disease 2019 (COVID-19) treatment guidelines. 2021 [internet publication]. https://covid19treatmentguidelines.nih.gov/
Implement standard interventions to prevent complications associated with critical illness.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1
Check baseline kidney function and monitor closely
Monitor kidney function especially closely if your patient with chronic kidney disease (CKD) or risk factors for CKD becomes ill with an acute condition.[759]National Institute for Health and Care Excellence. Acute kidney injury: prevention, detection and management. 2019 [internet publication]. https://www.nice.org.uk/guidance/ng148
CKD is a significant risk factor for acute kidney injury (AKI).[760]Hsu CY, Ordoñez JD, Chertow GM, et al. The risk of acute renal failure in patients with chronic kidney disease. Kidney Int. 2008 Jul;74(1):101-7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2673528/ http://www.ncbi.nlm.nih.gov/pubmed/18385668?tool=bestpractice.com
AKI in patients with COVID-19 may be common, although exact prevalence is uncertain. AKI is associated with increased mortality.[496]National Institute for Health and Care Excellence. COVID-19 rapid guideline: managing COVID-19. 2021 [internet publication]. https://www.nice.org.uk/guidance/ng191
Patients with CKD and COVID-19 will be at increased risk of AKI, which may be related to, among other factors, fever, dehydration, and use of non-steroidal anti-inflammatory drugs.
Explain to your patient with CKD that they are at increased risk of developing AKI when they become ill. Have mechanisms in place so patients being treated at home can be monitored closely for signs of disease progression.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1
For any patient with COVID-19 admitted to hospital, including those with CKD, check kidney function on admission, and ensure regular monitoring.
For patients with CKD:
Compare kidney function with last available results
Monitor kidney function daily, along with careful volume status monitoring (based on expert opinion).
Monitor for and respond to oliguria.[759]National Institute for Health and Care Excellence. Acute kidney injury: prevention, detection and management. 2019 [internet publication]. https://www.nice.org.uk/guidance/ng148
Assess fluid status and manage fluid balance particularly closely
It can be difficult to assess hypotension, low organ perfusion, and shock in a patient with heart failure and/or chronic kidney disease (CKD).
Hypovolaemia may be difficult to assess in a person with heart failure and/or CKD.[853]National Institute for Health and Care Excellence. Intravenous fluid therapy in adults in hospital. 2017 [internet publication]. https://www.nice.org.uk/guidance/cg174
Assess:[853]National Institute for Health and Care Excellence. Intravenous fluid therapy in adults in hospital. 2017 [internet publication]. https://www.nice.org.uk/guidance/cg174
Pulse
Blood pressure
For postural hypotension
Peripheral perfusion
Capillary refill
Jugular venous pressure
For presence of pulmonary and peripheral oedema.
Establish the patient’s baseline blood pressure as the fall from baseline is more significant than absolute systolic blood pressure (SBP). An SBP of <90 mmHg may suggest hypotension, but a patient on medication for chronic heart failure can have a baseline SBP of <90 mmHg (based on expert opinion).
A patient with CKD who is hypotensive, particularly if in shock, needs immediate fluid resuscitation.
Reassess the patient after initial fluid challenge and get senior input if the patient does not rapidly stabilise. Consider transfer to a more intensive level of care.
A patient with heart failure may need fluid resuscitation but seek senior review to assess volume status and the risk of volume overload. Consider transferring the patient to a more intensive level of care before initiating fluid resuscitation.
Continue to monitor fluid balance particularly closely
Maintaining optimal fluid status is critical but it can be hard to achieve in all patients with COVID-19.[496]National Institute for Health and Care Excellence. COVID-19 rapid guideline: managing COVID-19. 2021 [internet publication]. https://www.nice.org.uk/guidance/ng191 Seek senior advice, particularly for complex patients, such as those with heart failure and/or chronic kidney disease (CKD).
There is a risk of pulmonary oedema with fluid resuscitation in patients with heart failure and/or CKD so monitor closely (every hour initially).
Monitoring should include:
Regular clinical assessment of volume status (pulse, BP, jugular venous pressure [JVP], and check for pulmonary and peripheral oedema)
Fluid balance (input/output chart) and daily weight
Kidney function check, at least daily.
Consider bladder catheterisation if urinary output is difficult to measure, but be aware of increased risk of infection and trauma.
Central venous pressure or pulmonary artery catheterisation monitoring may be needed in complex patients.[800]Verbrugge FH, Grieten L, Mullens W. Management of the cardiorenal syndrome in decompensated heart failure. Cardiorenal Med. 2014 Dec;4(3-4):176-88. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4299260/ http://www.ncbi.nlm.nih.gov/pubmed/25737682?tool=bestpractice.com
It’s important to know when to de-escalate fluid therapy. Consider early senior input to support this decision.
If the patient has been volume overloaded with fluid (signs include elevated pulse rate, elevated respiratory rate due to pulmonary oedema, and an elevated JVP with peripheral oedema), stop fluid resuscitation, ask for senior help, and consider intravenous diuretics (based on expert opinion).
Unless there are extenuating circumstances, diuretics and intravenous fluids are not generally given together (based on expert opinion).
Specialist input may be required from a cardiologist and/or nephrologist.
NSAIDs in patients with chronic kidney disease, heart failure, or asthma
Non-steroidal anti-inflammatory drugs (NSAIDs):
Avoid NSAIDs in patients with chronic kidney disease and/or with heart failure (based on expert opinion)
NSAIDs can worsen symptoms in some patients with asthma, so check whether your patient has a known sensitivity.[768]Global Initiative for Asthma. Global strategy for asthma management and prevention. 2020 [internet publication]. https://ginasthma.org/gina-reports/
Baseline cognitive and delirium assessments with collateral history
Do a baseline cognitive assessment at the earliest opportunity in any patient admitted to hospital with an acute condition and with a history of dementia. Take a collateral history from family, friends, or carers.[804]Pendlebury ST, Klaus SP, Mather M, et al. Routine cognitive screening in older patients admitted to acute medicine: abbreviated mental test score (AMTS) and subjective memory complaint versus Montreal Cognitive Assessment and IQCODE. Age Ageing. 2015 Nov;44(6):1000-5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4621235/ http://www.ncbi.nlm.nih.gov/pubmed/26464420?tool=bestpractice.com
Use a validated scoring system that is feasible in the acute setting, such as:[804]Pendlebury ST, Klaus SP, Mather M, et al. Routine cognitive screening in older patients admitted to acute medicine: abbreviated mental test score (AMTS) and subjective memory complaint versus Montreal Cognitive Assessment and IQCODE. Age Ageing. 2015 Nov;44(6):1000-5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4621235/ http://www.ncbi.nlm.nih.gov/pubmed/26464420?tool=bestpractice.com
The abbreviated mental test score/10 (AMTS/10).[805]Hodkinson HM. Evaluation of a mental test score for assessment of mental impairment in the elderly. Age Ageing. 1972 Nov;1(4):233-8. http://www.ncbi.nlm.nih.gov/pubmed/4669880?tool=bestpractice.com British Geriatrics Society: Abbreviated Mental Test Score external link opens in a new window
The collateral history establishes whether the patient’s cognition is stable, or if any decline in cognition and function has been gradual or acute.
A standardised cognitive assessment score is useful for monitoring for any clinical improvement, and for establishing needs on discharge. This score is often best interpreted alongside a functional assessment, usually performed by a trained occupational therapist.
Assess for delirium whenever a patient with dementia presents with acute illness.[806]National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management. 2019 [internet publication]. https://www.nice.org.uk/guidance/CG103 The World Health Organization recommends that patients with COVID-19 are assessed for delirium using standardised protocols.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1
People living with dementia are at increased risk of delirium when they are admitted to hospital and throughout their admission.[807]National Institute for Health and Clinical Excellence. Dementia: assessment, management and support for people living with dementia and their carers. 2018 [internet publication]. https://www.nice.org.uk/guidance/ng97 [808]Scottish Intercollegiate Guidelines Network. Risk reduction and management of delirium: a national clinical guideline. 2019 [internet publication]. https://www.sign.ac.uk/our-guidelines/risk-reduction-and-management-of-delirium/
Delirium is not the same as dementia.[809]Nova Scotia Health Authority. This is not my Mom. 2012 [internet publication]. https://www.thisisnotmymom.ca It is a potentially life-threatening acute, fluctuating change in mental functioning, with inattention, disorganised thinking, and altered levels of consciousness.[810]Inouye SK, Schlesinger MJ, Lydon TJ. Delirium: a symptom of how hospital care is failing older persons and a window to improve quality of hospital care. Am J Med. 1999 May;106(5):565-73. http://www.ncbi.nlm.nih.gov/pubmed/10335730?tool=bestpractice.com
Use a screening tool to detect probable delirium, such as:
The 4-AT.[808]Scottish Intercollegiate Guidelines Network. Risk reduction and management of delirium: a national clinical guideline. 2019 [internet publication]. https://www.sign.ac.uk/our-guidelines/risk-reduction-and-management-of-delirium/ [811]Bellelli G, Morandi A, Davis DH, et al. Validation of the 4AT, a new instrument for rapid delirium screening: a study in 234 hospitalised older people. Age Ageing. 2014 Jul;43(4):496-502. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4066613/ http://www.ncbi.nlm.nih.gov/pubmed/24590568?tool=bestpractice.com [812]MacLullich AM, Shenkin SD, Goodacre S, et al. The 4 'A's test for detecting delirium in acute medical patients: a diagnostic accuracy study. Health Technol Assess. 2019 Aug;23(40):1-194. https://www.journalslibrary.nihr.ac.uk/hta/hta23400#/abstract http://www.ncbi.nlm.nih.gov/pubmed/31397263?tool=bestpractice.com
People with dementia may have communication difficulties, making it more difficult for them to report symptoms related to COVID-19. Their initial presentation may be with signs of delirium.[813]Public Health England. Coronavirus (COVID-19): admission and care of people in care homes. 2020 [internet publication]. https://www.gov.uk/government/publications/coronavirus-covid-19-admission-and-care-of-people-in-care-homes
Consider the following actions as part of multicomponent care intervention to reduce the risk of delirium during a hospital admission in people with dementia with any acute condition:[808]Scottish Intercollegiate Guidelines Network. Risk reduction and management of delirium: a national clinical guideline. 2019 [internet publication]. https://www.sign.ac.uk/our-guidelines/risk-reduction-and-management-of-delirium/ [814]British Geriatrics Society. Coronavirus: managing delirium in confirmed and suspected cases. 2020 [internet publication]. https://www.bgs.org.uk/resources/coronavirus-managing-delirium-in-confirmed-and-suspected-cases
Help with orientation; make sure patients have their own glasses and/or hearing aids
Get patients mobilised as soon as possible
Control pain adequately
Identify and treat superadded infections promptly
Keep well hydrated and help patients to eat adequately
Monitor and maintain regular bowel and bladder function
Use supplementary oxygen according to guideline recommendations.
Arrange a medication review with an experienced healthcare professional.[808]Scottish Intercollegiate Guidelines Network. Risk reduction and management of delirium: a national clinical guideline. 2019 [internet publication]. https://www.sign.ac.uk/our-guidelines/risk-reduction-and-management-of-delirium/
Challenges specifically related to COVID-19 include:[814]British Geriatrics Society. Coronavirus: managing delirium in confirmed and suspected cases. 2020 [internet publication]. https://www.bgs.org.uk/resources/coronavirus-managing-delirium-in-confirmed-and-suspected-cases
The need for isolation, which may exacerbate delirium in some patients
The ability to regularly monitor patients for delirium, which may be affected by staffing and time resources available.
Initial investigations for a patient with delirium
If a patient has delirium, check for and treat life-threatening causes:[808]Scottish Intercollegiate Guidelines Network. Risk reduction and management of delirium: a national clinical guideline. 2019 [internet publication]. https://www.sign.ac.uk/our-guidelines/risk-reduction-and-management-of-delirium/
Low blood glucose
Hypotension
Drug intoxication or withdrawal, including alcohol withdrawal.
Other investigations include (based on expert opinion):
Full blood count, electrolytes, renal function, thyroid function tests, liver function tests, calcium, glucose, CRP, folate, and vitamin B12
Blood cultures (if bacteraemia is suspected)
Urine culture
Chest x-ray.
Advanced non-routine investigations such as CT head may be needed, depending on specific clinical findings. Discuss with your senior.[808]Scottish Intercollegiate Guidelines Network. Risk reduction and management of delirium: a national clinical guideline. 2019 [internet publication]. https://www.sign.ac.uk/our-guidelines/risk-reduction-and-management-of-delirium/
Check for and treat any reversible causes of delirium.[806]National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management. 2019 [internet publication]. https://www.nice.org.uk/guidance/CG103 These include:
Infection
Pain
Dehydration
Constipation
Immobility
Poor sleep
Sensory impairment (e.g., ear wax or loss of glasses)
Medications
Ask about recently prescribed medications, especially opioid analgesics, anxiolytics, sedatives, antipsychotics, or medicines with strong anticholinergic properties
Consider calculating a total anticholinergic burden score.
Management of a patient with delirium
Manage patients with delirium initially, if possible with non-pharmacological treatment as recommended in management of delirium in a non-COVID-19 context.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1 [806]National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management. 2019 [internet publication]. https://www.nice.org.uk/guidance/CG103
Reduce disorientation by providing a well-lit room, with a clock and calendar visible (e.g., on the wall).
Encourage and facilitate family, friends, and carers to visit the patient, within restrictions of your visiting policy as determined by current levels of community COVID-19 transmission.
Use verbal and non-verbal techniques to de-escalate conflict and distress.
Where non-pharmacological treatments are ineffective, and the patient is distressed or considered a risk to themselves or others, short-term (often only 1-2 days is required) antipsychotic or sedative drugs may be considered, but only as a last resort. Any new antipsychotic prescribed for this purpose must be regularly reviewed, and discontinued as soon as practical (based on expert opinion).
The British Geriatrics Society has stated that in the context of management of a patient with COVID-19, it may be necessary to progress to pharmacological management earlier than would normally be considered in other circumstances because the risk of transmission of infection causing harm to others may be considered to be greater than potential harm to the individual.[814]British Geriatrics Society. Coronavirus: managing delirium in confirmed and suspected cases. 2020 [internet publication]. https://www.bgs.org.uk/resources/coronavirus-managing-delirium-in-confirmed-and-suspected-cases
The UK National Institute for Health and Care Excellence guideline on delirium (non-COVID-19 setting) recommends short-term use of haloperidol (usually for less than 1 week), but it is not suitable in all patients and must never be used in patients with Parkinson’s disease or in patients with dementia with Lewy bodies.[806]National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management. 2019 [internet publication]. https://www.nice.org.uk/guidance/CG103
The NICE rapid guideline on managing COVID-19 also recommends haloperidol as an option for the pharmacological management of delirium in patients with COVID-19 who can swallow.[496]National Institute for Health and Care Excellence. COVID-19 rapid guideline: managing COVID-19. 2021 [internet publication]. https://www.nice.org.uk/guidance/ng191
The evidence on the efficacy of antipsychotics for delirium is inconclusive, and hospital protocols may vary.[808]Scottish Intercollegiate Guidelines Network. Risk reduction and management of delirium: a national clinical guideline. 2019 [internet publication]. https://www.sign.ac.uk/our-guidelines/risk-reduction-and-management-of-delirium/ Follow your local hospital protocol for choice of medication.
Always start at the lowest dose for antipsychotic drugs and titrate carefully according to symptoms.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1 [806]National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management. 2019 [internet publication]. https://www.nice.org.uk/guidance/CG103 Only ever use oral or intramuscular medication (never intravenous) for this purpose (based on expert opinion).
Provide the family/carers with information so they understand what is happening and how they can work together with the clinical team to help the patient get back to their usual self.[808]Scottish Intercollegiate Guidelines Network. Risk reduction and management of delirium: a national clinical guideline. 2019 [internet publication]. https://www.sign.ac.uk/our-guidelines/risk-reduction-and-management-of-delirium/ Provide locally available information resources.[814]British Geriatrics Society. Coronavirus: managing delirium in confirmed and suspected cases. 2020 [internet publication]. https://www.bgs.org.uk/resources/coronavirus-managing-delirium-in-confirmed-and-suspected-cases
Antipsychotics are associated with increased mortality in people with dementia.
Short-term antipsychotics may sometimes be needed in people with dementia to enable safe care. However, antipsychotics have various adverse effects in older people and are associated with an increased risk of death in people with dementia.
A meta-analysis found that people with dementia who take atypical antipsychotics have an increased mortality risk compared with people taking placebo.[815]Ma H, Huang Y, Cong Z, et al. The efficacy and safety of atypical antipsychotics for the treatment of dementia: a meta-analysis of randomized placebo-controlled trials. J Alzheimers Dis. 2014;42(3):915-37. http://www.ncbi.nlm.nih.gov/pubmed/25024323?tool=bestpractice.com
A large cohort study of older people found that higher doses of antipsychotics are generally associated with greater risk. Of all the antipsychotics studied, haloperidol had the highest risk associated with its use.[816]Huybrechts KF, Gerhard T, Crystal S, et al. Differential risk of death in older residents in nursing homes prescribed specific antipsychotic drugs: population based cohort study. BMJ. 2012 Feb 23;344:e977. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3285717/ http://www.ncbi.nlm.nih.gov/pubmed/22362541?tool=bestpractice.com
Contrary to popular belief, long-term antipsychotic prescriptions can be safely withdrawn in most people with dementia once behaviour has settled.[817]Van Leeuwen E, Petrovic M, van Driel ML, et al. Withdrawal versus continuation of long-term antipsychotic drug use for behavioural and psychological symptoms in older people with dementia. Cochrane Database Syst Rev. 2018 Mar 30;(3):CD007726. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007726.pub3/full http://www.ncbi.nlm.nih.gov/pubmed/29605970?tool=bestpractice.com
If delirium is not responding to initial treatment within 48 hours, refer to a healthcare professional trained and skilled at diagnosing delirium to confirm the diagnosis and treatment plan (based on expert opinion).
Document the diagnosis of delirium clearly.[806]National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management. 2019 [internet publication]. https://www.nice.org.uk/guidance/CG103 [808]Scottish Intercollegiate Guidelines Network. Risk reduction and management of delirium: a national clinical guideline. 2019 [internet publication]. https://www.sign.ac.uk/our-guidelines/risk-reduction-and-management-of-delirium/
Baseline neurological assessment
Do a baseline neurological assessment at the earliest appropriate opportunity in patients who have a history of stroke and are admitted to hospital with an acute medical condition, including COVID-19.
Generally a patient with an acute condition (e.g., an infection and illness-related hypotension) is at increased risk of stroke (both ischaemic and haemorrhagic).[801]Grau AJ, Urbanek C, Palm F. Common infections and the risk of stroke. Nat Rev Neurol. 2010 Dec;6(12):681-94. http://www.ncbi.nlm.nih.gov/pubmed/21060340?tool=bestpractice.com [802]Eigenbrodt ML, Rose KM, Couper DJ, et al. Orthostatic hypotension as a risk factor for stroke: the atherosclerosis risk in communities (ARIC) study, 1987-1996. Stroke. 2000 Oct;31(10):2307-13. https://www.ahajournals.org/doi/10.1161/01.str.31.10.2307 http://www.ncbi.nlm.nih.gov/pubmed/11022055?tool=bestpractice.com This risk is even higher in anyone with a history of stroke.
Compare the baseline assessment results with the patient’s known pre-COVID-19 neurological status. This could be done by asking the patient, family, and carers about the patient’s functional ability before becoming ill (based on expert opinion).
This should reduce the risk of misattributing neurological signs on admission to the previous diagnosis of stroke.
If there is a change in neurological status during admission, repeat the neurological assessment in case of a new stroke.
Following assessment, ensure the right level of patient supervision (e.g., relating to the risk of confusion at night and the risk of falls associated with frailty). A patient with a history of stroke is at increased risk of falling and injury.[803]Winstein CJ, Stein J, Arena R, et al. Guidelines for adult stroke rehabilitation and recovery: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2016 Jun;47(6):e98-169. https://www.ahajournals.org/doi/10.1161/STR.0000000000000098 http://www.ncbi.nlm.nih.gov/pubmed/27145936?tool=bestpractice.com
The World Health Organization recommends that patients in hospital with COVID-19 are monitored closely for signs of clinical deterioration, including for signs or symptoms of stroke.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1
Reported neurological manifestations associated with COVID-19 have included acute ischaemic and haemorrhagic stroke.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1
Treatment recommended for ALL patients in selected patient group
Practical tip
Contact your hospital’s diabetes specialist team for support in managing any patients with COVID-19 and diabetes.
Never stop basal insulin (long-acting/background insulin [e.g., determir, glargine, or degludec]) in a patient with type 1 diabetes who presents with an acute illness, including COVID-19.[799]Bornstein SR, Rubino F, Khunti K, et al. Practical recommendations for the management of diabetes in patients with COVID-19. Lancet Diabetes Endocrinol. 2020 Jun;8(6):546-50. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7180013/ http://www.ncbi.nlm.nih.gov/pubmed/32334646?tool=bestpractice.com [854]Chowdhury TA, Cheston H, Claydon A. Managing adults with diabetes in hospital during an acute illness. BMJ. 2017 Jun 22;357:j2551. http://www.ncbi.nlm.nih.gov/pubmed/28642274?tool=bestpractice.com
Insulin deficiency (e.g., due to delayed or missed doses) will rapidly cause ketoacidosis.[854]Chowdhury TA, Cheston H, Claydon A. Managing adults with diabetes in hospital during an acute illness. BMJ. 2017 Jun 22;357:j2551. http://www.ncbi.nlm.nih.gov/pubmed/28642274?tool=bestpractice.com
Generally, any patient with type 2 diabetes who is on basal insulin should continue to receive it, but this may not always be the case so check with senior and/or diabetes specialist team (based on expert opinion).
Be aware that COVID-19 appears to increase the risk of potentially life-threatening emergencies including:[793]National Inpatient Diabetes COVID-19 Response Group. Concise advice on inpatient diabetes during COVID-19: front door guidance. 2020 [internet publication]. https://abcd.care/resource/concise-advice-inpatient-diabetes-during-covid-19-front-door-guidance [799]Bornstein SR, Rubino F, Khunti K, et al. Practical recommendations for the management of diabetes in patients with COVID-19. Lancet Diabetes Endocrinol. 2020 Jun;8(6):546-50. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7180013/ http://www.ncbi.nlm.nih.gov/pubmed/32334646?tool=bestpractice.com
Hyperglycaemia with ketones
Diabetic ketoacidosis (DKA)
Hyperosmolar hyperglycaemic state (HHS)
This is the case in patients with COVID-19 with and without known diabetes.
Check the following on admission to hospital:[793]National Inpatient Diabetes COVID-19 Response Group. Concise advice on inpatient diabetes during COVID-19: front door guidance. 2020 [internet publication]. https://abcd.care/resource/concise-advice-inpatient-diabetes-during-covid-19-front-door-guidance
Blood glucose, in all patients
Blood ketones in all patients with diabetes (type 1 and type 2) and any patient who has a blood glucose on admission >12 mmol/L (>216 mg/dL).
Diagnose DKA in your patient with known diabetes if:[793]National Inpatient Diabetes COVID-19 Response Group. Concise advice on inpatient diabetes during COVID-19: front door guidance. 2020 [internet publication]. https://abcd.care/resource/concise-advice-inpatient-diabetes-during-covid-19-front-door-guidance
Blood ketone level is ≥3 mmol/L (≥54 mg/dL) and
Blood pH <7.3 or bicarbonate <15 mmol/L (<270 mg/dL).
Note that the American Diabetes Association and the American Association of Clinical Endocrinologists/American College of Endocrinology each recommend using different criteria for diagnosing DKA compared with the criteria above.[855]Karslioglu French E, Donihi AC, Korytkowski MT. Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients. BMJ. 2019 May 29;365:l1114. https://www.bmj.com/content/365/bmj.l1114.long http://www.ncbi.nlm.nih.gov/pubmed/31142480?tool=bestpractice.com
Practical tip
In euglycaemic ketoacidosis, the glucose level may not be significantly elevated.
The diagnosis of HHS is highly likely in the presence of:[793]National Inpatient Diabetes COVID-19 Response Group. Concise advice on inpatient diabetes during COVID-19: front door guidance. 2020 [internet publication]. https://abcd.care/resource/concise-advice-inpatient-diabetes-during-covid-19-front-door-guidance
Blood glucose ≥30 mmol/L and
Serum osmolality ([(2 x Na) + glucose + urea]) >320 mOsm/kg and
pH >7.3.
Note that the American Diabetes Association recommends using different criteria for diagnosing HHS compared with the criteria above.[855]Karslioglu French E, Donihi AC, Korytkowski MT. Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients. BMJ. 2019 May 29;365:l1114. https://www.bmj.com/content/365/bmj.l1114.long http://www.ncbi.nlm.nih.gov/pubmed/31142480?tool=bestpractice.com
Contact the diabetes specialist team and follow your local guidelines for management of DKA or HHS in patients with COVID-19, or if you suspect mixed DKA/HHS.
Diagnose hypoglycaemia if blood glucose <4 mmol/L (<72 mg/dL).
Follow your local protocol for management of hypoglycaemia.
Stop the following medication:[793]National Inpatient Diabetes COVID-19 Response Group. Concise advice on inpatient diabetes during COVID-19: front door guidance. 2020 [internet publication]. https://abcd.care/resource/concise-advice-inpatient-diabetes-during-covid-19-front-door-guidance
Sodium-glucose cotransporter-2 (SGLT-2) inhibitors (e.g., dapagliflozin, canagliflozin, empagliflozin)
SGLT-2 inhibitors reduce blood glucose reabsorption in the kidneys (independently of insulin metabolism of glucose).[795]Peters AL, Buschur EO, Buse JB, et al. Euglycemic diabetic ketoacidosis: a potential complication of treatment with sodium-glucose cotransporter 2 inhibition. Diabetes Care. 2015 Sep;38(9):1687-93. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4542270/ http://www.ncbi.nlm.nih.gov/pubmed/26078479?tool=bestpractice.com
They can mask underlying ketoacidosis as the patient may have a normal (or near normal) serum glucose level (euglycaemic ketoacidosis).
Metformin
Metformin is contraindicated in patients with significant renal impairment (estimated GFR <30 mL/minute/1.73 m2), or metabolic acidosis (including lactic acidosis and DKA).
It is also contraindicated if the patient is at risk of lactic acidosis: for example, with acute kidney injury or tissue hypoxia, including dehydration, or if they are to be fasted for a prolonged period.
Consider re-starting metformin depending on results of the patient’s blood lactate, kidney function, and arterial blood gases.
The patient may need medication adjustment or to start insulin as a temporary measure if their usual SGLT-2 inhibitor or metformin is stopped. Seek diabetes specialist team advice.
Treatment recommended for ALL patients in selected patient group
Unfractionated heparin is preferred over fondaparinux in critically ill patients if low molecular weight heparin, as the preferred option for venous thromboembolism prophylaxis, cannot be used.[689]Moores LK, Tritschler T, Brosnahan S, et al. Prevention, diagnosis, and treatment of VTE in patients with coronavirus disease 2019: CHEST guideline and expert panel report. Chest. 2020 Sep;158(3):1143-63. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7265858/ http://www.ncbi.nlm.nih.gov/pubmed/32502594?tool=bestpractice.com
The UK National Institute for Health and Care Excellence (NICE) does not recommend treatment-dose low molecular weight heparin for VTE prophylaxis for patients receiving advanced respiratory support unless the patient is part of a nationally approved clinical trial because it is likely to cause harm in this group. NICE recommends reducing the dose to a locally agreed intermediate or standard dose and reassessing VTE and bleeding risks daily in patients who progress to needing high-flow oxygen, continuous positive airway pressure, non-invasive or invasive mechanical ventilation, or palliative care.[496]National Institute for Health and Care Excellence. COVID-19 rapid guideline: managing COVID-19. 2021 [internet publication]. https://www.nice.org.uk/guidance/ng191
NHS England recommends that therapeutic doses should not be offered unless there is a standard indication for therapeutic anticoagulation, as trials show that therapeutic doses do not improve clinical outcome of severe disease in the critical care setting.[740]Medicines and Healthcare products Regulatory Agency. Therapeutic anticoagulation (heparin) in the management of severe COVID-19 (SARS-CoV-2 positive) patients. 2020 [internet publication]. https://www.cas.mhra.gov.uk/ViewandAcknowledgment/ViewAlert.aspx?AlertID=103129
Some guidelines recommend that escalated doses can be considered in critically ill patients.[688]Barnes GD, Burnett A, Allen A, et al. Thromboembolism and anticoagulant therapy during the COVID-19 pandemic: interim clinical guidance from the Anticoagulation Forum. J Thromb Thrombolysis. 2020 Jul;50(1):72-81. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7241581/ http://www.ncbi.nlm.nih.gov/pubmed/32440883?tool=bestpractice.com [741]Thachil J, Tang N, Gando S, et al. ISTH interim guidance on recognition and management of coagulopathy in COVID-19. J Thromb Haemost. 2020 May;18(5):1023-6. https://onlinelibrary.wiley.com/doi/full/10.1111/jth.14810 http://www.ncbi.nlm.nih.gov/pubmed/32338827?tool=bestpractice.com
A multicentre randomised controlled trial found that intermediate-dose prophylactic anticoagulation did not result in a significant difference in the primary outcome of a composite of adjudicated venous or arterial thrombosis, treatment with extracorporeal membrane oxygenation, or 30-day mortality compared with standard-dose prophylactic anticoagulation among patients admitted to the intensive care unit. These results do not support the routine empirical use of intermediate-dose prophylactic anticoagulation in unselected patients admitted to the intensive care unit.[742]INSPIRATION Investigators; Sadeghipour P, Talasaz AH, Rashidi F, et al. Effect of intermediate-dose vs standard-dose prophylactic anticoagulation on thrombotic events, extracorporeal membrane oxygenation treatment, or mortality among patients with COVID-19 admitted to the intensive care unit: the INSPIRATION randomized clinical trial. JAMA. 2021 Mar 18 [Epub ahead of print]. https://jamanetwork.com/journals/jama/fullarticle/2777829 http://www.ncbi.nlm.nih.gov/pubmed/33734299?tool=bestpractice.com
Dose adjustments may be required in patients with extremes of body weight or renal impairment.[496]National Institute for Health and Care Excellence. COVID-19 rapid guideline: managing COVID-19. 2021 [internet publication]. https://www.nice.org.uk/guidance/ng191
See Severe COVID-19 above for more detailed information on VTE prophylaxis.
Anticoagulation in patients with chronic kidney disease
Check your local drug formulary/renal handbook for details on prescribing anticoagulants for venous thromboembolism prophylaxis in patients with reduced kidney function (chronic kidney disease, acute kidney injury).
Patients with impairment of kidney function may have an increased risk of bleeding with certain anticoagulants and careful patient monitoring is needed.[856]Law JP, Pickup L, Townend JN, et al. Anticoagulant strategies for the patient with chronic kidney disease. Clin Med (Lond). 2020 Mar;20(2):151-5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7081809/ http://www.ncbi.nlm.nih.gov/pubmed/32188649?tool=bestpractice.com
Depending on the degree of impairment of your patient’s kidney function, you may need to:
Adjust the dose
Avoid certain anticoagulants.
Follow local drug formulary guidance on recommended monitoring of anti-factor Xa activity.
Seek a nephrologist’s advice if the patient is on renal replacement therapy.
Primary options
enoxaparin: consult specialist for guidance on dose
enoxaparin open_in_new: consult specialist for guidance on dose
enoxaparin: consult specialist for guidance on dose
OR
dalteparin: consult specialist for guidance on dose
dalteparin open_in_new: consult specialist for guidance on dose
dalteparin: consult specialist for guidance on dose
Secondary options
heparin: consult specialist for guidance on dose
heparin open_in_new: consult specialist for guidance on dose
heparin: consult specialist for guidance on dose
OR
fondaparinux: consult specialist for guidance on dose
fondaparinux open_in_new: consult specialist for guidance on dose
fondaparinux: consult specialist for guidance on dose
These drug options and doses relate to a patient with no comorbidities.
Primary options
enoxaparin: consult specialist for guidance on dose
enoxaparin open_in_new: consult specialist for guidance on dose
enoxaparin: consult specialist for guidance on dose
OR
dalteparin: consult specialist for guidance on dose
dalteparin open_in_new: consult specialist for guidance on dose
dalteparin: consult specialist for guidance on dose
Secondary options
heparin: consult specialist for guidance on dose
heparin open_in_new: consult specialist for guidance on dose
heparin: consult specialist for guidance on dose
OR
fondaparinux: consult specialist for guidance on dose
fondaparinux open_in_new: consult specialist for guidance on dose
fondaparinux: consult specialist for guidance on dose
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Primary options
OR
Secondary options
OR
The Renal Handbook
Treatment recommended for ALL patients in selected patient group
Consider a trial of high-flow nasal oxygen (HFNO) or non-invasive ventilation (e.g., continuous positive airway pressure [CPAP] or bilevel positive airway pressure [BiPAP]) in selected patients with mild acute respiratory distress syndrome. Consider awake prone positioning (for 8-12 hours/day, broken into shorter periods over the day) in severely ill patients who require HFNO or non-invasive ventilation.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1
Airborne precautions are recommended for these interventions (including bubble CPAP) due to uncertainty about the potential for aerosolisation.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1
Patients with hypercapnia, haemodynamic instability, multi-organ failure, or abnormal mental status should generally not receive HFNO, although emerging data suggest that it may be safe in patients with mild to moderate and non-worsening hypercapnia. Patients with hypoxaemic respiratory failure and haemodynamic instability, multi-organ failure, or abnormal mental status should not receive these treatments in place of other options such as invasive ventilation.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1
There is ongoing debate about the optimal mode of respiratory support before mechanical ventilation.[709]McEnery T, Gough C, Costello RW. COVID-19: respiratory support outside the intensive care unit. Lancet Respir Med. 2020 Jun;8(6):538-9. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7146718/ http://www.ncbi.nlm.nih.gov/pubmed/32278367?tool=bestpractice.com NHS England recommends CPAP as the preferred form of non-invasive ventilation in patients with hypoxaemic (type 1) respiratory failure. It doesn't advocate the use of HFNO based on a lack of efficacy, oxygen use (HFNO can place a strain on oxygen supplies with the risk of site supply failure), and infection spread.[710]NHS England. Guidance for the role and use of non-invasive respiratory support in adult patients with COVID19 (confirmed or suspected). 2020 [internet publication]. https://www.nice.org.uk/Media/Default/About/COVID-19/Specialty-guides/specialty-guide-NIV-respiratory-support-and-coronavirus.pdf Other guidelines recommend HFNO over non-invasive ventilation, unless HFNO is not available.[3]National Institutes of Health. Coronavirus disease 2019 (COVID-19) treatment guidelines. 2021 [internet publication]. https://covid19treatmentguidelines.nih.gov/ [678]Alhazzani W, Evans L, Alshamsi F, et al. Surviving Sepsis Campaign guidelines on the management of adults with coronavirus disease 2019 (COVID-19) in the ICU: first update. Crit Care Med. 2021 Mar 1;49(3):e219-34. https://journals.lww.com/ccmjournal/Abstract/9000/Surviving_Sepsis_Campaign_Guidelines_on_the.95371.aspx http://www.ncbi.nlm.nih.gov/pubmed/33555780?tool=bestpractice.com Despite the trend to avoid HFNO, it has been shown to have a similar risk of aerosol generation to standard oxygen masks.[711]Li J, Fink JB, Ehrmann S. High-flow nasal cannula for COVID-19 patients: low risk of bio-aerosol dispersion. Eur Respir J. 2020 May 14;55(5):2000892. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7163690/ http://www.ncbi.nlm.nih.gov/pubmed/32299867?tool=bestpractice.com
Early CPAP may provide a bridge to invasive mechanical ventilation. Reserve the use of BiPAP for patients with hypercapnic acute on chronic ventilatory failure (type 2 respiratory failure).[710]NHS England. Guidance for the role and use of non-invasive respiratory support in adult patients with COVID19 (confirmed or suspected). 2020 [internet publication]. https://www.nice.org.uk/Media/Default/About/COVID-19/Specialty-guides/specialty-guide-NIV-respiratory-support-and-coronavirus.pdf
Monitor patients closely for acute deterioration. If patients do not improve after a short trial of these interventions, they require urgent endotracheal intubation.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1 [678]Alhazzani W, Evans L, Alshamsi F, et al. Surviving Sepsis Campaign guidelines on the management of adults with coronavirus disease 2019 (COVID-19) in the ICU: first update. Crit Care Med. 2021 Mar 1;49(3):e219-34. https://journals.lww.com/ccmjournal/Abstract/9000/Surviving_Sepsis_Campaign_Guidelines_on_the.95371.aspx http://www.ncbi.nlm.nih.gov/pubmed/33555780?tool=bestpractice.com
Oxygen therapy in patients with asthma
If the patient’s asthma is stable, follow guideline recommendations for oxygen saturation target for the presenting acute condition (i.e., COVID-19).[849]O'Driscoll BR, Howard LS, Earis J, et al. BTS guideline for oxygen use in adults in healthcare and emergency settings. Thorax. 2017 Jun;72(suppl 1):ii1-90. https://thorax.bmj.com/content/72/Suppl_1/ii1.long http://www.ncbi.nlm.nih.gov/pubmed/28507176?tool=bestpractice.com
Measure resting oxygen saturation in all patients with asthma with any acute illness.[849]O'Driscoll BR, Howard LS, Earis J, et al. BTS guideline for oxygen use in adults in healthcare and emergency settings. Thorax. 2017 Jun;72(suppl 1):ii1-90. https://thorax.bmj.com/content/72/Suppl_1/ii1.long http://www.ncbi.nlm.nih.gov/pubmed/28507176?tool=bestpractice.com This is routine practice in patients with COVID-19.
If COVID-19 triggers an acute exacerbation of the patient’s asthma, current opinion is to follow standard guideline recommendations for managing an acute exacerbation of asthma in adults.[777]British Thoracic Society; Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma: a national clinical guideline. 2019 [internet publication]. https://www.sign.ac.uk/media/1048/sign158.pdf [818]Centers for Disease Control and Prevention. Clinical questions about COVID-19: questions and answers – patients with asthma. 2020 [internet publication]. https://www.cdc.gov/coronavirus/2019-ncov/hcp/faq.html#Patients-with-Asthma
Follow your local hospital protocol on target oxygen saturations recommended in your hospital during the COVID-19 pandemic for acutely ill patients.
Hypercapnia in asthma is a near fatal sign showing a patient is tiring and needs ventilatory support.[777]British Thoracic Society; Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma: a national clinical guideline. 2019 [internet publication]. https://www.sign.ac.uk/media/1048/sign158.pdf Intensive care support is needed immediately.[777]British Thoracic Society; Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma: a national clinical guideline. 2019 [internet publication]. https://www.sign.ac.uk/media/1048/sign158.pdf
Oxygen therapy in patients with COPD
If your patient with comorbid COPD is suitable for full escalation of care, refer for consideration of ventilation support if they are:
Severely hypoxaemic (PaO2 <7.3 kPa [54.8 mmHg]) despite oxygen therapy (based on expert opinion)
Hypercapnic (PaCO2 >6 kPa [45 mmHg]) with respiratory acidosis (pH <7.35)[849]O'Driscoll BR, Howard LS, Earis J, et al. BTS guideline for oxygen use in adults in healthcare and emergency settings. Thorax. 2017 Jun;72(suppl 1):ii1-90. https://thorax.bmj.com/content/72/Suppl_1/ii1.long http://www.ncbi.nlm.nih.gov/pubmed/28507176?tool=bestpractice.com
AND/OR
Exhibiting changes in mental status (confusion, coma).
If your patient with comorbid COPD develops type 2 respiratory failure and it has been agreed that they are not suitable for full escalation of care involving intensive care unit admission:
Follow the guidance on oxygen as below
Discuss with your senior or respiratory expert whether ward-based non-invasive ventilation is suitable.
Practical tip
Take the same care when prescribing any supplemental oxygen in patients at risk of type 2 respiratory failure with COVID-19 as you would for patients with any other acute medical condition. Oxygen therapy for these patients should almost always be controlled. High-flow nasal oxygen (HFNO) is therefore not suitable for these patients. HFNO may be considered in patients not at risk of type 2 respiratory failure, but with severe hypoxaemia. Be aware that this should be prescribed by a senior decision-maker and should only ever be used with careful observation and repeat ABG measurements (based on expert opinion).
Measure resting oxygen saturations and be aware of additional factors to consider when prescribing oxygen therapy in a patient with COPD who is hypoxic.
Guidelines on emergency oxygen use (not specifically for COVID-19) from the British Thoracic Society recommend that any patient with COPD requiring oxygen supplementation needs an arterial blood gas (ABG) measurement.[849]O'Driscoll BR, Howard LS, Earis J, et al. BTS guideline for oxygen use in adults in healthcare and emergency settings. Thorax. 2017 Jun;72(suppl 1):ii1-90. https://thorax.bmj.com/content/72/Suppl_1/ii1.long http://www.ncbi.nlm.nih.gov/pubmed/28507176?tool=bestpractice.com
Re-check ABG after 30 to 60 minutes in all patients.[849]O'Driscoll BR, Howard LS, Earis J, et al. BTS guideline for oxygen use in adults in healthcare and emergency settings. Thorax. 2017 Jun;72(suppl 1):ii1-90. https://thorax.bmj.com/content/72/Suppl_1/ii1.long http://www.ncbi.nlm.nih.gov/pubmed/28507176?tool=bestpractice.com
The British Thoracic Society recommends that standard protocols should be followed in patients admitted to hospital with COVID-19 who also have COPD and evidence of acute on chronic type 2 respiratory failure, as detailed in the sections below.[850]British Thoracic Society. BTS guidance: respiratory support of patients on medical wards. 2020 [internet publication]. https://www.brit-thoracic.org.uk/about-us/covid-19-information-for-the-respiratory-community/
If a patient with comorbid COPD is critically ill (e.g., shock, sepsis, major head injury, status epilepticus, anaphylaxis, major trauma) and needs high levels of oxygen:
The British Thoracic Society (BTS) recommends an initial target oxygen saturation of 94% to 98%, although more recent evidence suggests an upper target of 96% may be preferred in most cases.[849]O'Driscoll BR, Howard LS, Earis J, et al. BTS guideline for oxygen use in adults in healthcare and emergency settings. Thorax. 2017 Jun;72(suppl 1):ii1-90. https://thorax.bmj.com/content/72/Suppl_1/ii1.long http://www.ncbi.nlm.nih.gov/pubmed/28507176?tool=bestpractice.com [851]Chu DK, Kim LH, Young PJ, et al. Mortality and morbidity in acutely ill adults treated with liberal versus conservative oxygen therapy (IOTA): a systematic review and meta-analysis. Lancet. 2018 Apr 28;391(10131):1693-705. http://www.ncbi.nlm.nih.gov/pubmed/29726345?tool=bestpractice.com [852]Siemieniuk RAC, Chu DK, Kim LH, et al. Oxygen therapy for acutely ill medical patients: a clinical practice guideline. BMJ. 2018 Oct 24;363:k4169. http://www.ncbi.nlm.nih.gov/pubmed/30355567?tool=bestpractice.com Follow your local hospital protocol on target oxygen saturations recommended in your hospital during the COVID-19 pandemic for acutely ill patients
Subsequently, you may need to adjust to controlled oxygen therapy with a target oxygen saturation range of 88% to 92% depending on the ABG results.[849]O'Driscoll BR, Howard LS, Earis J, et al. BTS guideline for oxygen use in adults in healthcare and emergency settings. Thorax. 2017 Jun;72(suppl 1):ii1-90. https://thorax.bmj.com/content/72/Suppl_1/ii1.long http://www.ncbi.nlm.nih.gov/pubmed/28507176?tool=bestpractice.com
If a patient with comorbid COPD is acutely but not critically ill and is at risk of hypercapnic failure (including any patient with moderate or severe COPD, particularly if on long-term oxygen therapy, or with an alert card, or with a previous history of hypercapnic respiratory failure):[849]O'Driscoll BR, Howard LS, Earis J, et al. BTS guideline for oxygen use in adults in healthcare and emergency settings. Thorax. 2017 Jun;72(suppl 1):ii1-90. https://thorax.bmj.com/content/72/Suppl_1/ii1.long http://www.ncbi.nlm.nih.gov/pubmed/28507176?tool=bestpractice.com
Use an initial target oxygen saturation of 88% to 92%
Check ABG and recheck after 30 to 60 minutes.
If a patient with comorbid COPD is acutely but not critically ill and is NOT at risk of hypercapnic respiratory failure (e.g., stable, mild COPD with minimal symptoms):
Use an initial target oxygen saturation as recommended by guidelines for the presenting acute condition.
The BTS recommends a target oxygen saturation of between 94% and 98% pending ABG results for most acutely ill patients, although more recent evidence suggests an upper target of 96% may be preferred.[849]O'Driscoll BR, Howard LS, Earis J, et al. BTS guideline for oxygen use in adults in healthcare and emergency settings. Thorax. 2017 Jun;72(suppl 1):ii1-90. https://thorax.bmj.com/content/72/Suppl_1/ii1.long http://www.ncbi.nlm.nih.gov/pubmed/28507176?tool=bestpractice.com [851]Chu DK, Kim LH, Young PJ, et al. Mortality and morbidity in acutely ill adults treated with liberal versus conservative oxygen therapy (IOTA): a systematic review and meta-analysis. Lancet. 2018 Apr 28;391(10131):1693-705. http://www.ncbi.nlm.nih.gov/pubmed/29726345?tool=bestpractice.com [852]Siemieniuk RAC, Chu DK, Kim LH, et al. Oxygen therapy for acutely ill medical patients: a clinical practice guideline. BMJ. 2018 Oct 24;363:k4169. http://www.ncbi.nlm.nih.gov/pubmed/30355567?tool=bestpractice.com This target saturation level may be lower depending on local hospital oxygen supplies (follow your local protocol)
Measure ABG as soon as possible[849]O'Driscoll BR, Howard LS, Earis J, et al. BTS guideline for oxygen use in adults in healthcare and emergency settings. Thorax. 2017 Jun;72(suppl 1):ii1-90. https://thorax.bmj.com/content/72/Suppl_1/ii1.long http://www.ncbi.nlm.nih.gov/pubmed/28507176?tool=bestpractice.com
Subsequently, you may need to adjust to controlled oxygen therapy with a target oxygen saturation range of 88% to 92% depending on the ABG results.[849]O'Driscoll BR, Howard LS, Earis J, et al. BTS guideline for oxygen use in adults in healthcare and emergency settings. Thorax. 2017 Jun;72(suppl 1):ii1-90. https://thorax.bmj.com/content/72/Suppl_1/ii1.long http://www.ncbi.nlm.nih.gov/pubmed/28507176?tool=bestpractice.com
Treatment recommended for ALL patients in selected patient group
Consider endotracheal intubation and mechanical ventilation in patients who are acutely deteriorating despite advanced oxygen/non-invasive ventilatory support measures.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1 [3]National Institutes of Health. Coronavirus disease 2019 (COVID-19) treatment guidelines. 2021 [internet publication]. https://covid19treatmentguidelines.nih.gov/
Endotracheal intubation should be performed by an experienced provider using airborne precautions.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1 Intubation by video laryngoscopy is recommended if possible.[3]National Institutes of Health. Coronavirus disease 2019 (COVID-19) treatment guidelines. 2021 [internet publication]. https://covid19treatmentguidelines.nih.gov/ Young children, or adults who are obese or pregnant, may desaturate quickly during intubation and therefore require pre-oxygenation with 100% fraction of inspired oxygen (FiO₂) for 5 minutes.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1
Mechanically ventilated patients with acute respiratory distress syndrome (ARDS) should receive a lung-protective, low tidal volume/low inspiratory pressure ventilation strategy (lower targets are recommended in children). A higher positive end-expiratory pressure (PEEP) strategy is preferred over a lower PEEP strategy in moderate to severe ARDS. However, individualisation of PEEP, where the patient is monitored for beneficial or harmful effects and driving pressure during titration with consideration of the risks and benefits of PEEP titration, is recommended.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1 [3]National Institutes of Health. Coronavirus disease 2019 (COVID-19) treatment guidelines. 2021 [internet publication]. https://covid19treatmentguidelines.nih.gov/ [678]Alhazzani W, Evans L, Alshamsi F, et al. Surviving Sepsis Campaign guidelines on the management of adults with coronavirus disease 2019 (COVID-19) in the ICU: first update. Crit Care Med. 2021 Mar 1;49(3):e219-34. https://journals.lww.com/ccmjournal/Abstract/9000/Surviving_Sepsis_Campaign_Guidelines_on_the.95371.aspx http://www.ncbi.nlm.nih.gov/pubmed/33555780?tool=bestpractice.com NHS England recommends a low PEEP strategy in patients with normal compliance where recruitment may not be required.[719]NHS England. Clinical guide for the management of critical care for adults with COVID-19 during the coronavirus pandemic. 2020 [internet publication]. https://www.nice.org.uk/Media/Default/About/COVID-19/Specialty-guides/Specialty-guide_Adult-critical-care.pdf
Although some patients with COVID-19 pneumonia meet the criteria for ARDS, there is some discussion about whether COVID-19 pneumonia is its own specific disease with atypical phenotypes. Anecdotal evidence suggests that the main characteristic of the atypical presentation is the dissociation between well-preserved lung mechanics and the severity of hypoxaemia.[720]Gattinoni L, Coppola S, Cressoni M, et al. Covid-19 does not lead to a "typical" acute respiratory distress syndrome. Am J Respir Crit Care Med. 2020 May 15;201(10):1299-300. https://www.atsjournals.org/doi/pdf/10.1164/rccm.202003-0817LE http://www.ncbi.nlm.nih.gov/pubmed/32228035?tool=bestpractice.com [721]Gattinoni L, Chiumello D, Rossi S. COVID-19 pneumonia: ARDS or not? Crit Care. 2020 Apr 16;24(1):154. https://ccforum.biomedcentral.com/articles/10.1186/s13054-020-02880-z http://www.ncbi.nlm.nih.gov/pubmed/32299472?tool=bestpractice.com [722]Gattinoni L, Chiumello D, Caironi P, et al. COVID-19 pneumonia: different respiratory treatments for different phenotypes? Intensive Care Med. 2020 Jun;46(6):1099-102. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7154064/ http://www.ncbi.nlm.nih.gov/pubmed/32291463?tool=bestpractice.com [723]Marini JJ, Gattinoni L. Management of COVID-19 respiratory distress. JAMA. 2020 Jun 9;323(22):2329-30. https://jamanetwork.com/journals/jama/fullarticle/2765302 http://www.ncbi.nlm.nih.gov/pubmed/32329799?tool=bestpractice.com [724]Rello J, Storti E, Belliato M, et al. Clinical phenotypes of SARS-CoV-2: implications for clinicians and researchers. Eur Respir J. 2020 May 21;55(5):2001028. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7236837/ http://www.ncbi.nlm.nih.gov/pubmed/32341111?tool=bestpractice.com [725]Tsolaki V, Siempos I, Magira E, et al. PEEP levels in COVID-19 pneumonia. Crit Care. 2020 Jun 6;24(1):303. https://ccforum.biomedcentral.com/articles/10.1186/s13054-020-03049-4 http://www.ncbi.nlm.nih.gov/pubmed/32505186?tool=bestpractice.com However, this approach has been criticised.[726]Bos LD, Paulus F, Vlaar APJ, et al. Subphenotyping acute respiratory distress syndrome in patients with COVID-19: consequences for ventilator management. Ann Am Thorac Soc. 2020 Sep;17(9):1161-3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7462326/ http://www.ncbi.nlm.nih.gov/pubmed/32396457?tool=bestpractice.com [727]Jain A, Doyle DJ. Stages or phenotypes? A critical look at COVID-19 pathophysiology. Intensive Care Med. 2020 May 18;:1-2. https://link.springer.com/article/10.1007%2Fs00134-020-06083-6 http://www.ncbi.nlm.nih.gov/pubmed/32425310?tool=bestpractice.com It has been argued that an evidence-based approach extrapolating data from ARDS not related to COVID-19 is the most reasonable approach for intensive care of COVID-19 patients.[728]Rice TW, Janz DR. In defense of evidence-based medicine for the treatment of COVID-19 ARDS. Ann Am Thorac Soc. 2020 Jul;17(7):787-9. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7328187/ http://www.ncbi.nlm.nih.gov/pubmed/32320268?tool=bestpractice.com As a consequence of this, some clinicians have warned that protocol-driven ventilator use may be causing lung injury in some patients, and that ventilator settings should be based on physiological findings rather than using standard protocols. High PEEP may have a detrimental effect on patients with normal compliance.[720]Gattinoni L, Coppola S, Cressoni M, et al. Covid-19 does not lead to a "typical" acute respiratory distress syndrome. Am J Respir Crit Care Med. 2020 May 15;201(10):1299-300. https://www.atsjournals.org/doi/pdf/10.1164/rccm.202003-0817LE http://www.ncbi.nlm.nih.gov/pubmed/32228035?tool=bestpractice.com PEEP should always be carefully titrated.[729]Dondorp AM, Hayat M, Aryal D, et al. Respiratory support in COVID-19 patients, with a focus on resource-limited settings. Am J Trop Med Hyg. 2020 Jun;102(6):1191-7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7253105/ http://www.ncbi.nlm.nih.gov/pubmed/32319424?tool=bestpractice.com
Consider prone ventilation in patients with severe ARDS for 12 to 16 hours per day. Pregnant women in the third trimester may benefit from being placed in the lateral decubitus position. Caution is required in children.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1 [3]National Institutes of Health. Coronavirus disease 2019 (COVID-19) treatment guidelines. 2021 [internet publication]. https://covid19treatmentguidelines.nih.gov/ [678]Alhazzani W, Evans L, Alshamsi F, et al. Surviving Sepsis Campaign guidelines on the management of adults with coronavirus disease 2019 (COVID-19) in the ICU: first update. Crit Care Med. 2021 Mar 1;49(3):e219-34. https://journals.lww.com/ccmjournal/Abstract/9000/Surviving_Sepsis_Campaign_Guidelines_on_the.95371.aspx http://www.ncbi.nlm.nih.gov/pubmed/33555780?tool=bestpractice.com Longer durations may be feasible in some patients.[730]Carsetti A, Damia Paciarini A, Marini B, et al. Prolonged prone position ventilation for SARS-CoV-2 patients is feasible and effective. Crit Care. 2020 May 15;24(1):225. https://ccforum.biomedcentral.com/articles/10.1186/s13054-020-02956-w http://www.ncbi.nlm.nih.gov/pubmed/32414420?tool=bestpractice.com
Lung recruitment manoeuvres are suggested, but staircase recruitment manoeuvres are not recommended.[3]National Institutes of Health. Coronavirus disease 2019 (COVID-19) treatment guidelines. 2021 [internet publication]. https://covid19treatmentguidelines.nih.gov/ [678]Alhazzani W, Evans L, Alshamsi F, et al. Surviving Sepsis Campaign guidelines on the management of adults with coronavirus disease 2019 (COVID-19) in the ICU: first update. Crit Care Med. 2021 Mar 1;49(3):e219-34. https://journals.lww.com/ccmjournal/Abstract/9000/Surviving_Sepsis_Campaign_Guidelines_on_the.95371.aspx http://www.ncbi.nlm.nih.gov/pubmed/33555780?tool=bestpractice.com
Treatment recommended for SOME patients in selected patient group
Consider a trial of an inhaled pulmonary vasodilator in adults who have severe acute respiratory distress syndrome and hypoxaemia despite optimising ventilation. Taper off if there is no rapid improvement in oxygenation.[3]National Institutes of Health. Coronavirus disease 2019 (COVID-19) treatment guidelines. 2021 [internet publication]. https://covid19treatmentguidelines.nih.gov/ [678]Alhazzani W, Evans L, Alshamsi F, et al. Surviving Sepsis Campaign guidelines on the management of adults with coronavirus disease 2019 (COVID-19) in the ICU: first update. Crit Care Med. 2021 Mar 1;49(3):e219-34. https://journals.lww.com/ccmjournal/Abstract/9000/Surviving_Sepsis_Campaign_Guidelines_on_the.95371.aspx http://www.ncbi.nlm.nih.gov/pubmed/33555780?tool=bestpractice.com
Treatment recommended for SOME patients in selected patient group
Consider extracorporeal membrane oxygenation (ECMO) according to availability and expertise if the above methods fail.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1 [678]Alhazzani W, Evans L, Alshamsi F, et al. Surviving Sepsis Campaign guidelines on the management of adults with coronavirus disease 2019 (COVID-19) in the ICU: first update. Crit Care Med. 2021 Mar 1;49(3):e219-34. https://journals.lww.com/ccmjournal/Abstract/9000/Surviving_Sepsis_Campaign_Guidelines_on_the.95371.aspx http://www.ncbi.nlm.nih.gov/pubmed/33555780?tool=bestpractice.com [734]American Thoracic Society. Diagnosis and management of COVID-19 disease. 2020 [internet publication]. https://www.thoracic.org/patients/patient-resources/resources/covid-19-diagnosis-and-mgmt.pdf [735]Ramanathan K, Antognini D, Combes A, et al. Planning and provision of ECMO services for severe ARDS during the COVID-19 pandemic and other outbreaks of emerging infectious diseases. Lancet Respir Med. 2020 May;8(5):518-26. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7102637/ http://www.ncbi.nlm.nih.gov/pubmed/32203711?tool=bestpractice.com ECMO is not suitable for all patients, and only those who meet certain inclusion criteria may be considered for ECMO.[736]NHS England. Clinical guide for extra corporeal membrane oxygenation (ECMO) for respiratory failure in adults during the coronavirus pandemic. 2020 [internet publication]. https://www.nice.org.uk/Media/Default/About/COVID-19/Specialty-guides/Speciality-Guide-Extra-Corporeal-Membrane-Oxygenation-ECMO-Adult.pdf
There is insufficient evidence to recommend either for or against the routine use of ECMO.[3]National Institutes of Health. Coronavirus disease 2019 (COVID-19) treatment guidelines. 2021 [internet publication]. https://covid19treatmentguidelines.nih.gov/
The estimated 60-day survival rate of ECMO-rescued patients with COVID-19 (31%) was similar to that of previous studies of ECMO for severe ARDS.[737]Schmidt M, Hajage D, Lebreton G, et al. Extracorporeal membrane oxygenation for severe acute respiratory distress syndrome associated with COVID-19: a retrospective cohort study. Lancet Respir Med. 2020 Nov;8(11):1121-31. https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(20)30328-3/fulltext http://www.ncbi.nlm.nih.gov/pubmed/32798468?tool=bestpractice.com
An international cohort study of 1035 patients found that both the estimated mortality 90 days after ECMO initiation and mortality in those who achieved a final outcome of death or discharge were <40%, consistent with previously reported survival rates in acute hypoxaemic respiratory failure.[738]Barbaro RP, MacLaren G, Boonstra PS, et al. Extracorporeal membrane oxygenation support in COVID-19: an international cohort study of the Extracorporeal Life Support Organization registry. Lancet. 2020 Oct 10;396(10257):1071-8. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)32008-0/fulltext http://www.ncbi.nlm.nih.gov/pubmed/32987008?tool=bestpractice.com
Single-access, dual-stage venovenous ECMO with early extubation appears to be safe and effective in patients with COVID-19 respiratory failure.[739]Mustafa AK, Alexander PJ, Joshi DJ, et al. Extracorporeal membrane oxygenation for patients with COVID-19 in severe respiratory failure. JAMA Surg. 2020 Aug 11;155(10):990-2. https://jamanetwork.com/journals/jamasurgery/fullarticle/2769429 http://www.ncbi.nlm.nih.gov/pubmed/32780089?tool=bestpractice.com
Treatment recommended for SOME patients in selected patient group
The management of sepsis and septic shock in patients with COVID-19 is beyond the scope of this topic. See the Complications external link opens in a new windowsection.
Treatment recommended for SOME patients in selected patient group
[Figure caption and citation for the preceding image starts]: Recommendations and evidence for the use of corticosteroids in hospitalised patients with COVID-19BMJ. 2020;370:m3379 [Citation ends].
The World Health Organization (WHO) strongly recommends systemic corticosteroid therapy (low-dose intravenous or oral dexamethasone or hydrocortisone) for 7 to 10 days in adults with critical COVID-19. This recommendation is based on two meta-analyses that pooled data from eight randomised trials (over 7000 patients), including the UK RECOVERY trial. Moderate-quality evidence suggests that systemic corticosteroids probably reduce 28-day mortality in patients with severe and critical COVID-19. They also probably reduce the need for invasive ventilation. There is no evidence directly comparing dexamethasone and hydrocortisone. The harms of treatment in this context are considered to be minor. It is unclear whether these recommendations can be applied to children or those who are immunocompromised.[652]World Health Organization. Therapeutics and COVID-19: living guideline. 2021 [internet publication]. https://www.who.int/publications/i/item/therapeutics-and-covid-19-living-guideline [696]WHO Rapid Evidence Appraisal for COVID-19 Therapies (REACT) Working Group; Sterne JAC, Murthy S, Diaz JV, et al. Association between administration of systemic corticosteroids and mortality among critically ill patients with COVID-19: a meta-analysis. JAMA. 2020 Oct 6;324(13):1330-41. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7489434/ http://www.ncbi.nlm.nih.gov/pubmed/32876694?tool=bestpractice.com [697]Rochwerg B, Siemieniuk RA, Agoritsas T, et al. A living WHO guideline on drugs for covid-19. BMJ. 2020 Sep 4;370:m3379. https://www.bmj.com/content/370/bmj.m3379.long http://www.ncbi.nlm.nih.gov/pubmed/32887691?tool=bestpractice.com [698]Rochwerg B, Siemieniuk RA, Lamontagne R, et al. Update to living WHO guideline on drugs for covid-19. BMJ. 2021 Mar 31;372:n860. https://www.bmj.com/content/372/bmj.n860.long http://www.ncbi.nlm.nih.gov/pubmed/33789884?tool=bestpractice.com [699]RECOVERY Collaborative Group; Horby P, Lim WS, Emberson JR, et al. Dexamethasone in hospitalized patients with Covid-19. N Engl J Med. 2021 Feb 25;384(8):693-704. https://www.nejm.org/doi/full/10.1056/NEJMoa2021436 http://www.ncbi.nlm.nih.gov/pubmed/32678530?tool=bestpractice.com There is also evidence that corticosteroids probably increase ventilator-free days (moderate certainty).[700]Siemieniuk RA, Bartoszko JJ, Ge L, et al. Drug treatments for covid-19: living systematic review and network meta-analysis. BMJ. 2020 Jul 30;370:m2980. https://www.bmj.com/content/370/bmj.m2980 http://www.ncbi.nlm.nih.gov/pubmed/32732190?tool=bestpractice.com [701]Siemieniuk RA, Bartoszko JJ, Ge L, et al. Update to living systematic review on drug treatments for covid-19. BMJ. 2021 Mar 31;372:n858. https://www.bmj.com/content/372/bmj.n858.long http://www.ncbi.nlm.nih.gov/pubmed/33789885?tool=bestpractice.com
In Europe, the European Medicines Agency has endorsed the use of dexamethasone for patients with severe disease who require oxygen therapy or mechanical ventilation.[702]European Medicines Agency. EMA endorses use of dexamethasone in COVID-19 patients on oxygen or mechanical ventilation. 2020 [internet publication]. https://www.ema.europa.eu/en/news/ema-endorses-use-dexamethasone-covid-19-patients-oxygen-mechanical-ventilation
In the US, the National Institutes of Health guidelines panel recommends using dexamethasone, either alone or in combination with remdesivir (see the Emerging external link opens in a new windowsection for information on remdesivir), in hospitalised patients who require high-flow oxygen or non-invasive ventilation. The panel recommends dexamethasone alone in patients on mechanical ventilation or extracorporeal membrane oxygenation. Alternative corticosteroids may be used in situations where dexamethasone is not available.[3]National Institutes of Health. Coronavirus disease 2019 (COVID-19) treatment guidelines. 2021 [internet publication]. https://covid19treatmentguidelines.nih.gov/ The Infectious Diseases Society of America supports the use of dexamethasone in hospitalised patients with severe disease.[703]Bhimraj A, Morgan RL, Hirsch Shumaker A, et al. Infectious Diseases Society of America guidelines on the treatment and management of patients with COVID-19 infection. 2021 [internet publication]. https://www.idsociety.org/practice-guideline/covid-19-guideline-treatment-and-management/
Monitor patients for adverse effects (e.g., hyperglycaemia, secondary infections, psychiatric effects, reactivation of latent infections) and assess for drug-drug interactions.[3]National Institutes of Health. Coronavirus disease 2019 (COVID-19) treatment guidelines. 2021 [internet publication]. https://covid19treatmentguidelines.nih.gov/
A meta-analysis found an increased risk of venous thromboembolism with corticosteroid administration in patients with critical disease. However, no definite findings were available due to the differing corticosteroid regimens and the heterogeneity of the studies.[743]Sarfraz A, Sarfraz Z, Razzack AA, et al. Venous thromboembolism, corticosteroids and COVID-19: a systematic review and meta-analysis. Clin Appl Thromb Hemost. 2021 Jan-Dec;27:1076029621993573. https://journals.sagepub.com/doi/10.1177/1076029621993573 http://www.ncbi.nlm.nih.gov/pubmed/33571009?tool=bestpractice.com
Manage the patient’s diabetes when they are taking corticosteroids
Giving corticosteroids to someone with diabetes will worsen their glycaemic control, so test blood glucose at least four times a day.[857]National Inpatient Diabetes COVID-19 Response Group. Concise advice on inpatient diabetes during COVID-19 (COVID:Diabetes): dexamethasone therapy in covid-19 patients – implications and guidance for the management of blood glucose in people with and without diabetes. 2020 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/Resources/COVID-19/COvID_Dex_v1.4.pdf
For patients with diabetes, use the same doses of corticosteroid as for patients without diabetes but adjust diabetes medication, as their diabetes control will get worse.
Synthetic corticosteroids can cause hyperglycaemia by affecting carbohydrate metabolism and inducing insulin resistance.[858]Joint British Diabetes Societies for inpatient care. Management of hyperglycaemia and steroid (glucocorticosteroid) therapy. 2014 [internet publication]. https://abcd.care/sites/abcd.care/files/resources/JBDS_IP_Steroids.pdf
COVID-19 is also associated with increased insulin resistance as well as reduced insulin secretion from the pancreatic beta cells.[857]National Inpatient Diabetes COVID-19 Response Group. Concise advice on inpatient diabetes during COVID-19 (COVID:Diabetes): dexamethasone therapy in covid-19 patients – implications and guidance for the management of blood glucose in people with and without diabetes. 2020 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/Resources/COVID-19/COvID_Dex_v1.4.pdf
If hyperglycaemia does occur, rule out diabetic ketoacidosis or hyperosmolar hyperglycaemic state and follow your hospital protocol on managing blood glucose in patients with diabetes and COVID-19 taking corticosteroids.[857]National Inpatient Diabetes COVID-19 Response Group. Concise advice on inpatient diabetes during COVID-19 (COVID:Diabetes): dexamethasone therapy in covid-19 patients – implications and guidance for the management of blood glucose in people with and without diabetes. 2020 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/Resources/COVID-19/COvID_Dex_v1.4.pdf
The recommended protocol by the UK-based National Inpatient Diabetes COVID-19 Response Group uses subcutaneous insulin.
The group highlights that sulfonylureas are not recommended in this scenario due to potential impairment of beta cell function and likely severe insulin resistance.[857]National Inpatient Diabetes COVID-19 Response Group. Concise advice on inpatient diabetes during COVID-19 (COVID:Diabetes): dexamethasone therapy in covid-19 patients – implications and guidance for the management of blood glucose in people with and without diabetes. 2020 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/Resources/COVID-19/COvID_Dex_v1.4.pdf
When you stop the corticosteroid dose, glycaemic control will likely improve, although this may occur over a few days.
Follow your local protocol on titrating antidiabetic medication.
Monitor for psychiatric complications of corticosteroids
Check previous response to corticosteroids.
Past incidence of psychiatric complications during corticosteroid therapy increases the risk of recurrence in subsequent treatments.[859]Judd LL, Schettler PJ, Brown ES, et al. Adverse consequences of glucocorticoid medication: psychological, cognitive, and behavioral effects. Am J Psychiatry. 2014 Oct;171(10):1045-51. https://ajp.psychiatryonline.org/doi/10.1176/appi.ajp.2014.13091264 http://www.ncbi.nlm.nih.gov/pubmed/25272344?tool=bestpractice.com
Monitor for psychiatric adverse effects.[860]Kenna HA, Poon AW, de los Angeles CP, et al. Psychiatric complications of treatment with corticosteroids: review with case report. Psychiatry Clin Neurosci. 2011 Oct;65(6):549-60. https://onlinelibrary.wiley.com/doi/full/10.1111/j.1440-1819.2011.02260.x http://www.ncbi.nlm.nih.gov/pubmed/22003987?tool=bestpractice.com
These may vary in severity and include:
Minor changes in temperament
Severe mood changes, including manic states
Cognitive impairment.
Starting corticosteroid treatment is most often linked with manic episodes and delirious states. Chronic corticosteroid therapy most frequently presents with depression.[861]Warrington TP, Bostwick JM. Psychiatric adverse effects of corticosteroids. Mayo Clin Proc. 2006 Oct;81(10):1361-7. https://www.mayoclinicproceedings.org/article/S0025-6196(11)61160-9/fulltext http://www.ncbi.nlm.nih.gov/pubmed/17036562?tool=bestpractice.com
Effects seem to be dose-related and are more common with long-term regimens or long-acting formulations, and in older patients.[859]Judd LL, Schettler PJ, Brown ES, et al. Adverse consequences of glucocorticoid medication: psychological, cognitive, and behavioral effects. Am J Psychiatry. 2014 Oct;171(10):1045-51. https://ajp.psychiatryonline.org/doi/10.1176/appi.ajp.2014.13091264 http://www.ncbi.nlm.nih.gov/pubmed/25272344?tool=bestpractice.com This also stands true for patients who have neuropsychiatric adverse effects related to discontinuing long-term corticosteroid therapy.[862]Fardet L, Nazareth I, Whitaker HJ, et al. Severe neuropsychiatric outcomes following discontinuation of long-term glucocorticoid therapy: a cohort study. J Clin Psychiatry. 2013 Apr;74(4):e281-6. http://www.ncbi.nlm.nih.gov/pubmed/23656853?tool=bestpractice.com
Liaise with the psychiatry team for advice on appropriate management of the patient’s mood-related complications (based on expert opinion).
This may involve:
Adjusting the dose or discontinuing the corticosteroid therapy if clinically indicated.
If discontinuing corticosteroids, being mindful of a possible withdrawal reaction.[862]Fardet L, Nazareth I, Whitaker HJ, et al. Severe neuropsychiatric outcomes following discontinuation of long-term glucocorticoid therapy: a cohort study. J Clin Psychiatry. 2013 Apr;74(4):e281-6. http://www.ncbi.nlm.nih.gov/pubmed/23656853?tool=bestpractice.com This can present with weakness, fatigue, gastrointestinal symptoms, and delirium, as well as with psychiatric complications including depression
Considering prophylactic medication to reduce the risk of psychiatric adverse effects when a patient with a history of mood disorder is started on corticosteroid therapy. Seek expert psychiatric advice.
Primary options
dexamethasone: adults: 6 mg orally/intravenously once daily for 7-10 days
dexamethasone open_in_new: adults: 6 mg orally/intravenously once daily for 7-10 days
dexamethasone: adults: 6 mg orally/intravenously once daily for 7-10 days
OR
hydrocortisone: adults: 50 mg orally/intravenously every 8 hours for 7-10 days
hydrocortisone open_in_new: adults: 50 mg orally/intravenously every 8 hours for 7-10 days
hydrocortisone: adults: 50 mg orally/intravenously every 8 hours for 7-10 days
Secondary options
prednisolone: adults: 40 mg/day orally given in 1-2 divided doses for 7-10 days
prednisolone open_in_new: adults: 40 mg/day orally given in 1-2 divided doses for 7-10 days
prednisolone: adults: 40 mg/day orally given in 1-2 divided doses for 7-10 days
OR
methylprednisolone: adults: 32 mg/day orally/intravenously given in 1-2 divided doses for 7-10 days
methylprednisolone open_in_new: adults: 32 mg/day orally/intravenously given in 1-2 divided doses for 7-10 days
methylprednisolone: adults: 32 mg/day orally/intravenously given in 1-2 divided doses for 7-10 days
These drug options and doses relate to a patient with no comorbidities.
Primary options
dexamethasone: adults: 6 mg orally/intravenously once daily for 7-10 days
dexamethasone open_in_new: adults: 6 mg orally/intravenously once daily for 7-10 days
dexamethasone: adults: 6 mg orally/intravenously once daily for 7-10 days
OR
hydrocortisone: adults: 50 mg orally/intravenously every 8 hours for 7-10 days
hydrocortisone open_in_new: adults: 50 mg orally/intravenously every 8 hours for 7-10 days
hydrocortisone: adults: 50 mg orally/intravenously every 8 hours for 7-10 days
Secondary options
prednisolone: adults: 40 mg/day orally given in 1-2 divided doses for 7-10 days
prednisolone open_in_new: adults: 40 mg/day orally given in 1-2 divided doses for 7-10 days
prednisolone: adults: 40 mg/day orally given in 1-2 divided doses for 7-10 days
OR
methylprednisolone: adults: 32 mg/day orally/intravenously given in 1-2 divided doses for 7-10 days
methylprednisolone open_in_new: adults: 32 mg/day orally/intravenously given in 1-2 divided doses for 7-10 days
methylprednisolone: adults: 32 mg/day orally/intravenously given in 1-2 divided doses for 7-10 days
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Primary options
OR
Secondary options
OR
The Renal Handbook
Treatment recommended for SOME patients in selected patient group
Treat laboratory-confirmed co-infections (e.g., malaria, tuberculosis, influenza) as appropriate according to local protocols.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1 The treatment of influenza is the same in all patients regardless of SARS-CoV-2 co-infection. Start empirical treatment with oseltamivir in hospitalised patients who are suspected of having either or both infections as soon as possible without waiting for influenza test results. Antiviral therapy can be stopped once influenza has been ruled out.[3]National Institutes of Health. Coronavirus disease 2019 (COVID-19) treatment guidelines. 2021 [internet publication]. https://covid19treatmentguidelines.nih.gov/
Treatment recommended for ALL patients in selected patient group
Guidelines from several professional respiratory organisations agree that patients with asthma or COPD should be advised to continue to take their inhalers as prescribed (including inhaled corticosteroids), whether they do or do not also have COVID-19.[769]Global Initiative for Asthma. Recommendations for inhaled asthma controller medications. 2020 [internet publication]. https://ginasthma.org/recommendations-for-inhaled-asthma-controller-medications/ [770]British Thoracic Society. Advice for healthcare professionals treating people with asthma (adults) in relation to COVID-19. 2020 [internet publication]. https://www.brit-thoracic.org.uk/about-us/covid-19-information-for-the-respiratory-community/ [771]Global Initiative for Chronic Obstructive Lung Disease. GOLD COVID-19 guidance. 2020 [internet publication]. https://goldcopd.org/gold-covid-19-guidance/ [772]National Institute for Health and Care Excellence. COVID-19 rapid guideline: community-based care of patients with chronic obstructive pulmonary disease (COPD). 2020 [internet publication]. https://www.nice.org.uk/guidance/ng168 [773]Hasan SS, Capstick T, Zaidi STR, et al. Use of corticosteroids in asthma and COPD patients with or without COVID-19. Respir Med. 2020 Aug-Sep;170:106045. https://www.resmedjournal.com/article/S0954-6111(20)30185-2/fulltext http://www.ncbi.nlm.nih.gov/pubmed/32843175?tool=bestpractice.com
It is still unclear whether infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may trigger an exacerbation of asthma or COPD, but if it were to occur it could further compromise pulmonary reserve.[773]Hasan SS, Capstick T, Zaidi STR, et al. Use of corticosteroids in asthma and COPD patients with or without COVID-19. Respir Med. 2020 Aug-Sep;170:106045. https://www.resmedjournal.com/article/S0954-6111(20)30185-2/fulltext http://www.ncbi.nlm.nih.gov/pubmed/32843175?tool=bestpractice.com
The overall aim for continuing inhaled corticosteroids is to reduce the risk of an exacerbation of asthma or COPD.[773]Hasan SS, Capstick T, Zaidi STR, et al. Use of corticosteroids in asthma and COPD patients with or without COVID-19. Respir Med. 2020 Aug-Sep;170:106045. https://www.resmedjournal.com/article/S0954-6111(20)30185-2/fulltext http://www.ncbi.nlm.nih.gov/pubmed/32843175?tool=bestpractice.com
There is no evidence that inhaled corticosteroids are related to COVID-19 infection in people with asthma.[774]Centre for Evidence-Based Medicine; Hartmann-Boyce J, Hobbs R. Inhaled steroids in asthma during the COVID-19 outbreak. 2020 [internet publication]. https://www.cebm.net/covid-19/inhaled-steroids-in-asthma-during-the-covid-19-outbreak/ There is also no evidence they increase the risks associated with COVID-19 in people with COPD.[772]National Institute for Health and Care Excellence. COVID-19 rapid guideline: community-based care of patients with chronic obstructive pulmonary disease (COPD). 2020 [internet publication]. https://www.nice.org.uk/guidance/ng168
Patients being cared for at home or in hospital with an acute medical condition can forget to tell you about their inhalers prescribed for COPD or asthma. Remember to check and prescribe if appropriate.
Many inhalers contain a combination of medications, so ensure no dual prescribing.
Patients with COPD or asthma who develop acute kidney injury with an estimated GFR <50 mL/minute/1.73 m² may need to temporarily stop their usual inhaled long-acting muscarinic receptor antagonist, depending on which specific drug is used. Check local formulary or seek pharmacist advice.
Other prescribed medication
Patients with severe asthma or COPD who take oral corticosteroids as regular prescribed maintenance therapy should also continue to take these at the lowest dose possible, as their condition may deteriorate if these are stopped.[769]Global Initiative for Asthma. Recommendations for inhaled asthma controller medications. 2020 [internet publication]. https://ginasthma.org/recommendations-for-inhaled-asthma-controller-medications/ [772]National Institute for Health and Care Excellence. COVID-19 rapid guideline: community-based care of patients with chronic obstructive pulmonary disease (COPD). 2020 [internet publication]. https://www.nice.org.uk/guidance/ng168 [775]National Institute for Health and Care Excellence. COVID-19 rapid guideline: severe asthma. 2020 [internet publication]. https://www.nice.org.uk/guidance/ng166
The UK National Institute for Health and Care Excellence rapid guideline on severe asthma recommends that patients who take regular biological therapy for asthma should continue to take this during the COVID-19 pandemic, but if they become ill with COVID-19, patients should contact the specialist team responsible for their care.[775]National Institute for Health and Care Excellence. COVID-19 rapid guideline: severe asthma. 2020 [internet publication]. https://www.nice.org.uk/guidance/ng166
Treatment recommended for ALL patients in selected patient group
The World Health Organization recommends that antihypertensive drugs should not routinely be stopped in patients with COVID-19, but may need adjusting depending on the patient’s clinical condition, particularly their blood pressure and kidney function.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1
Despite concern about possible increased risk of infection or more severe disease in patients prescribed ACE inhibitors or angiotensin-II receptor antagonists, due to upregulation of angiotensin-converting enzyme-2 (ACE2) receptor expression, the UK National Institute for Health and Care Excellence states that the current evidence is insufficient to draw any conclusion.[779]National Institute for Health and Care Excellence. COVID-19 rapid evidence summary: angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) in people with or at risk of COVID-19. 2020 [internet publication]. https://www.nice.org.uk/advice/es24/chapter/Key-messages
Several professional societies have recommended that during the pandemic patients who are already on these medications (e.g., for hypertension, heart failure, coronary artery disease, CKD, or complications of diabetes) continue to take them (if they don’t have COVID-19). If patients become ill with COVID-19, it is recommended they receive a full clinical assessment by their doctor before making any decisions to stop these medications.[780]American Heart Association; Heart Failure Society of America; American College of Cardiology. Patients taking ACE-i and ARBs who contract COVID-19 should continue treatment, unless otherwise advised by their physician. 2020 [internet publication]. https://newsroom.heart.org/news/patients-taking-ace-i-and-arbs-who-contract-covid-19-should-continue-treatment-unless-otherwise-advised-by-their-physician [781]European Society of Cardiology Council on Hypertension. Position statement of the ESC Council on Hypertension on ACE-inhibitors and angiotensin receptor blockers. 2020 [internet publication]. https://www.escardio.org/Councils/Council-on-Hypertension-(CHT)/News/position-statement-of-the-esc-council-on-hypertension-on-ace-inhibitors-and-ang [782]British Cardiovascular Society; British Society for Heart Failure. BSH & BCS joint statement on ACEi or ARB in relation to COVID-19. 2020 [internet publication]. https://www.britishcardiovascularsociety.org/news/ACEi-or-ARB-and-COVID-19 [783]The Renal Association. The Renal Association, UK position statement on COVID-19 and ACE inhibitor/angiotensin receptor blocker use. 2020 [internet publication]. https://renal.org/health-professionals/covid-19/ra-resources/renal-association-uk-position-statement-covid-19-and-ace
The UK Renal Association and the British Cardiovascular Society recommend following standard current guidance for patients with any intercurrent acute illness when weighing up benefit versus risk of these medications in patients ill with suspected COVID-19.[782]British Cardiovascular Society; British Society for Heart Failure. BSH & BCS joint statement on ACEi or ARB in relation to COVID-19. 2020 [internet publication]. https://www.britishcardiovascularsociety.org/news/ACEi-or-ARB-and-COVID-19 [783]The Renal Association. The Renal Association, UK position statement on COVID-19 and ACE inhibitor/angiotensin receptor blocker use. 2020 [internet publication]. https://renal.org/health-professionals/covid-19/ra-resources/renal-association-uk-position-statement-covid-19-and-ace [784]Clark AL, Kalra PR, Petrie MC, et al. Change in renal function associated with drug treatment in heart failure: national guidance. Heart. 2019 Jun;105(12):904-10. https://heart.bmj.com/content/105/12/904.long http://www.ncbi.nlm.nih.gov/pubmed/31118203?tool=bestpractice.com These include to:
Do an individual clinical assessment
Consider the original indication for any renin-angiotensin-aldosterone system (RAAS) inhibitors (ACE inhibitors, angiotensin-II receptor antagonists, mineralocorticoid receptor/aldosterone antagonists) and degree of prognostic benefit
If medication is temporarily withheld, consider when to re-introduce again once health improves.
Consider calculating a frailty score as patients with higher frailty scores may be more likely to experience medication-related harm when acutely unwell (based on expert opinion).
Consider the benefit versus risk of stopping other medications associated with an increased risk of acute kidney injury during intercurrent illness, such as other antihypertensives and diuretics.
If your patient with chronic kidney disease has been taking non-steroidal anti-inflammatory drugs, advise them to stop taking these when they are ill.
Patients who self-manage their heart failure in a community setting may wish to reduce their dose of diuretics during an intercurrent illness that may result in dehydration (based on expert opinion).
Seek advice from the patient’s cardiology or nephrology team if they have complex conditions (e.g., on renal replacement therapy or immunosuppressive therapy).
Treatment recommended for ALL patients in selected patient group
The World Health Organization recommends that potential adverse effects and drug-drug interactions are considered when treating patients with COVID-19.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1 With this in mind, if possible ask the patient which medications they are taking for their depression. Alternatively, review their primary care records for relevant information (if available).
Prescribe the patient’s usual antidepressant medication, unless there are good reasons not to (based on expert opinion).
If antidepressants are stopped abruptly, the patient may develop discontinuation symptoms.[833]Cleare A, Pariante CM, Young AH, et al. Evidence-based guidelines for treating depressive disorders with antidepressants: a revision of the 2008 British Association for Psychopharmacology guidelines. J Psychopharmacol. 2015 May;29(5):459-525. https://www.bap.org.uk/pdfs/BAP_Guidelines-Antidepressants.pdf http://www.ncbi.nlm.nih.gov/pubmed/25969470?tool=bestpractice.com
The severity of symptoms of discontinuation may vary, but it may be unpleasant and may complicate the management of the acute medical condition.[834]National Institute for Health and Care Excellence. Depression in adults with a chronic physical health problem: recognition and management. 2009 [internet publication]. https://www.nice.org.uk/guidance/cg91
When reviewing current medication, look out for:
Perceived current and previous adverse effects
Recent changes in dose
Recent switches from a different class of medication
Pharmacological nuances of specific depression subtypes (e.g., it is likely that patients suffering from psychotic depression would be co-prescribed an antipsychotic)
Augmenting strategies that may be in use in treating resistant depression (e.g., lithium or quetiapine augmentation of a selective serotonin-reuptake inhibitor [SSRI]).
Consider drug-drug interactions.
Antidepressant medications may cause pharmacokinetic (by inhibiting the CYP450 pathway) and pharmacodynamic interactions with medications used for other conditions.[833]Cleare A, Pariante CM, Young AH, et al. Evidence-based guidelines for treating depressive disorders with antidepressants: a revision of the 2008 British Association for Psychopharmacology guidelines. J Psychopharmacol. 2015 May;29(5):459-525. https://www.bap.org.uk/pdfs/BAP_Guidelines-Antidepressants.pdf http://www.ncbi.nlm.nih.gov/pubmed/25969470?tool=bestpractice.com [835]Taylor DM, Barnes TRE, Young AH. The Maudsley prescribing guidelines in psychiatry. 13th edition. Chichester: Wiley-Blackwell; 2018. Consider this issue for all medications prescribed in patients with COVID-19 as well as any experimental therapies (see the Emerging section).
Drug-drug interactions and their associated adverse effects of particular relevance to patients with COVID-19 include sedation, cardiotoxicity (QT prolongation), and respiratory depression.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1
Practical tip
Be aware that smoking cessation or switching from tobacco smoking to any other alternatives (including nicotine replacement therapy) may result in a change to the plasma concentration of any psychotropic medication the patient may be taking (e.g., for depression). This is because nicotine replacement therapy does not impact hepatic enzyme activity like tobacco smoking.[836]Flowers L. Nicotine replacement therapy. Am J Psychiatry Resid J. 2016 Jun;11(6):4-7. https://psychiatryonline.org/doi/10.1176/appi.ajp-rj.2016.110602 [837]Desai HD, Seabolt J, Jann MW. Smoking in patients receiving psychotropic medications: a pharmacokinetic perspective. CNS Drugs. 2001;15(6):469-94. http://www.ncbi.nlm.nih.gov/pubmed/11524025?tool=bestpractice.com [838]Oliveira P, Ribeiro J, Donato H, et al. Smoking and antidepressants pharmacokinetics: a systematic review. Ann Gen Psychiatry. 2017 Mar 6;16:17. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5340025/ http://www.ncbi.nlm.nih.gov/pubmed/28286537?tool=bestpractice.com [839]National Centre for Smoking Cessation and Training. Smoking cessation and mental health: a briefing for front-line staff. 2014 [internet publication]. https://www.ncsct.co.uk/usr/pub/mental%20health%20briefing%20A4.pdf Seek advice on whether any adjustment to the dose of psychotropic medication is appropriate.
Consider psychiatric complications when prescribing non-psychotropic drugs.
Take particular care when prescribing corticosteroids, anticonvulsants, and antiparkinsonian medication.
Consider adverse effects, which may include the following.
Respiratory depression. Be aware that certain antidepressants may precipitate respiratory depression, especially when co-prescribed with other sedative drugs. Particular caution is needed with tricyclic antidepressants and mirtazapine.
QT prolongation, arrhythmias, increased heart rate, or postural hypotension with tricyclic antidepressants. Check ECG, especially in people at risk of arrhythmias.
Hyponatraemia, caused by antidepressants, especially SSRIs, and compounded by other co-prescribed drugs (e.g., diuretics). Check the patient’s serum electrolytes.
Serotonin syndrome (altered mental state, agitation, tremor, hyper-reflexia, clonus, muscle rigidity, diaphoresis, tachycardia, increased bowel sounds, temperature >38℃), especially with polypharmacy and/or overdose of a serotonergic agent.[840]Boyer EW, Shannon M. The serotonin syndrome. N Engl J Med. 2005 Mar 17;352(11):1112-20. https://www.doi.org/10.1056/NEJMra041867 http://www.ncbi.nlm.nih.gov/pubmed/15784664?tool=bestpractice.com
Be particularly aware of increased risk of serotonin syndrome in patients with end-stage renal disease on SSRIs. Treating depression in patients with renal impairment requires a multidisciplinary approach and demands extra caution.
Hepatotoxicity. Adjust doses of antidepressants in patients with hepatic impairment if necessary and avoid drugs that are known to be hepatotoxic.
This list of adverse effects and drug-drug interactions is not exhaustive – consult local formulary for further information. Consult your liaison psychiatry colleagues and/or a pharmacist for advice.
If possible, ask the patient about non-pharmacological treatments for their depression and check current level of support in the community.
This may include other health professionals involved in their care, charities, family and social networks, and psychological therapy.
Treatment recommended for SOME patients in selected patient group
Consider appropriate experimental or emerging therapies.
Antiviral therapies will have a greater effect early in the course of the disease, whereas immunosuppressive/anti-inflammatory therapies are likely to have a greater effect later in the course of the disease.[3]National Institutes of Health. Coronavirus disease 2019 (COVID-19) treatment guidelines. 2021 [internet publication]. https://covid19treatmentguidelines.nih.gov/
See the Emerging external link opens in a new windowsection for more information.
Take the patient’s comorbidities into account when considering experimental therapies
The World Health Organization (WHO) recommends that you consider potential adverse effects and drug-drug interactions in patients with COVID-19.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1
One example of this is the effect on the QT interval. A patient may be on a drug that prolongs the QT interval. The patient may then receive another drug for COVID-19 that also prolongs the QT interval.
Consider your patient’s comorbidities and current treatments when prescribing any new medication.
Follow local drug protocol guidelines and consult senior colleagues before starting any new treatments.
Treatment recommended for SOME patients in selected patient group
Routinely assess intensive care patients for mobility, functional swallow, cognitive impairment, and mental health concerns, and based on that assessment determine whether the patient is ready for discharge, and whether the patient has any rehabilitation and follow-up requirements.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1
Ensure plans are in place for follow-up of comorbidities
Ensure the patient has follow-up plans in place concerning any comorbidities as well as discharge and follow-up criteria related to COVID-19.
Knowledge and experience concerning the rehabilitation needs of patients post-hospital discharge is still increasing.[863]Greenhalgh T, Knight M, A’Court C, et al. Management of post-acute covid-19 in primary care. BMJ. 2020 Aug 11;370:m3026. https://www.bmj.com/content/370/bmj.m3026 http://www.ncbi.nlm.nih.gov/pubmed/32784198?tool=bestpractice.com [864]British Geriatrics Society. COVID-19: rehabilitation of older people. 2020 [internet publication]. https://www.bgs.org.uk/resources/covid-19-rehabilitation-of-older-people
COVID-19 may have long-term effects that relate to other comorbidities. UK-based patients with certain comorbidities may find the following sources of information useful:
Follow your local protocols and ask advice from relevant speciality teams.
Consider use of telemedicine to facilitate remote consultations in selected patients.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1 [762]Shore JH, Schneck CD, Mishkind MC. Telepsychiatry and the coronavirus disease 2019 pandemic-current and future outcomes of the rapid virtualization of psychiatric care. JAMA Psychiatry. 2020 May 11 [Epub ahead of print]. https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2765954 http://www.ncbi.nlm.nih.gov/pubmed/32391861?tool=bestpractice.com [763]Hubley S, Lynch SB, Schneck C, et al. Review of key telepsychiatry outcomes. World J Psychiatry. 2016 Jun 22;6(2):269-82. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4919267/ http://www.ncbi.nlm.nih.gov/pubmed/27354970?tool=bestpractice.com
Treatment recommended for SOME patients in selected patient group
Palliative care interventions should be made accessible at each institution that provides care for patients with COVID-19. Identify whether the patient has an advance care plan and respect the patient’s priorities and preferences when formulating the patient’s care plan.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1 Follow local palliative care guidelines.
Treatment recommended for ALL patients in selected patient group
Practical tip
Asthma exacerbation and COVID-19 may be difficult to differentiate clinically, and they may present together. Cough and shortness of breath are features of both; however, additional symptoms such as fever, fatigue, and change in taste or smell are more likely to suggest COVID-19 infection.[770]British Thoracic Society. Advice for healthcare professionals treating people with asthma (adults) in relation to COVID-19. 2020 [internet publication]. https://www.brit-thoracic.org.uk/about-us/covid-19-information-for-the-respiratory-community/
Monitor for acute worsening of respiratory symptoms and be aware that this may suggest a patient with comorbid asthma is having an acute exacerbation of their asthma.
Seek senior advice.
Follow standard guideline recommendations on assessing severity and managing an acute exacerbation of asthma in adults, even if COVID-19 is suspected as the trigger.[777]British Thoracic Society; Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma: a national clinical guideline. 2019 [internet publication]. https://www.sign.ac.uk/media/1048/sign158.pdf [818]Centers for Disease Control and Prevention. Clinical questions about COVID-19: questions and answers – patients with asthma. 2020 [internet publication]. https://www.cdc.gov/coronavirus/2019-ncov/hcp/faq.html#Patients-with-Asthma
See our topic Acute exacerbation of asthma in adults.
Temporarily stop any long-acting muscarinic receptor antagonist (LAMA) the patient may be on for maintenance therapy (e.g., tiotropium, aclidinium, glycopyrronium, umeclidinium) if you prescribe a nebulised short-acting muscarinic antagonist (e.g., ipratropium) (based on expert opinion). This is due to concern over possible additive anticholinergic adverse effects.
Ensure to re-prescribe the LAMA once the nebuliser treatment has been stopped.
Practical tip
There are currently differences of opinion between organisations in different countries on whether use of a nebuliser is an aerosol-generating procedure and therefore the specific personal protective equipment required.[769]Global Initiative for Asthma. Recommendations for inhaled asthma controller medications. 2020 [internet publication]. https://ginasthma.org/recommendations-for-inhaled-asthma-controller-medications/ [775]National Institute for Health and Care Excellence. COVID-19 rapid guideline: severe asthma. 2020 [internet publication]. https://www.nice.org.uk/guidance/ng166 Follow your local guidance and protocols. Consider whether it may be clinically appropriate to use a metered-dose inhaler delivered via a spacer device as an alternative delivery mechanism.[819]Global Initiative for Asthma. COVID-19: GINA answers to frequently asked questions on asthma management. 2020 [internet publication]. https://ginasthma.org/covid-19-gina-answers-to-frequently-asked-questions-on-asthma-management/
Treatment recommended for ALL patients in selected patient group
If an exacerbation of COPD is suspected in a patient with COVID-19 and pre-existing COPD, follow the patient’s personalised action plan.
Based on the limited evidence available, the Global Initiative for Chronic Obstructive Lung Disease recommends to follow established guidelines on the management of an exacerbation of COPD, including prescription of short-term oral corticosteroids if clinically indicated.[773]Hasan SS, Capstick T, Zaidi STR, et al. Use of corticosteroids in asthma and COPD patients with or without COVID-19. Respir Med. 2020 Aug-Sep;170:106045. https://www.resmedjournal.com/article/S0954-6111(20)30185-2/fulltext http://www.ncbi.nlm.nih.gov/pubmed/32843175?tool=bestpractice.com [778]Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease. 2021 [internet publication]. https://goldcopd.org/2021-gold-reports/
See our topic Acute exacerbation of COPD.
Seek senior or specialist advice.
Differentiate from other conditions, such as acute coronary syndrome, acute heart failure, and pneumonia, as well as from complications of COVID-19.
Practical tip
There are currently differences of opinion between organisations in different countries on whether use of a nebuliser is an aerosol-generating procedure and therefore the specific personal protective equipment required.[775]National Institute for Health and Care Excellence. COVID-19 rapid guideline: severe asthma. 2020 [internet publication]. https://www.nice.org.uk/guidance/ng166 [778]Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease. 2021 [internet publication]. https://goldcopd.org/2021-gold-reports/ Follow your local guidance and protocols.
If a nebuliser is used, bronchodilator therapy via a nebuliser should only be used for 24 to 48 hours and then the patient should be switched back onto their usual inhaler(s).
Temporarily stop any long-acting muscarinic receptor antagonist (LAMA) the patient may be on for maintenance therapy (e.g., tiotropium, aclidinium, glycopyrronium, umeclidinium) if you prescribe a nebulised short-acting muscarinic antagonist (e.g., ipratropium) (based on expert opinion). This is due to concern over possible additive anticholinergic adverse effects.
Ensure to re-prescribe the LAMA once the nebuliser treatment has been stopped.
Treatment recommended for ALL patients in selected patient group
Monitor blood glucose levels at least four times a day (pre-meal and before bedtime if eating) in any acutely unwell patient with diabetes mellitus.[820]American Diabetes Association. Diabetes care in the hospital: standards of medical care in diabetes - 2020. Diabetes Care. 2020 Jan;43(suppl 1):S193-202. https://care.diabetesjournals.org/content/43/Supplement_1/S193 http://www.ncbi.nlm.nih.gov/pubmed/31862758?tool=bestpractice.com
Follow your local protocol on blood glucose monitoring for inpatients with COVID-19 who have diabetes.
There is no consensus on target blood glucose levels for people with diabetes in hospital with an acute medical condition.
The UK Joint British Diabetes Societies for Inpatient Care (JBDS-IP) recommends an ideal range of 6 to 10 mmol/L (108-180 mg/dL), and an acceptable upper level of 12 mmol/L (216 mg/dL).[821]Joint British Diabetes Societies for inpatient care. The use of variable rate intravenous insulin infusion (VRIII) in medical inpatients. 2014 [internet publication]. https://abcd.care/sites/abcd.care/files/resources/JBDS_IP_VRIII.pdf A more liberal blood glucose target is considered appropriate if your patient is at high risk of falls, is frail, or has dementia.[821]Joint British Diabetes Societies for inpatient care. The use of variable rate intravenous insulin infusion (VRIII) in medical inpatients. 2014 [internet publication]. https://abcd.care/sites/abcd.care/files/resources/JBDS_IP_VRIII.pdf
The UK-based National Inpatient Diabetes COVID-19 Response Group makes the same recommendation for patients in hospital with COVID-19.[822]National Inpatient Diabetes COVID-19 Response Group. Concise advice on inpatient diabetes during COVID-19 (COVID:Diabetes): guidance for managing inpatient hyperglycaemia. 2020 [internet publication]. https://abcd.care/sites/abcd.care/files/resources/COvID_Hyper_v4.2.pdf
Consensus guidance from an international group of experts recommends aiming for levels of between 4 and 10 mmol/L (72 and 180 mg/dL) in patients with COVID-19, but to adjust the lower level to 5 mmol/L (90 mg/dL) in patients who are frail.[799]Bornstein SR, Rubino F, Khunti K, et al. Practical recommendations for the management of diabetes in patients with COVID-19. Lancet Diabetes Endocrinol. 2020 Jun;8(6):546-50. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7180013/ http://www.ncbi.nlm.nih.gov/pubmed/32334646?tool=bestpractice.com
The American Diabetes Association recommends a target range of 7.8 to 10 mmol/L (140-180 mg/dL) for most critically and non-critically ill patients (not specifically with COVID-19).[820]American Diabetes Association. Diabetes care in the hospital: standards of medical care in diabetes - 2020. Diabetes Care. 2020 Jan;43(suppl 1):S193-202. https://care.diabetesjournals.org/content/43/Supplement_1/S193 http://www.ncbi.nlm.nih.gov/pubmed/31862758?tool=bestpractice.com
Data are still limited on blood glucose control and its association with outcomes for patients with COVID-19.[794]Hartmann-Boyce J, Morris E, Goyder C, et al. Diabetes and COVID-19: risks, management, and learnings from other national disasters. Diabetes Care. 2020 Aug;43(8):1695-703. https://care.diabetesjournals.org/content/43/8/1695 http://www.ncbi.nlm.nih.gov/pubmed/32546593?tool=bestpractice.com
Hyperglycaemia during the ongoing hospital admission
Treat hyperglycaemia to avoid diabetic ketoacidosis (DKA) and hyperosmolar hyperglycaemic state (HHS), which are medical emergencies.
Follow your local hospital protocol if your patient’s capillary blood glucose is ≥12 mmol/L (≥216 mg/dL).
COVID-19 guidance generally emphasises the importance of managing hyperglycaemia.[794]Hartmann-Boyce J, Morris E, Goyder C, et al. Diabetes and COVID-19: risks, management, and learnings from other national disasters. Diabetes Care. 2020 Aug;43(8):1695-703. https://care.diabetesjournals.org/content/43/8/1695 http://www.ncbi.nlm.nih.gov/pubmed/32546593?tool=bestpractice.com
Exclude DKA or HHS, both of which require specific urgent management.
Consider other conditions associated with hyperglycaemia, such as sepsis.[793]National Inpatient Diabetes COVID-19 Response Group. Concise advice on inpatient diabetes during COVID-19: front door guidance. 2020 [internet publication]. https://abcd.care/resource/concise-advice-inpatient-diabetes-during-covid-19-front-door-guidance
Be aware that the following medications may be associated with hyperglycaemia and may need to be reviewed:[823]Rehman A, Setter SM, Vue MH. Drug-induced glucose alterations part 2: drug-induced hyperglycemia. Diabetes Spect. 2011 Nov;24(4):234-8. https://spectrum.diabetesjournals.org/content/24/4/234
Corticosteroids (e.g., dexamethasone)
Some beta-blockers (e.g., propranolol, atenolol)
Thiazide diuretics (e.g., hydrochlorothiazide)
Some second-generation antipsychotics (e.g., olanzapine, clozapine)
Certain fluoroquinolone antibiotics (e.g., ciprofloxacin)
Calcineurin inhibitors (e.g., ciclosporin, tacrolimus)
Protease inhibitors (e.g., as a component in antiretroviral therapy, lopinavir/ritonavir may be used to treat some patients with COVID-19).
Some experimental drugs used in the management of COVID-19 may be associated with (or cause) hyperglycaemia. Check local drug formularies for further information before prescribing these therapies in patients with diabetes.
If your patient has persistently elevated blood glucose, they may need insulin therapy (intravenous or subcutaneous protocols). Follow your local protocols on management of hyperglycaemia in patients with COVID-19.
Infusion pump devices may not be available outside of intensive care unit (ICU) settings, depending on the need for these devices elsewhere. In this situation, some protocols recommend alternative subcutaneous regimens when managing hyperglycaemia and mild DKA.[822]National Inpatient Diabetes COVID-19 Response Group. Concise advice on inpatient diabetes during COVID-19 (COVID:Diabetes): guidance for managing inpatient hyperglycaemia. 2020 [internet publication]. https://abcd.care/sites/abcd.care/files/resources/COvID_Hyper_v4.2.pdf [824]National Inpatient Diabetes COVID-19 Response Group. Concise advice on inpatient diabetes during COVID-19 (COVID:Diabetes): guideline for managing DKA using subcutaneous insulin. 2020 [internet publication]. https://abcd.care/sites/abcd.care/files/resources/COvID_DKA_SC_v3.3.pdf
Be aware that patients with type 2 diabetes in ICU may have significant degrees of insulin resistance.[822]National Inpatient Diabetes COVID-19 Response Group. Concise advice on inpatient diabetes during COVID-19 (COVID:Diabetes): guidance for managing inpatient hyperglycaemia. 2020 [internet publication]. https://abcd.care/sites/abcd.care/files/resources/COvID_Hyper_v4.2.pdf
Practical tip
Ask for expert advice from the inpatient diabetes team.
Hypoglycaemia during the ongoing hospital admission
Monitor blood glucose and adjust medication in response to illness and hospital meal times, to reduce the risk of hypoglycaemic episodes.
1 in 5 inpatients with diabetes in England and Wales have a hypoglycaemic episode during their hospital stay.[825]NHS Digital. National Diabetes Inpatient Audit (NaDIA) - 2017. 2018 [internet publication]. https://digital.nhs.uk/data-and-information/publications/statistical/national-diabetes-inpatient-audit/national-diabetes-inpatient-audit-nadia-2017
Causes of hypoglycaemia include:[826]Joint British Diabetes Societies for inpatient care. The hospital management of hypoglycaemia in adults with diabetes mellitus. 4th ed. 2020 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_HypoGuideline_4th_edition_FINAL.pdf
Recovery from an acute illness
Patients recovering from COVID-19 may have a rapid change in insulin requirements, so monitor and adjust insulin regimens carefully[822]National Inpatient Diabetes COVID-19 Response Group. Concise advice on inpatient diabetes during COVID-19 (COVID:Diabetes): guidance for managing inpatient hyperglycaemia. 2020 [internet publication]. https://abcd.care/sites/abcd.care/files/resources/COvID_Hyper_v4.2.pdf
Accidental interruptions to patient feeding, which may occur especially when patients with COVID-19 are nursed in the prone position[822]National Inpatient Diabetes COVID-19 Response Group. Concise advice on inpatient diabetes during COVID-19 (COVID:Diabetes): guidance for managing inpatient hyperglycaemia. 2020 [internet publication]. https://abcd.care/sites/abcd.care/files/resources/COvID_Hyper_v4.2.pdf
Reducing doses of corticosteroids, particularly dexamethasone in patients with COVID-19[822]National Inpatient Diabetes COVID-19 Response Group. Concise advice on inpatient diabetes during COVID-19 (COVID:Diabetes): guidance for managing inpatient hyperglycaemia. 2020 [internet publication]. https://abcd.care/sites/abcd.care/files/resources/COvID_Hyper_v4.2.pdf
Insulin or oral hypoglycaemic medication error
Wrong timing of insulin in relation to meals
Patients eating less but taking the same amount of diabetes medication
No bedtime snacks
Reduced appetite or vomiting.
Some experimental drugs used in the management of COVID-19 may be associated with (or cause) hypoglycaemia (e.g., hydroxychloroquine). Check local drug formularies for further information before prescribing these therapies in patients with diabetes.
Be aware that hypoglycaemia as an adverse effect of sulfonylurea medication (e.g., glibenclamide, gliclazide, glimepiride, glipizide) is more likely if meals are skipped or doses are excessive.
In the acute hospital setting, meal times may be interrupted or may not always be at exactly the same time each day.
Give sulfonylurea medication before or with food. Check local drug formulary for more specific guidance on timing of dose in relation to food for specific sulfonylurea.
Never give sulfonylurea medication at bedtime and, if the patient is taking a dose with their evening meal, consider reducing the evening dose to reduce the risk of nocturnal hypoglycaemia (based on expert opinion).
Practical tip
Bedtime snacks can reduce the risk of early morning hypoglycaemia.[825]NHS Digital. National Diabetes Inpatient Audit (NaDIA) - 2017. 2018 [internet publication]. https://digital.nhs.uk/data-and-information/publications/statistical/national-diabetes-inpatient-audit/national-diabetes-inpatient-audit-nadia-2017
Treat hypoglycaemia actively if the blood glucose falls below 4 mmol/L (72 mg/dL).[826]Joint British Diabetes Societies for inpatient care. The hospital management of hypoglycaemia in adults with diabetes mellitus. 4th ed. 2020 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_HypoGuideline_4th_edition_FINAL.pdf Follow hospital protocol. The JBDS-IP guidelines recommend that you:[826]Joint British Diabetes Societies for inpatient care. The hospital management of hypoglycaemia in adults with diabetes mellitus. 4th ed. 2020 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_HypoGuideline_4th_edition_FINAL.pdf
Retest blood glucose at 15 minutes to determine response to treatment
Never stop the next scheduled dose of insulin if the hypoglycaemia has been corrected. This can cause rebound hyperglycaemia and DKA in people with type 1 diabetes.
Follow local protocols and guidance on self-monitoring of blood glucose by patients in hospital.
These may have been adapted in the context of patients with COVID-19. For instance, some hospitals in the US have been utilising ‘virtual’ formats, including expanding self-management protocols, to reduce need for personal protective equipment, where it is safe to do so.[794]Hartmann-Boyce J, Morris E, Goyder C, et al. Diabetes and COVID-19: risks, management, and learnings from other national disasters. Diabetes Care. 2020 Aug;43(8):1695-703. https://care.diabetesjournals.org/content/43/8/1695 http://www.ncbi.nlm.nih.gov/pubmed/32546593?tool=bestpractice.com
Treatment recommended for ALL patients in selected patient group
Check the feet of any adult with diabetes on admission to hospital and whenever they seem more unwell.[827]National Institute for Health and Care Excellence. Diabetic foot problems: prevention and management. 2019 [internet publication]. https://www.nice.org.uk/guidance/ng19 This is still a recommendation for adults with diabetes admitted to hospital with COVID-19.[793]National Inpatient Diabetes COVID-19 Response Group. Concise advice on inpatient diabetes during COVID-19: front door guidance. 2020 [internet publication]. https://abcd.care/resource/concise-advice-inpatient-diabetes-during-covid-19-front-door-guidance
A foot check is needed to detect new ulceration or infection, which may be unnoticed by the patient. It may even be the cause of their acute illness (e.g., patient presenting with sepsis, or endocarditis where the original focus of infection is the foot lesion).
Inspect the foot for lesions and examine for loss of protective sensation.
Follow your local guidelines, but a quick simple test is the Ipswich Touch Test©️, which involves lightly touching/resting the tip of the index finger for 1 to 2 seconds on the tips of the first, third, and fifth toes.[828]Rayman G, Vas PR, Baker N, et al. The Ipswich Touch Test: a simple and novel method to identify inpatients with diabetes at risk of foot ulceration. Diabetes Care. 2011 Jul;34(7):1517-8. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3120164/ http://www.ncbi.nlm.nih.gov/pubmed/21593300?tool=bestpractice.com
If your patient is unable to feel at two or more of these six sites, they have reduced protective sensation.
If your patient has reduced sensation, they are at high risk of pressure ulceration. Inform the nursing staff and provide pressure relieving devices.
A daily heel check for signs of pressure trauma should be done by nursing or healthcare assistant staff.
There is a debate about whether compression stockings should or should not be used in people with diabetes – do not use them if there is vascular disease.
Treatment recommended for ALL patients in selected patient group
Do a mental state examination as the clinical situation allows and if the patient is responsive (based on expert opinion).
The mental state examination is one of the main clinical tools routinely used in psychiatric practice, aiding diagnosis and guiding further management. Mood is one of the assessed domains.
Consider assessing depression by using the PHQ-9 questionnaire.[829]Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001 Sep;16(9):606-13. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1495268/ http://www.ncbi.nlm.nih.gov/pubmed/11556941?tool=bestpractice.com
This is self-administered and takes less than 3 minutes to complete.
Results indicate severity of depressive symptoms.
A score of 5 or above should trigger a referral to your liaison psychiatry service (based on expert opinion).
While data continue to emerge on the psychiatric impact of COVID-19, it is interesting to note that other severe coronavirus infections (severe acute respiratory syndrome [SARS] and Middle East respiratory syndrome [MERS]) have been found to be associated with low mood both in the acute phase of the illness as well as at follow-up.[830]Rogers JP, Chesney E, Oliver D, et al. Psychiatric and neuropsychiatric presentations associated with severe coronavirus infections: a systematic review and meta-analysis with comparison to the COVID-19 pandemic. Lancet Psychiatry. 2020 Jul;7(7):611-27. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7234781/ http://www.ncbi.nlm.nih.gov/pubmed/32437679?tool=bestpractice.com [831]National Institute for Health Research. High rates of delirium, persistent fatigue and post-traumatic stress disorder were common after severe infection in previous coronavirus outbreaks. 2020 [internet publication]. https://evidence.nihr.ac.uk/alert/high-rates-of-delirium-persistent-fatigue-and-post-traumatic-stress-disorder-were-common-after-severe-infection-in-previous-coronavirus-outbreaks/
Consider other factors that may be influencing the patient’s mental state (e.g., the effect of any illicit drug use or alcohol).[832]Boden JM, Fergusson DM. Alcohol and depression. Addiction. 2011 May;106(5):906-14. http://www.ncbi.nlm.nih.gov/pubmed/21382111?tool=bestpractice.com
Treatment recommended for ALL patients in selected patient group
Consider a referral to the liaison psychiatry team/service for any patient with established or suspected depression who is admitted to hospital with an acute condition.[841]National Institute for Health and Care Excellence. Liaison psychiatry. In: Emergency acute medical care in over 16s: service delivery and organisation. 2018 [internet publication]. https://www.nice.org.uk/guidance/ng94/evidence/23.liaison-psychiatry-pdf-172397464636 [842]National Confidential Enquiry into Patient Outcome and Death. Treat as one: bridging the gap between mental and physical healthcare in general hospitals. 2017 [internet publication]. https://www.ncepod.org.uk/2017report1/downloads/TreatAsOne_Summary.pdf
Follow your local protocols/referral pathways in your hospital during the COVID-19 pandemic.
COVID-19 is associated with psychiatric and neurological manifestations including depression.[2]World Health Organization. COVID-19 clinical management: living guidance. 2021 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1
Comorbid depression is linked to poor adherence with recommended physical health treatments, from medication to rehabilitation.[843]DiMatteo MR, Lepper HS, Croghan TW. Depression is a risk factor for noncompliance with medical treatment: meta-analysis of the effects of anxiety and depression on patient adherence. Arch Intern Med. 2000 Jul 24;160(14):2101-7. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/485411 http://www.ncbi.nlm.nih.gov/pubmed/10904452?tool=bestpractice.com
This may lead to worse clinical outcomes, including longer hospital stays.[834]National Institute for Health and Care Excellence. Depression in adults with a chronic physical health problem: recognition and management. 2009 [internet publication]. https://www.nice.org.uk/guidance/cg91 [844]Prina AM, Cosco TD, Dening T, et al. The association between depressive symptoms in the community, non-psychiatric hospital admission and hospital outcomes: a systematic review. J Psychosom Res. 2015 Jan;78(1):25-33. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4292984/ http://www.ncbi.nlm.nih.gov/pubmed/25466985?tool=bestpractice.com [845]Clarke DM, Currie KC. Depression, anxiety and their relationship with chronic diseases: a review of the epidemiology, risk and treatment evidence. Med J Aust. 2009 Apr 6;190(s7):S54-60. http://www.ncbi.nlm.nih.gov/pubmed/19351294?tool=bestpractice.com
Most importantly, depression is linked with excess mortality.[846]World Health Organization. Excess mortality in persons with severe mental disorders. 2016 [internet publication]. https://www.who.int/mental_health/evidence/excess_mortality_report/en/
Treatment recommended for ALL patients in selected patient group
Consider prescribing nicotine replacement therapy to current smokers admitted with an acute condition. This is regardless of intention to quit smoking. However, because there is an increased risk for severe COVID-19 associated with tobacco smoking, in addition to the well-recognised harms, the World Health Organization does recommend smoking cessation using evidence-based methods.[253]World Health Organization. Smoking and COVID-19: scientific brief. 2020 [internet publication]. https://www.who.int/publications/i/item/WHO-2019-nCoV-Sci_Brief-Smoking-2020.2 [847]Patanavanich R, Glantz SA. Smoking is associated with COVID-19 progression: a meta-analysis. Nicotine Tob Res. 2020 Aug 24;22(9):1653-6. https://academic.oup.com/ntr/advance-article/doi/10.1093/ntr/ntaa082/5835834 http://www.ncbi.nlm.nih.gov/pubmed/32399563?tool=bestpractice.com [848]National Institute for Health and Care Excellence. Smoking: acute, maternity and mental health services. 2020 [internet publication]. https://www.nice.org.uk/guidance/ph48
Nicotine replacement therapy prevents rapid withdrawal during admission, which can be distressing and uncomfortable.
Preparations include transdermal patches or, for patients with skin allergies, inhalators, lozenges, gum, or sprays. Dose depends on how many cigarettes are smoked/day and the formulation chosen.
Use with caution in haemodynamically unstable patients hospitalised with acute stroke, myocardial infarction, and/or uncontrolled hypertension and in patients with severe renal impairment.
Monitor blood glucose closely if starting nicotine replacement therapy in patients with diabetes.
Consult your local drug formulary and hospital guidance for more comprehensive details.
Practical tip
Be aware that switching from tobacco smoking to any other alternatives (including nicotine replacement therapy) may result in a change to the plasma concentration of any psychotropic medication the patient may be taking (e.g., for depression). This is because nicotine replacement therapy does not impact hepatic enzyme activity like tobacco smoking.[836]Flowers L. Nicotine replacement therapy. Am J Psychiatry Resid J. 2016 Jun;11(6):4-7. https://psychiatryonline.org/doi/10.1176/appi.ajp-rj.2016.110602 Seek advice on whether any adjustment to the dose of psychotropic medication is appropriate.
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