BMJ Best Practice

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

ADD COMORBIDITIES TO THIS TREATMENT ALGORITHMomorbidities:

ACUTE

mild COVID-19

1st line – consider home isolation

Isolate 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 to contain virus transmission.[2]

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][3]
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.[809]
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]

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

Monitor patients with risk factors closely and consider the most appropriate setting of care, taking into account these risk factors.[899]

The World Health Organization lists the following comorbidities as risk factors for severe disease and death:[899]

Cardiac disease
Diabetes mellitus
Chronic lung disease
Chronic kidney disease
Cerebrovascular disease
Dementia
Mental disorders
Cancer
Immunosuppression
Obesity
Hypertension.

Older people and those with higher levels of frailty are reported to have an increased mortality risk with COVID-19.[899][900]

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.[899]

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]

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.[811] 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.[812]

Plus – monitor comorbidities during hospital stay

Plus – monitoring

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][3]

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]

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.[901]

CKD is a significant risk factor for acute kidney injury (AKI).[902]
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.
- AKI in patients with COVID-19 may be common (although exact prevalence is uncertain). AKI is associated with increased mortality.[903]
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.[899]

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.[901]

Plus – monitor comorbidities during hospital stay

Plus – symptom management and supportive care

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.[605]

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.[820]

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][605]

Other supportive care measures include:

Advise patients to improve air circulation by opening a window or door[605]
Provide basic mental health and psychosocial support for all patients, and manage any symptoms of insomnia, depression, or anxiety as appropriate[2]
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.[821]

Most children with mild disease can be managed with supportive care alone.[3]

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.[904]
Consider use of telemedicine to facilitate remote consultations.[899][905][906] Royal College of Psychiatrists: digital - COVID-19 guidance for clinicians external link opens in a new window
Advise your patient on where to find locally relevant information and sources of support, for example:
- Royal College of Psychiatrists: Covid-19 – support for patients and carers external link opens in a new window

Plus – monitor comorbidities during hospital stay

Plus – set an escalation plan

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:[907]
- 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 advance care planning, including legally binding advanced directives.[899][907]

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).[908] Follow the appropriate legislation in your region.
In England and Wales, health professionals must comply with the 2005 Mental Capacity Act.[909] Assessments should follow the principles in the Act.[909]
If a patient is assessed to lack mental capacity, ensure decisions are made in the best interests of the patient.[908][909]

If the patient is assessed to lack mental capacity, consult with next of kin to make ‘best interests’ decisions.[909]

According to the 2005 Mental Capacity Act in England and Wales, if a patient has no family members or other carers and a decision is not urgent, you should seek an independent mental capacity advocate to perform this role.[910]
Check the appropriate legislation for your territory.

Plus – monitor comorbidities during hospital stay

Consider – antipyretic/analgesic

Treatment recommended for SOME patients in selected patient group

Paracetamol or ibuprofen are recommended.[2][605]

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.[813][814][815][816][817][818][819]
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

Chronic kidney disease and/or heart failure

Avoid non-steroidal anti-inflammatory drugs (NSAIDs) in patients with chronic kidney disease and/or with heart failure (based on expert opinion).

Asthma

NSAIDs can worsen symptoms in some patients with asthma, so check whether your patient has a known sensitivity.[911]

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

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

Plus – monitor comorbidities during hospital stay

Consider – experimental therapies

Plus – monitor comorbidities during hospital stay

Plus – continue the patient's inhalers as prescribed for asthma or COPD if appropriate

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.[912][913][914][915][916]

The overall aim for continuing inhaled corticosteroids is to reduce the risk of an exacerbation of asthma or COPD.[916]
There is no evidence that inhaled corticosteroids are related to COVID-19 infection in people with asthma.[917] There is also no evidence they increase the risks associated with COVID-19 in people with COPD.[915]

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.[912][915][918]
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.[918]

Plus – monitor comorbidities during hospital stay

Plus – ensure plans are in place in case of any asthma exacerbation

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.[913]

Follow established guidelines if asthma worsens, and consider hospital admission. Start oral corticosteroids as indicated for asthma exacerbations.[916][919][920]
Ensure safety netting measures are in place in case the patient does not improve or the situation changes.[919]

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.[913] Advise your patient with known COVID-19 to seek medical advice if there is a deterioration in symptoms.

Plus – monitor comorbidities during hospital stay

Plus – ensure plans are in place in case of any COPD exacerbation

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.[915]

Follow established guidelines on the management of an exacerbation of COPD, including prescription of short-term oral corticosteroids if clinically indicated.[914][916] Seek specialist advice and consider hospital admission.
- The standard recommended length of course for oral corticosteroids if prescribed for exacerbation of COPD is 5 days only.[921][922]
- Advise patients not to start oral corticosteroids and/or antibiotics for symptoms of COVID-19, such as fever, myalgia, and dry cough.[915]
Differentiate from other conditions, such as acute coronary syndrome, acute heart failure, and pneumonia, as well as from complications of COVID-19.
See our topic Acute exacerbation of COPD.

Plus – monitor comorbidities during hospital stay

Plus – weigh up risks versus benefits of prescribed cardiovascular or kidney medication

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.[899]

Despite concern about the possible increased risk of infection or more severe disease in patients prescribed ACE inhibitors or angiotensin-II receptor antagonists, a living systematic review found high-certainty evidence that the use of these drugs is not associated with severe disease.[923][924]
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.[925][926][927][928]

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.[927][928][929] 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 ill (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).

Plus – monitor comorbidities during hospital stay

Plus – advise patients on self-management of their diabetes

Treatment recommended for ALL patients in selected patient group

If your patient with diabetes has mild COVID-19 and you consider them well enough to stay at home:

Advise them to follow sick-day rules from their individual healthcare provider or relevant national or regional professional diabetes organisation[930][931][932][933][934][935][936]
Despite limited evidence for this situation, diabetes self-management during illness with COVID-19 generally still follows the standard sick-day rules.[937]

Advise your patient to seek urgent medical help if they are unable to keep any fluids down and cannot control their blood glucose.

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.

Key general points for all patients with diabetes[932][933]

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, for example:
- Their blood glucose levels remain higher than usual
- They feel ill and are not improving
- They are not sure how to manage their condition themselves.

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, including those with type 2 diabetes (especially if they are taking a sodium-glucose cotransporter-2 (SGLT-2) inhibitor).[938]

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:[933]

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 an SGLT-2 inhibitor (e.g., dapagliflozin, canagliflozin, empagliflozin), most COVID-related consensus statements recommend these should be stopped during acute illness.[939]

Advise your patient to test their blood for ketones even if their blood glucose is not elevated.[938]
Patients on SGLT-2 inhibitors are at risk of euglycaemic ketoacidosis.[940][941] 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.[939] They are at risk of euglycaemic ketoacidosis with SGLT-2 inhibitors and should check for blood ketones even once the medication is stopped.[940][941][942] This may be something the patient is not familiar with doing, so organise this to be done urgently.[942]
- Patients who usually take metformin are also advised, in most COVID-related consensus statements, to stop this medication during acute illness.[939] 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.[942] 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).[943] Other guidance recommends that patients who are on GLP-1 agonists should be monitored closely due to serious adverse effects with dehydration.[944]

Practical tip

Check blood ketones as urinary ketone measurement may be unreliable.

Plus – monitor comorbidities during hospital stay

moderate COVID-19

1st line – consider home isolation or hospital admission

Isolate patients with suspected or confirmed moderate disease (i.e., clinical signs of pneumonia but no signs of severe pneumonia) to contain virus transmission.[2]

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][3]

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

Monitor patients with risk factors closely and consider the most appropriate setting of care, taking into account these risk factors.[899]

The World Health Organization lists the following comorbidities as risk factors for severe disease and death:[899]

Cardiac disease
Diabetes mellitus
Chronic lung disease
Chronic kidney disease
Cerebrovascular disease
Dementia
Mental disorders
Cancer
Immunosuppression
Obesity
Hypertension.

Older people and those with higher levels of frailty are reported to have an increased mortality risk with COVID-19.[899][900]

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.[899]

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]

The US Centers for Disease Control and Prevention (CDC) recommends discontinuing isolation once at least 10 days (not moderately to severely immunocompromised) or up to 20 days (moderately to 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 moderately to severely immunocompromised) or up to 20 days (moderately to severely immunocompromised) have passed since the date of a positive test. Moderately to 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 moderately to severely immunocompromised patients.[822] 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.[812]

Plus – monitor comorbidities during hospital stay

Plus – monitoring

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).[2][3]

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]
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]

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.[901]

CKD is a significant risk factor for acute kidney injury (AKI).[902]
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.
- AKI in patients with COVID-19 may be common (although exact prevalence is uncertain). AKI is associated with increased mortality.[903]
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.[899]

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.[901]

Plus – monitor comorbidities during hospital stay

Plus – symptom management and supportive care

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.[605]

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.[820]

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][605]

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.[903] 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.[945]
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.

Other supportive care measures include:

Advise patients to improve air circulation by opening a window or door[605]
Provide basic mental health and psychosocial support for all patients, and manage any symptoms of insomnia, depression, or anxiety as appropriate[2]
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.[821]

Most children with moderate disease can be managed with supportive care alone.[3]

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.[904]
Consider use of telemedicine to facilitate remote consultations.[899][905][906] Royal College of Psychiatrists: digital - COVID-19 guidance for clinicians external link opens in a new window
Advise your patient on where to find locally relevant information and sources of support, for example:
- Royal College of Psychiatrists: Covid-19 – support for patients and carers external link opens in a new window

Plus – monitor comorbidities during hospital stay

Plus – set an escalation plan

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:[907]
- 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 advance care planning, including legally binding advanced directives.[899][907]

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).[908] Follow the appropriate legislation in your region.
In England and Wales, health professionals must comply with the 2005 Mental Capacity Act.[909] Assessments should follow the principles in the Act.[909]
If a patient is assessed to lack mental capacity, ensure decisions are made in the best interests of the patient.[908][909]

If the patient is assessed to lack mental capacity, consult with next of kin to make ‘best interests’ decisions.[909]

According to the 2005 Mental Capacity Act in England and Wales, if a patient has no family members or other carers and a decision is not urgent, you should seek an independent mental capacity advocate to perform this role.[910]
Check the appropriate legislation for your territory.

Plus – monitor comorbidities during hospital stay

Plus – monitor and manage diabetes

Plus – monitor comorbidities during hospital stay

Consider – antibiotics

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][3][605] 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]
Do not offer an antibiotic for preventing secondary bacterial pneumonia in people with COVID-19.[605]

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.[605]

Plus – monitor comorbidities during hospital stay

Consider – antipyretic/analgesic

Treatment recommended for SOME patients in selected patient group

Paracetamol or ibuprofen are recommended.[2][605]

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.[813][814][815][816][817][818][819]
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

Chronic kidney disease and/or heart failure

Avoid non-steroidal anti-inflammatory drugs (NSAIDs) in patients with chronic kidney disease and/or with heart failure (based on expert opinion).

Asthma

NSAIDs can worsen symptoms in some patients with asthma, so check whether your patient has a known sensitivity.[911]

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

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

Plus – monitor comorbidities during hospital stay

Consider – experimental therapies

Plus – monitor comorbidities during hospital stay

Plus – continue the patient's inhalers as prescribed for asthma or COPD if appropriate

Treatment recommended for ALL patients in selected patient group

The overall aim for continuing inhaled corticosteroids is to reduce the risk of an exacerbation of asthma or COPD.[916]
There is no evidence that inhaled corticosteroids are related to COVID-19 infection in people with asthma.[917] There is also no evidence they increase the risks associated with COVID-19 in people with COPD.[915]

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.[912][915][918]
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.[918]

Plus – monitor comorbidities during hospital stay

Plus – weigh up risks versus benefits of prescribed cardiovascular or kidney medication

Treatment recommended for ALL patients in selected patient group

Despite concern about the possible increased risk of infection or more severe disease in patients prescribed ACE inhibitors or angiotensin-II receptor antagonists, a living systematic review found high-certainty evidence that the use of these drugs is not associated with severe disease.[923][924]
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.[925][926][927][928]

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 ill (based on expert opinion).

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.

Seek advice from the patient’s cardiology or nephrology team if they have complex conditions (e.g., on renal replacement therapy or immunosuppressive therapy).

Plus – monitor comorbidities during hospital stay

– baseline neurological assessment

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).[946][947] This risk is even higher in anyone with a history of stroke.
Compare the baseline assessment 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.[948]

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.[899]

Reported neurological manifestations associated with COVID-19 have included acute ischaemic and haemorrhagic stroke.[899]

– baseline cognitive and delirium assessments with collateral history

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.[949]

Use a validated scoring system that is feasible in the acute setting, such as:[949]
- The abbreviated mental test score/10 (AMTS/10).[950] 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.[951] The World Health Organization recommends that patients with COVID-19 are assessed for delirium using standardised protocols.[899]

People living with dementia are at increased risk of delirium when they are admitted to hospital and throughout their admission.[952][953]
Delirium is not the same as dementia.[954][955] It is a potentially life-threatening acute, fluctuating change in mental functioning, with inattention, disorganised thinking, and altered levels of consciousness.[955]
Use a screening tool to detect probable delirium, such as:
- The 4-AT external link opens in a new window.[953][956][957]
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.[958]

Consider the following actions as part of multicomponent care to reduce the risk of delirium during a hospital admission in people with dementia with any acute condition:[953][959]

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.[953]

Challenges specifically related to COVID-19 include:[959]

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.



More info: Investigations

Initial investigations for a patient with delirium

If a patient has delirium, check for and treat life-threatening causes:[953]

Hypoxia
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.[953]

Check for and treat any reversible causes of delirium.[951] 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.[899][951]

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.[959]
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.[951]
- 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.[903]
The evidence on the efficacy of antipsychotics for delirium is inconclusive, and hospital protocols may vary.[953] Follow your local hospital protocol for choice of medication.
Always start at the lowest dose for antipsychotic drugs and titrate carefully according to symptoms.[899][951] 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.[953] Provide locally available information resources.[959]



Evidence: Risks and safe withdrawal of antipsychotics in older people

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.[960]
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.[961]
Contrary to popular belief, long-term antipsychotic prescriptions can be safely withdrawn in most people with dementia once behaviour has settled.[962]

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.[951][953]

– ensure monitoring is in place to detect any asthma exacerbation during the patient's hospital admission

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.[913]

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.[920][963]
- See our topic Acute exacerbation of asthma in adults.
- Consider whether it may be clinically appropriate to use a metered-dose inhaler delivered via a spacer device as an alternative delivery mechanism to a nebuliser.[911] Follow your local protocols.
Start oral corticosteroids as clinically indicated for asthma exacerbations.[913][916]
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

– ensure monitoring is in place to detect any COPD exacerbation during the patient's hospital admission

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.[964]

Differentiate from other conditions, such as acute coronary syndrome, acute heart failure, and pneumonia, as well as from complications of COVID-19.
Follow established guidelines on the management of an exacerbation of COPD, including prescription of short-term oral corticosteroids if clinically indicated.[914][916] See our topic Acute exacerbation of COPD.
Seek senior or specialist advice.

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.[914][918] Consider using pressurised metered-dose inhalers, dry powder inhalers, or soft mist inhalers for drug delivery instead in non-critically ill patients not receiving ventilatory support.[914] 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.

– monitor and manage blood glucose during the hospital admission

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 ill patient with diabetes mellitus.[965]

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) for medical inpatients, and an acceptable upper level of 12 mmol/L (216 mg/dL).[966] A more liberal blood glucose target is considered appropriate if your patient is at high risk of falls, is frail, or has dementia.[966][967]
- The UK-based National Inpatient Diabetes COVID-19 Response Group makes the same recommendation for patients in hospital with COVID-19.[968]
- 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.[944]
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 (once insulin has been started for persistent hyperglycaemia; not specifically for patients with COVID-19).[965]

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.[939]
- Exclude DKA or HHS, both of which require specific urgent management.
- Consider other conditions associated with hyperglycaemia, such as sepsis.[938]
Be aware that the following medications may be associated with hyperglycaemia and may need to be reviewed:[969]
- 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.[968][970]
- Be aware that patients with type 2 diabetes in ICU may have significant degrees of insulin resistance.[968]

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.

Approximately 1 in 5 inpatients with diabetes in England and Wales have a hypoglycaemic episode during their hospital stay.[971]

Causes of hypoglycaemia include:[972]

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[968]
Accidental interruptions to patient feeding, which may occur especially when patients with COVID-19 are nursed in the prone position[968]
Reducing doses of corticosteroids, particularly dexamethasone in patients with COVID-19[968]
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. 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.[971]

Treat hypoglycaemia actively if the blood glucose falls below 4 mmol/L (72 mg/dL).[972] Follow hospital protocol. The JBDS-IP guidelines recommend that you:[972]

Retest blood glucose at 10 to 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.[939]

– check the patient’s feet

– mental state examination

– review current treatment for depression

Treatment recommended for ALL patients in selected patient group

Ask the patient which medications they are taking for their depression. Alternatively, review their primary care records for relevant information (if available).

Drug-drug interactions and their associated adverse effects of particular relevance to patients with COVID-19 include sedation, cardiotoxicity (QT prolongation), and respiratory depression.[899]

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.[977]
The severity of symptoms of discontinuation may vary, but it may be unpleasant and may complicate the management of the acute medical condition.[978]

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.[977][979] Consider this issue for all medications prescribed in patients with COVID-19 as well as any experimental therapies (see the Emerging section).

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.[980][981][982][983] 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.[979]

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.[984][985]
- 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.

– consider referral to liaison psychiatry team

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.[986][987]

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.[899]



Evidence: Depression and adherence to treatment

Comorbid depression is linked to poor adherence with recommended physical health treatments, from medication to rehabilitation.[988]

This may lead to worse clinical outcomes, including longer hospital stays.[978][989][990]
Most importantly, depression is linked with excess mortality.[991]

– manage nicotine dependence in current smokers

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.[992]

Nicotine replacement therapy prevents rapid withdrawal during admission, which can be distressing and uncomfortable.

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.
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.
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.[980] Seek advice on whether any adjustment to the dose of psychotropic medication is appropriate.

The evidence suggests there is an increased risk for severe COVID-19 associated with tobacco smoking.

In light of this, in addition to the well-recognised harms, the World Health Organization recommends smoking cessation using evidence-based methods.[250]

severe COVID-19

1st line – hospital admission

Admit patients with suspected or confirmed severe disease to an appropriate healthcare facility under the guidance of a specialist team as these patients are at risk of rapid clinical deterioration.

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]
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] 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.[884]
Implement local infection prevention and control procedures when managing patients with COVID-19.

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.[605]
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).[823] 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.[825]

Be aware of any comorbidity-associated risk of clinical deterioration and severe disease

Monitor patients with risk factors closely and consider the most appropriate setting of care, taking into account these risk factors.[899]

The World Health Organization lists the following comorbidities as risk factors for severe disease and death:[899]

Cardiac disease
Diabetes mellitus
Chronic lung disease
Chronic kidney disease
Cerebrovascular disease
Dementia
Mental disorders
Cancer
Immunosuppression
Obesity
Hypertension.

Older people and those with higher levels of frailty are reported to have an increased mortality risk with COVID-19.[899][900]

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.[899]

Baseline neurological assessment

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).[946][947] This risk is even higher in anyone with a history of stroke.
Compare the baseline assessment 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.[948]

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.[899]

Reported neurological manifestations associated with COVID-19 have included acute ischaemic and haemorrhagic stroke.[899]

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. Moderately to 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 moderately to severely immunocompromised patients.[822]
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.[812]

Plus – monitor comorbidities during hospital stay

Plus – set an escalation plan

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:[907]
- 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 advance care planning, including legally binding advanced directives.[899][907]

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).[908] Follow the appropriate legislation in your region.
In England and Wales, health professionals must comply with the 2005 Mental Capacity Act.[909] Assessments should follow the principles in the Act.[909]
If a patient is assessed to lack mental capacity, ensure decisions are made in the best interests of the patient.[908][909]

If the patient is assessed to lack mental capacity, consult with next of kin to make ‘best interests’ decisions.[909]

According to the 2005 Mental Capacity Act in England and Wales, if a patient has no family members or other carers and a decision is not urgent, you should seek an independent mental capacity advocate to perform this role.[910]
Check the appropriate legislation for your territory.

Plus – monitor comorbidities during hospital stay

Plus – consider oxygen therapy

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][3]

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]
Some guidelines recommend that SpO₂ should be maintained no higher than 96%.[827]
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.[828]

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][3]
Awake prone positioning of non-intubated patients was associated with improvement in oxygen variables (PaO₂/FiO₂, PaO₂, and SpO₂), respiratory rate, and mortality, but no significant difference was noted in the rate of intubation. However, evidence is limited.[829][830]

Monitor patients closely for signs of progressive acute hypoxaemic respiratory failure.[2][3]

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).[993]

Measure resting oxygen saturation in all patients with asthma with any acute illness.[993] 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.[920][963]

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.[920] Intensive care support is needed immediately.[920]

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)[993]
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.[914] 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.[993]
Re-check ABG after 30 to 60 minutes in all patients.[993]

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.[994]

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.[993][995][996] 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.[993]

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):[993]

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.[993][995][996] This target saturation level may be lower depending on local hospital oxygen supplies (follow your local protocol)
Measure ABG as soon as possible[993]
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.[993]

Plus – monitor comorbidities during hospital stay

Plus – symptom management and supportive care

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]
Correct any electrolyte or metabolic abnormalities, such as hyperglycaemia or metabolic acidosis, according to local protocols.[831]

Assess fluid status and manage fluid balance particularly closely

Be aware that hypovolaemia may be difficult to assess in a person with heart failure and/or chronic kidney disease (CKD).[997]

Assess:[997]

Pulse
Blood pressure
Peripheral perfusion
Capillary refill
Jugular venous pressure
For postural hypotension
For 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).

Patients with CKD

A patient with CKD who is hypotensive, particularly if in shock, needs immediate fluid resuscitation (based on expert opinion).

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.

Patients with heart failure

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.[605]
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.[820]

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.[605]

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][605]
Low doses of haloperidol (or another suitable antipsychotic) can be considered for agitation.[2]
Non-pharmacological interventions are the mainstay for the management of delirium when possible, and prevention is key.[832]

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.[949]

Use a validated scoring system that is feasible in the acute setting, such as:[949]
- The abbreviated mental test score/10 (AMTS/10).[998] 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.

People living with dementia are at increased risk of delirium when they are admitted to hospital and throughout their admission.[952][953]
Delirium is not the same as dementia.[954] It is a potentially life-threatening acute, fluctuating change in mental functioning, with inattention, disorganised thinking, and altered levels of consciousness.[955]
Use a screening tool to detect probable delirium, such as:
- The 4-AT external link opens in a new window.[953][956][957]
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.[958]

Consider the following actions as part of multicomponent care to reduce the risk of delirium during a hospital admission in people with dementia with any acute condition:[953][959]

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.[953]

Challenges specifically related to COVID-19 include:[959]

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.



More info: Investigations

Initial investigations for a patient with delirium

If a patient has delirium, check for and treat life-threatening causes:[953]

Hypoxia
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.[953]

Check for and treat any reversible causes of delirium.[951] 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.[899][951]

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.

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.[959]
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.[951]
- 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.[903]
The evidence on the efficacy of antipsychotics for delirium is inconclusive, and hospital protocols may vary.[899][953] Follow your local hospital protocol for choice of medication.
Always start at the lowest dose for antipsychotic drugs and titrate carefully according to symptoms.[951] Only ever use oral or intramuscular medication (never intravenous) for this purpose (based on expert opinion).



Evidence: Risks and safe withdrawal of antipsychotics in older people

Antipsychotics are associated with increased mortality 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.[960]
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.[961]
Contrary to popular belief, long-term antipsychotic prescriptions can be safely withdrawn in most people with dementia once behaviour has settled.[962]

Document the diagnosis of delirium clearly.[951][953]

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.[833]

Mental health symptoms

Provide basic mental health and psychosocial support for all patients, and manage any symptoms of insomnia or depression as appropriate.[2]

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.[975]
- 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).
Depression has been reported to be a common finding in people hospitalised with COVID-19.[899]
Consider other factors that may be influencing the patient’s mental state (e.g., the effect of any illicit drug use or alcohol).[976]

Plus – monitor comorbidities during hospital stay

Plus – check blood glucose on admission and review diabetes medication (NEVER stop insulin in a person with type 1 diabetes)

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.[944][999]

Insulin deficiency (e.g., due to delayed or missed doses) will rapidly cause ketoacidosis.[999]

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:[938][944]

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:[938]

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:[938]

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.[1000]

Practical tip

In euglycaemic ketoacidosis, the glucose level may not be significantly elevated.

The diagnosis of HHS is highly likely in the presence of:[938]

Blood glucose ≥30 mmol/L (≥541 mg/dL) 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.[1000]

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:[938]

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).[1001]
- They can mask underlying ketoacidosis as the patient may have a normal (or near normal) serum glucose level (euglycaemic ketoacidosis).[1001]
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 restarting metformin depending on results of the patient’s blood lactate, kidney function, and arterial blood gases, as there is some evidence metformin may protect against progression to severe COVID-19.[938]

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.

Plus – monitor comorbidities during hospital stay

Plus – venous thromboembolism prophylaxis

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.[605]

Start venous thromboembolism (VTE) prophylaxis in acutely ill hospitalised adults and adolescents, provided there are no contraindications.[2][3][834][835]

The UK National Institute for Health and Care Excellence (NICE) recommends starting as soon as possible (within 14 hours of admission), in young people and adults who need low-flow oxygen and who do not have an increased bleeding risk, and continuing for a minimum of 7 days including after discharge.[605]
For hospitalised children, indications for VTE prophylaxis should be the same as those for children without COVID-19.[3]

Low molecular weight heparin, unfractionated heparin, or fondaparinux are the recommended options for standard thromboprophylaxis.[2]

NICE recommends low molecular weight heparin first-line, with fondaparinux or unfractionated heparin reserved for patients who cannot have low molecular weight heparin.[605]
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.[835][837]

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 across most guidelines.[839] 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]
NICE recommends a prophylactic dose of a low molecular weight heparin for a minimum of 7 days (including after discharge) in young people and adults who need low-flow oxygen and who do not have an increased bleeding risk. A treatment dose of a low molecular weight heparin for 14 days or until discharge (whichever is sooner) may be considered in young people and adults who need low-flow oxygen and who do not have an increased bleeding risk; however, this is a conditional recommendation only. The decision should be carefully considered, and choice of the most appropriate dose regimen should be guided by bleeding risk, clinical judgement, and local protocols. For those who do not need supplemental oxygen, follow standard VTE prophylaxis guidelines.[605]
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]
Dose adjustments may be required in patients with extremes of body weight or renal impairment.[605]
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.[605]

Monitor patients for signs and symptoms suggestive of thromboembolism and proceed with appropriate diagnostic and management pathways if clinically suspected.[2]

If the patient’s clinical condition changes, assess the risk of VTE, reassess the bleeding risk, and review VTE prophylaxis.[605]

Continue until hospital discharge.[2]

Routine post-discharge VTE prophylaxis is not generally recommended, except in certain high-risk patients.[3][834][835]
Ensure patients who require VTE prophylaxis after discharge are able to use it correctly or have arrangements made for someone to help them.[605]

There is currently insufficient evidence to determine the risks and benefits of prophylactic anticoagulation in hospitalised patients with COVID-19.[843]

A systematic review and meta-analysis found that the pooled odds of mortality between anticoagulated and non-anticoagulated hospitalised patients were similar, but lower in the standard prophylactic-dose group. Prophylactic-dose anticoagulation significantly decreased the odds of in-hospital death by 17% compared with no anticoagulation. Mortality increased in the intermediate- to therapeutic-dose group with an increased risk of major bleeding.[844]
Clinicians should rely on pre-COVID-19 evidence-based principles of anticoagulation management combined with rational approaches to address clinical challenges.[834]

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.[1002]

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

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

heparin: consult specialist for guidance on dose

heparin open_in_new: consult specialist for guidance on dose

heparin: consult specialist for guidance on dose

Plus – monitor comorbidities during hospital stay

Plus – monitoring

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]

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.[901]

CKD is a significant risk factor for acute kidney injury (AKI).[902]
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.
- AKI in patients with COVID-19 may be common (although exact prevalence is uncertain). AKI is associated with increased mortality.[903]
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.[899]

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.[901]

Continue to monitor fluid balance particularly closely

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.[945]
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.

Plus – monitor comorbidities during hospital stay

Consider – antibiotics

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][3][605]
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.[605]
There is insufficient evidence to recommend empirical broad-spectrum antibiotics in the absence of another indication.[3]

Seek specialist advice.

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.[605]
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.[605]

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]

Plus – monitor comorbidities during hospital stay

Consider – corticosteroid

Treatment recommended for SOME patients in selected patient group

Recommendations and evidence for the use of corticosteroids in hospitalised patients with COVID-19 [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].

Consider a systemic corticosteroid. Guideline recommendations vary.

The World Health Organization strongly recommends systemic corticosteroid therapy (low-dose intravenous or oral dexamethasone or hydrocortisone) for 7 to 10 days in adults with severe disease. 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 disease. 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.[797][798][799][846][847]
BMJ rapid recommendations: a living WHO guideline on drugs for COVID-19 external link opens in a new window
In the UK, the National Institute for Health and Care Excellence recommends offering dexamethasone (or an alternative such as hydrocortisone or prednisolone when dexamethasone cannot be used or is unavailable) to people who need supplemental oxygen to meet their prescribed oxygen saturation levels, or who have a level of hypoxia that needs supplemental oxygen but who are unable to have or tolerate it. Treatment is for up to 10 days unless there is a clear indication to stop early.[605]
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 adults who require supplemental oxygen. Alternative corticosteroids may be used in situations where dexamethasone is not available. It is not routinely recommended for paediatric patients who require only low levels of oxygen support (i.e., via a nasal cannula only). Use of dexamethasone for the treatment of severe disease in children who are profoundly immunocompromised has not been evaluated, may be harmful, and therefore should be considered only on a case-by-case basis.[3]
The Infectious Diseases Society of America supports the use of dexamethasone in hospitalised patients with severe disease.[848]

Monitor patients for adverse effects (e.g., hyperglycaemia, secondary infections, psychiatric effects, reactivation of latent infections) and assess for drug-drug interactions.[3]

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.[1003]

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.[1004]
COVID-19 is also associated with increased insulin resistance as well as reduced insulin secretion from the pancreatic beta cells.[1003]
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.[1003]
- The recommended protocol by the UK-based National Inpatient Diabetes COVID-19 Response Group for the ward setting uses subcutaneous insulin.[1003][1005]
- The group highlights that sulfonylureas are not recommended in this scenario due to potential impairment of beta cell function and likely severe insulin resistance.[1003]

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 may increase the risk of recurrence in subsequent treatments.[1006]

Monitor for psychiatric adverse effects.[1007]

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.[1008]
Effects seem to be dose-related and are more common with long-term regimens or long-acting formulations, and in older patients.[1006] This also stands true for patients who have neuropsychiatric adverse effects related to discontinuing long-term corticosteroid therapy.[1009]

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.[1009] 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: children: consult specialist for guidance on dose; adults: 6 mg orally/intravenously once daily for 7-10 days

dexamethasone open_in_new: children: consult specialist for guidance on dose; adults: 6 mg orally/intravenously once daily for 7-10 days

dexamethasone: children: consult specialist for guidance on dose; adults: 6 mg orally/intravenously once daily for 7-10 days

hydrocortisone: children: consult specialist for guidance on dose; adults: 50 mg orally/intravenously every 8 hours for 7-10 days

hydrocortisone open_in_new: children: consult specialist for guidance on dose; adults: 50 mg orally/intravenously every 8 hours for 7-10 days

hydrocortisone: children: consult specialist for guidance on dose; adults: 50 mg orally/intravenously every 8 hours for 7-10 days

Secondary options

prednisolone: children: consult specialist for guidance on dose; adults: 40 mg/day orally given in 1-2 divided doses for 7-10 days

prednisolone open_in_new: children: consult specialist for guidance on dose; adults: 40 mg/day orally given in 1-2 divided doses for 7-10 days

prednisolone: children: consult specialist for guidance on dose; adults: 40 mg/day orally given in 1-2 divided doses for 7-10 days

methylprednisolone: children: consult specialist for guidance on dose; adults: 32 mg/day orally/intravenously given in 1-2 divided doses for 7-10 days

methylprednisolone open_in_new: children: consult specialist for guidance on dose; adults: 32 mg/day orally/intravenously given in 1-2 divided doses for 7-10 days

methylprednisolone: children: consult specialist for guidance on dose; adults: 32 mg/day orally/intravenously given in 1-2 divided doses for 7-10 days

Plus – monitor comorbidities during hospital stay

Consider – interleukin-6 (IL-6) inhibitor

Treatment recommended for SOME patients in selected patient group

Recommendations and evidence for the use of IL-6 inhibitors in hospitalised patients with COVID-19 [Figure caption and citation for the preceding image starts]: Recommendations and evidence for the use of IL-6 inhibitors in hospitalised patients with COVID-19BMJ. 2020;370:m3379 [Citation ends].

Consider an IL-6 inhibitor. Guideline recommendations vary.

The World Health Organization strongly recommends an IL-6 inhibitor (tocilizumab or sarilumab), in combination with a systemic corticosteroid and initiated at the same time, in patients with severe disease. This recommendation is based on high-certainty evidence that shows IL-6 inhibitors reduce mortality and the need for mechanical ventilation, and low-certainty evidence that suggests that IL-6 inhibitors may also reduce the duration of mechanical ventilation and hospitalisation. The evidence regarding the risk of severe adverse events is uncertain. The applicability of this recommendation to children is currently uncertain.[797][798][799] This recommendation is based on data from the UK RECOVERY and REMAP-CAP trials.[849][850]
BMJ rapid recommendations: a living WHO guideline on drugs for COVID-19 external link opens in a new window
In the UK, the National Institute for Health and Care Excellence recommends a single dose of tocilizumab in hospitalised adults if all of the following conditions apply: they are having or have completed a course of corticosteroids such as dexamethasone (unless they cannot have corticosteroids); they have not had another IL-6 inhibitor during this admission; there is no evidence of a bacterial or viral infection (other than SARS-CoV-2) that might be worsened by tocilizumab; AND they either need supplemental oxygen and have a C-reactive protein level of ≥75 mg/L, OR they are within 48 hours of starting high-flow nasal oxygen, continuous positive airway pressure, non-invasive ventilation, or invasive mechanical ventilation. Consider tocilizumab for children and young people who have severe disease or paediatric inflammatory multisystem syndrome only if they are aged 1 year and over, and only in the context of a clinical trial. Sarilumab may be considered an alternative option in adults only if tocilizumab cannot be used or is unavailable (use the same eligibility criteria as those for tocilizumab).[605] Tocilizumab has not been granted a conditional marketing authorisation for this indication in the UK as yet.
In the US, the Infectious Diseases Society of America recommends considering tocilizumab in hospitalised adults with progressive severe disease who have elevated markers of systemic inflammation, in addition to standard of care (i.e., corticosteroids), rather than standard of care alone.[848] Tocilizumab has been granted an emergency-use authorisation in the US for the treatment of hospitalised adults and paediatric patients 2 years of age and older who are receiving systemic corticosteroids and require supplemental oxygen.[851]

Patients on IL-6 inhibitors are at increased risk of infection including active tuberculosis, invasive fungal infections, and opportunistic pathogens.

Routine blood work including neutrophil count, platelets, transaminases, and total bilirubin should be checked prior to initiation of therapy. All patients should be monitored for signs and symptoms of infection given the increased risk of immunosuppression in addition to systemic corticosteroids.[797]
These drugs should be avoided in patients who are significantly immunocompromised.[3]

Primary options

tocilizumab: children: consult specialist for guidance on dose; adults: 8 mg/kg intravenously as a single dose, maximum 800 mg/dose

tocilizumab open_in_new: children: consult specialist for guidance on dose; adults: 8 mg/kg intravenously as a single dose, maximum 800 mg/dose

tocilizumab: children: consult specialist for guidance on dose; adults: 8 mg/kg intravenously as a single dose, maximum 800 mg/dose

sarilumab: children: consult specialist for guidance on dose; adults: 400 mg intravenously as a single dose

sarilumab open_in_new: children: consult specialist for guidance on dose; adults: 400 mg intravenously as a single dose

sarilumab: children: consult specialist for guidance on dose; adults: 400 mg intravenously as a single dose

Plus – monitor comorbidities during hospital stay

Consider – treatment of co-infections

Plus – monitor comorbidities during hospital stay

Consider – antipyretic/analgesic

Treatment recommended for SOME patients in selected patient group

Paracetamol or ibuprofen are recommended.[2][605]

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.[813][814][815][816][817][818][819]
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

Chronic kidney disease and/or heart failure

Avoid non-steroidal anti-inflammatory drugs (NSAIDs) in patients with chronic kidney disease and/or with heart failure (based on expert opinion).

Asthma

NSAIDs can worsen symptoms in some patients with asthma, so check whether your patient has a known sensitivity.[911]

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

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

Plus – monitor comorbidities during hospital stay

Plus – continue the patient's inhalers as prescribed for asthma or COPD if appropriate

Treatment recommended for ALL patients in selected patient group

The overall aim for continuing inhaled corticosteroids is to reduce the risk of an exacerbation of asthma or COPD.[916]
There is no evidence that inhaled corticosteroids are related to COVID-19 infection in people with asthma.[917] There is also no evidence they increase the risks associated with COVID-19 in people with COPD.[915]

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.[912][915][918]
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.[918]

Plus – monitor comorbidities during hospital stay

Plus – weigh up risks versus benefits of prescribed cardiovascular or kidney medication

Treatment recommended for ALL patients in selected patient group

Despite concern about the possible increased risk of infection or more severe disease in patients prescribed ACE inhibitors or angiotensin-II receptor antagonists, a living systematic review found high-certainty evidence that the use of these drugs is not associated with severe disease.[923][924]
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.[925][926][927][928]

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 ill (based on expert opinion).

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.

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

Practical tip

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.[920][963]
- See our topic Acute exacerbation of asthma in adults.
- Consider whether it may be clinically appropriate to use a metered-dose inhaler delivered via a spacer device as an alternative delivery mechanism to a nebuliser.[911] Follow your local protocols.
Start oral corticosteroids as clinically indicated for asthma exacerbations.[913][916]
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

– ensure monitoring is in place to detect any COPD exacerbation during the patient's hospital admission

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.[964]

Differentiate from other conditions, such as acute coronary syndrome, acute heart failure, and pneumonia, as well as from complications of COVID-19.
Follow established guidelines on the management of an exacerbation of COPD, including prescription of short-term oral corticosteroids if clinically indicated.[914][916] See our topic Acute exacerbation of COPD.
Seek senior or specialist advice.

Practical tip

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).

Ensure to re-prescribe the LAMA once the nebuliser treatment has been stopped.

– monitor and manage blood glucose during the hospital admission

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 ill patient with diabetes mellitus.[965]

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) for medical inpatients, and an acceptable upper level of 12 mmol/L (216 mg/dL).[966] A more liberal blood glucose target is considered appropriate if your patient is at high risk of falls, is frail, or has dementia.[966][967]
- The UK-based National Inpatient Diabetes COVID-19 Response Group makes the same recommendation for patients in hospital with COVID-19.[968]
- 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.[944]
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 (once insulin has been started for persistent hyperglycaemia; not specifically for patients with COVID-19).[965]

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.[939]
- Exclude DKA or HHS, both of which require specific urgent management.
- Consider other conditions associated with hyperglycaemia, such as sepsis.[938]
Be aware that the following medications may be associated with hyperglycaemia and may need to be reviewed:[969]
- 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.[968][970]
- Be aware that patients with type 2 diabetes in ICU may have significant degrees of insulin resistance.[968]

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.

Approximately 1 in 5 inpatients with diabetes in England and Wales have a hypoglycaemic episode during their hospital stay.[971]

Causes of hypoglycaemia include:[972]

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[968]
Accidental interruptions to patient feeding, which may occur especially when patients with COVID-19 are nursed in the prone position[968]
Reducing doses of corticosteroids, particularly dexamethasone in patients with COVID-19[968]
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.

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.[971]

Treat hypoglycaemia actively if the blood glucose falls below 4 mmol/L (72 mg/dL).[972] Follow hospital protocol. The JBDS-IP guidelines recommend that you:[972]

Retest blood glucose at 10 to 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.[939]

– check the patient’s feet

– review current treatment for depression

Treatment recommended for ALL patients in selected patient group

Ask the patient which medications they are taking for their depression. Alternatively, review their primary care records for relevant information (if available).

Drug-drug interactions and their associated adverse effects of particular relevance to patients with COVID-19 include sedation, cardiotoxicity (QT prolongation), and respiratory depression.[899]

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.[977]
The severity of symptoms of discontinuation may vary, but it may be unpleasant and may complicate the management of the acute medical condition.[978]

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.[977][979] Consider this issue for all medications prescribed in patients with COVID-19 as well as any experimental therapies (see the Emerging section).

Practical tip

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.[979]

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.[984][985]
- 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.

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.

– consider referral to liaison psychiatry team

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.[986][987]

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.[899]



Evidence: Depression and adherence to treatment

Comorbid depression is linked to poor adherence with recommended physical health treatments, from medication to rehabilitation.[988]

This may lead to worse clinical outcomes, including longer hospital stays.[978][989][990]
Most importantly, depression is linked with excess mortality.[991]

– manage nicotine dependence in current smokers

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.[992]

Nicotine replacement therapy prevents rapid withdrawal during admission, which can be distressing and uncomfortable.

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.
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.
Consult your local drug formulary and hospital guidance for more comprehensive details.

Practical tip

The evidence suggests there is an increased risk for severe COVID-19 associated with tobacco smoking.

In light of this, in addition to the well-recognised harms, the World Health Organization recommends smoking cessation using evidence-based methods.[250]

critical COVID-19

1st line – intensive/critical care unit admission

Admit or transfer patients with critical disease (i.e., presence of acute respiratory distress syndrome, sepsis, or septic shock) to an intensive/critical care unit under the guidance of a specialist team.[2]

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.[605]
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] 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.[884]

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.

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[1010]
The patient has a blood pressure ≥40 mmHg lower than baseline, has developed orthostatic hypotension, or has postural symptoms (based on expert opinion)
- Orthostatic hypotension is 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.[1011]

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).

Restart one at a time at a lower dose and ask the patient's general practitioner to titrate back to normal dose.
- Most patients won’t tolerate restarting all medications at the original doses in one go.
- 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.

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:[907]
- 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 advance care planning, including legally binding advanced directives.[899][907]

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).[908] Follow the appropriate legislation in your region.
In England and Wales, health professionals must comply with the 2005 Mental Capacity Act.[909] Assessments should follow the principles in the Act.[909]
If a patient is assessed to lack mental capacity, ensure decisions are made in the best interests of the patient.[908][909]

If the patient is assessed to lack mental capacity, consult with next of kin to make ‘best interests’ decisions.[909]

According to the 2005 Mental Capacity Act in England and Wales, if a patient has no family members or other carers and a decision is not urgent, you should seek an independent mental capacity advocate to perform this role.[910]
Check the appropriate legislation for your territory.

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. Moderately to 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 moderately to severely immunocompromised patients.[822]
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.[812]

Plus – monitor comorbidities during hospital stay

Plus – symptom management and supportive care

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]

Implement standard interventions to prevent complications associated with critical illness.[2]

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.[901]

CKD is a significant risk factor for acute kidney injury (AKI).[902]
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.
- AKI in patients with COVID-19 may be common (although exact prevalence is uncertain). AKI is associated with increased mortality.[903]
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.[899]

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.[901]

Assess fluid status and manage fluid balance particularly closely

Be aware that hypovolaemia may be difficult to assess in a person with heart failure and/or chronic kidney disease (CKD).[997]

Assess:[997]

Pulse
Blood pressure
Peripheral perfusion
Capillary refill
Jugular venous pressure
For postural hypotension
For 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).

Patients with CKD

A patient with CKD who is hypotensive, particularly if in shock, needs immediate fluid resuscitation (based on expert opinion).

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.

Patients with heart failure

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

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.[945]
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

Chronic kidney disease and/or heart failure

Avoid non-steroidal anti-inflammatory drugs (NSAIDs) in patients with chronic kidney disease and/or with heart failure (based on expert opinion).

Asthma

NSAIDs can worsen symptoms in some patients with asthma, so check whether your patient has a known sensitivity.[911]

Baseline cognitive and delirium assessments with collateral history

Use a validated scoring system that is feasible in the acute setting, such as:[949]
- The abbreviated mental test score/10 (AMTS/10).[998] 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.

People living with dementia are at increased risk of delirium when they are admitted to hospital and throughout their admission.[952][953]
Delirium is not the same as dementia.[954] It is a potentially life-threatening acute, fluctuating change in mental functioning, with inattention, disorganised thinking, and altered levels of consciousness.[955]
Use a screening tool to detect probable delirium, such as:
- The 4-AT external link opens in a new window.[953][956][957]
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.[958]

Consider the following actions as part of multicomponent care to reduce the risk of delirium during a hospital admission in people with dementia with any acute condition:[953][959]

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.[953]

Challenges specifically related to COVID-19 include:[959]

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.



More info: Investigations

Initial investigations for a patient with delirium

If a patient has delirium, check for and treat life-threatening causes:[953]

Hypoxia
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.[953]

Check for and treat any reversible causes of delirium.[951] 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.[899][951]

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.

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.[959]
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.[951]
- 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.[903]
The evidence on the efficacy of antipsychotics for delirium is inconclusive, and hospital protocols may vary.[899][953] Follow your local hospital protocol for choice of medication.
Always start at the lowest dose for antipsychotic drugs and titrate carefully according to symptoms.[951] Only ever use oral or intramuscular medication (never intravenous) for this purpose (based on expert opinion).



Evidence: Risks and safe withdrawal of antipsychotics in older people

Antipsychotics are associated with increased mortality 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.[960]
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.[961]
Contrary to popular belief, long-term antipsychotic prescriptions can be safely withdrawn in most people with dementia once behaviour has settled.[962]

Document the diagnosis of delirium clearly.[951][953]

Baseline neurological assessment

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).[946][947] This risk is even higher in anyone with a history of stroke.
Compare the baseline assessment 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.[948]

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.[899]

Reported neurological manifestations associated with COVID-19 have included acute ischaemic and haemorrhagic stroke.[899]

Plus – monitor comorbidities during hospital stay

Plus – check blood glucose on admission and review diabetes medication (NEVER stop insulin in a person with type 1 diabetes)

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.

Insulin deficiency (e.g., due to delayed or missed doses) will rapidly cause ketoacidosis.[999]

Be aware that COVID-19 appears to increase the risk of potentially life-threatening emergencies including:[938][944]

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:[938]

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:[938]

Blood ketone level is ≥3 mmol/L (≥54 mg/dL) and
Blood pH <7.3 or bicarbonate <15 mmol/L (<270 mg/dL).

Practical tip

In euglycaemic ketoacidosis, the glucose level may not be significantly elevated.

The diagnosis of HHS is highly likely in the presence of:[938]

Blood glucose ≥30 mmol/L (≥541 mg/dL) 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.[1000]

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:[938]

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).[1001]
- They can mask underlying ketoacidosis as the patient may have a normal (or near normal) serum glucose level (euglycaemic ketoacidosis).[1001]
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 restarting metformin depending on results of the patient’s blood lactate, kidney function, and arterial blood gases, as there is some evidence metformin may protect against progression to severe COVID-19.[938]

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.

Plus – monitor comorbidities during hospital stay

Plus – venous thromboembolism prophylaxis

Treatment recommended for ALL patients in selected patient group

Start venous thromboembolism (VTE) prophylaxis in acutely ill hospitalised adults and adolescents, provided there are no contraindications.[2][3][834][835]

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.[835]
The UK National Institute for Health and Care Excellence (NICE) recommends a prophylactic dose of a low molecular weight heparin to young people and adults who need high-flow nasal oxygen, continuous positive airway pressure, non-invasive ventilation, or invasive mechanical ventilation, and who do not have an increased bleeding risk. An intermediate or treatment dose of a low molecular weight heparin is only recommended in these patients as part of a clinical trial.[605]
Some guidelines recommend that escalated doses can be considered in critically ill patients.[834][616]
Dose adjustments may be required in patients with extremes of body weight or renal impairment.[605]

Evidence is limited in patients with critical disease.

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.[882]
An open-label, multiplatform randomised controlled trial found that an initial strategy of therapeutic-dose heparin did not result in a greater probability of survival to hospital discharge or a greater number of organ support-free days in critically ill patients compared with usual-care thromboprophylaxis.[842]

See Severe COVID-19 above for more detailed information on VTE prophylaxis.

Anticoagulation in patients with chronic kidney disease

Patients with impairment of kidney function may have an increased risk of bleeding with certain anticoagulants and careful patient monitoring is needed.[1002]

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

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

fondaparinux: consult specialist for guidance on dose

fondaparinux open_in_new: consult specialist for guidance on dose

fondaparinux: consult specialist for guidance on dose

Plus – monitor comorbidities during hospital stay

Plus – consider high-flow nasal oxygen or non-invasive ventilation

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.[2]

In the UK, the National Institute for Health and Care Excellence recommends CPAP in patients with hypoxaemia that is not responding to supplemental oxygen with a fraction of inspired oxygen of ≥0.4 (40%), and escalation to invasive mechanical ventilation would be an option but it is not immediately needed or it is agreed that respiratory support should not be escalated beyond CPAP. Ensure there is access to critical care providers for advice, regular review, and prompt escalation of treatment if needed, and regular assessment and management of symptoms alongside non-invasive respiratory support. Consider using HFNO for people having CPAP when they need a break from CPAP (e.g., mealtimes), need humidified oxygen, or need weaning from CPAP. Do not routinely offer HFNO as the main form of respiratory support for people with respiratory failure in whom escalation to invasive mechanical ventilation would be appropriate.[605]
In the US, the National Institutes of Health guidelines panel recommends HFNO over non-invasive ventilation in patients with acute hypoxaemic respiratory failure despite conventional oxygen therapy. The panel recommends a closely monitored trial of non-invasive ventilation if HFNO is not available.[3]
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]
Airborne precautions are recommended for these interventions (including bubble CPAP) due to uncertainty about the potential for aerosolisation.[2] Despite the trend to avoid HFNO, it has been shown to have a similar risk of aerosol generation to standard oxygen masks.[864]

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]

A trial of awake prone positioning is recommended in patients with persistent hypoxaemia despite increasing supplemental oxygen requirements in whom endotracheal intubation is not otherwise indicated.[3]
Ensure that pharmacological and non-pharmacological management strategies, including body positioning, are optimised before escalating treatment to non-invasive respiratory support.[605]
Awake prone positioning of non-intubated patients was associated with improvement in oxygen variables (PaO₂/FiO₂, PaO₂, and SpO₂), respiratory rate, and mortality, but no significant difference was noted in the rate of intubation. However, evidence is limited.[829][830]

Monitor patients closely for acute deterioration.

If patients do not improve after a short trial of these interventions, they require urgent endotracheal intubation.[2][827]

Evidence is limited.

Indirect and low-certainty evidence suggests that non-invasive ventilation probably reduces mortality in patients with COVID-19, similar to mechanical ventilation, but may increase the risk of viral transmission.[857][858]
The RECOVERY-RS trial (an open-label, multicentre, adaptive randomised controlled trial) found that CPAP reduced the need for invasive mechanical ventilation in adults admitted to hospital with acute respiratory failure. Neither CPAP nor HFNO reduced mortality when compared with conventional oxygen therapy. This preprint study has not been published as yet.[859]

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).[993]

Measure resting oxygen saturation in all patients with asthma with any acute illness.[993] This is routine practice in patients with COVID-19.

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.[920] Intensive care support is needed immediately.[920]

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)[993]
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

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.[993]
Re-check ABG after 30 to 60 minutes in all patients.[993]

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.[993][995][996] 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.[993]

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.[993][995][996] This target saturation level may be lower depending on local hospital oxygen supplies (follow your local protocol)
Measure ABG as soon as possible[993]
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.[993]

Plus – monitor comorbidities during hospital stay

Plus – consider invasive mechanical ventilation

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][3]

Endotracheal intubation should be performed by an experienced provider using airborne precautions.[2]
Intubation by video laryngoscopy is recommended if possible.[3]
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]

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][3][827] NHS England recommends a low PEEP strategy in patients with normal compliance where recruitment may not be required.[866]
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.[867][868][869][870][871][872] However, this approach has been criticised.[873][874] 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.[875] 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.[867] PEEP should always be carefully titrated.[876]

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][3][827]
Longer durations may be feasible in some patients.[877]
Lung recruitment manoeuvres are suggested, but staircase recruitment manoeuvres are not recommended.[3][827]

Plus – monitor comorbidities during hospital stay

Consider – inhaled pulmonary vasodilator

Plus – monitor comorbidities during hospital stay

Consider – extracorporeal membrane oxygenation

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][827][878]

ECMO is not suitable for all patients, and only those who meet certain inclusion criteria may be considered for ECMO.[879]

There is insufficient evidence to recommend either for or against the routine use of ECMO.[3]

A systematic review and meta-analysis found that in-hospital mortality in adults receiving ECMO was 37.1% during the first year of the pandemic, similar to those with non-COVID-19-related acute respiratory distress syndrome. Increasing age was a risk factor for death. The duration of treatment appears to be prolonged in COVID-19 patients; however, a prolonged treatment course was not a predictor of mortality.[880]
Single-access, dual-stage venovenous ECMO with early extubation appears to be safe and effective in patients with COVID-19 respiratory failure.[881]

Plus – monitor comorbidities during hospital stay

Consider – management of sepsis/septic shock

Plus – monitor comorbidities during hospital stay

Consider – corticosteroid

Treatment recommended for SOME patients in selected patient group

Consider a systemic corticosteroid. Guideline recommendations vary.

The World Health Organization strongly recommends systemic corticosteroid therapy (low-dose intravenous or oral dexamethasone or hydrocortisone) for 7 to 10 days in adults with critical disease. 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 critical disease. 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.[797][798][799][846][847] There is also evidence that corticosteroids probably increase ventilator-free days (moderate certainty).[853][854]
BMJ rapid recommendations: a living WHO guideline on drugs for COVID-19 external link opens in a new window
In the UK, the National Institute for Health and Care Excellence recommends offering dexamethasone (or an alternative such as hydrocortisone or prednisolone when dexamethasone cannot be used or is unavailable) to people who need supplemental oxygen to meet their prescribed oxygen saturation levels, or who have a level of hypoxia that needs supplemental oxygen but who are unable to have or tolerate it. Treatment is for up to 10 days unless there is a clear indication to stop early.[605]
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. In patients who are on mechanical ventilation or extracorporeal membrane oxygenation, the panel recommends dexamethasone alone or in combination with tocilizumab for patients who are within 24 hours of admission to the intensive care unit. Alternative corticosteroids may be used in situations where dexamethasone is not available. The panel recommends using dexamethasone in hospitalised children who require high-flow oxygen, non-invasive ventilation, invasive mechanical ventilation, or extracorporeal membrane oxygenation.[3]

Monitor patients for adverse effects (e.g., hyperglycaemia, secondary infections, psychiatric effects, reactivation of latent infections) and assess for drug-drug interactions.[3]

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.[883]

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.[1003]

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.[1004]
COVID-19 is also associated with increased insulin resistance as well as reduced insulin secretion from the pancreatic beta cells.[1003]
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.[1003]
- The recommended protocol by the UK-based National Inpatient Diabetes COVID-19 Response Group for the ward setting uses subcutaneous insulin.[1003][1005]
- The group highlights that sulfonylureas are not recommended in this scenario due to potential impairment of beta cell function and likely severe insulin resistance.[1003]

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 may increase the risk of recurrence in subsequent treatments.[1006]

Monitor for psychiatric adverse effects.[1007]

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.[1008]
Effects seem to be dose-related and are more common with long-term regimens or long-acting formulations, and in older patients.[1006] This also stands true for patients who have neuropsychiatric adverse effects related to discontinuing long-term corticosteroid therapy.[1009]

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.[1009] 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: children: consult specialist for guidance on dose; adults: 6 mg orally/intravenously once daily for 7-10 days

dexamethasone open_in_new: children: consult specialist for guidance on dose; adults: 6 mg orally/intravenously once daily for 7-10 days

dexamethasone: children: consult specialist for guidance on dose; adults: 6 mg orally/intravenously once daily for 7-10 days

hydrocortisone: children: consult specialist for guidance on dose; adults: 50 mg orally/intravenously every 8 hours for 7-10 days

hydrocortisone open_in_new: children: consult specialist for guidance on dose; adults: 50 mg orally/intravenously every 8 hours for 7-10 days

hydrocortisone: children: consult specialist for guidance on dose; adults: 50 mg orally/intravenously every 8 hours for 7-10 days

Secondary options

prednisolone: children: consult specialist for guidance on dose; adults: 40 mg/day orally given in 1-2 divided doses for 7-10 days

prednisolone open_in_new: children: consult specialist for guidance on dose; adults: 40 mg/day orally given in 1-2 divided doses for 7-10 days

prednisolone: children: consult specialist for guidance on dose; adults: 40 mg/day orally given in 1-2 divided doses for 7-10 days

methylprednisolone: children: consult specialist for guidance on dose; adults: 32 mg/day orally/intravenously given in 1-2 divided doses for 7-10 days

methylprednisolone open_in_new: children: consult specialist for guidance on dose; adults: 32 mg/day orally/intravenously given in 1-2 divided doses for 7-10 days

methylprednisolone: children: consult specialist for guidance on dose; adults: 32 mg/day orally/intravenously given in 1-2 divided doses for 7-10 days

Plus – monitor comorbidities during hospital stay

Consider – interleukin-6 (IL-6) inhibitor

Treatment recommended for SOME patients in selected patient group

Consider an IL-6 inhibitor. Guideline recommendations vary.

The World Health Organization strongly recommends an IL-6 inhibitor (tocilizumab or sarilumab), in combination with a systemic corticosteroid and initiated at the same time, in patients with critical disease. This recommendation is based on high-certainty evidence that shows IL-6 inhibitors reduce mortality and the need for mechanical ventilation, and low-certainty evidence that suggests that IL-6 inhibitors may also reduce the duration of mechanical ventilation and hospitalisation. The evidence regarding the risk of severe adverse events is uncertain. The applicability of this recommendation to children is currently uncertain.[797][798][799] This recommendation is based on data from the UK RECOVERY and REMAP-CAP trials.[849][850]
BMJ rapid recommendations: a living WHO guideline on drugs for COVID-19 external link opens in a new window
In the US, the National Institutes of Health guidelines panel recommends adding tocilizumab to dexamethasone (or a suitable alternative corticosteroid) or dexamethasone plus remdesivir in patients who require non-invasive mechanical ventilation or high-flow nasal oxygen and have been recently hospitalised (e.g., within 3 days) with rapidly increasing oxygen needs and systemic inflammation. In patients who are on mechanical ventilation or extracorporeal membrane oxygenation, the panel recommends adding tocilizumab to dexamethasone for patients who are within 24 hours of admission to the intensive care unit. There is insufficient evidence for the panel to recommend either for or against the use of tocilizumab in hospitalised children. Sarilumab may be used as an alternative if tocilizumab is not available or it is not feasible to use it.[3] Tocilizumab has been granted an emergency-use authorisation in the US for the treatment of hospitalised adults and paediatric patients 2 years of age and older who are receiving systemic corticosteroids and require non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation.[851]

Patients on IL-6 inhibitors are at increased risk of infection including active tuberculosis, invasive fungal infections, and opportunistic pathogens.

Routine blood work including neutrophil count, platelets, transaminases, and total bilirubin should be checked prior to initiation of therapy. All patients should be monitored for signs and symptoms of infection given the increased risk of immunosuppression in addition to systemic corticosteroids.[797]
These drugs should be avoided in patients who are significantly immunocompromised.[3]

Primary options

tocilizumab: children: consult specialist for guidance on dose; adults: 8 mg/kg intravenously as a single dose, maximum 800 mg/dose

tocilizumab open_in_new: children: consult specialist for guidance on dose; adults: 8 mg/kg intravenously as a single dose, maximum 800 mg/dose

tocilizumab: children: consult specialist for guidance on dose; adults: 8 mg/kg intravenously as a single dose, maximum 800 mg/dose

sarilumab: children: consult specialist for guidance on dose; adults: 400 mg intravenously as a single dose

sarilumab open_in_new: children: consult specialist for guidance on dose; adults: 400 mg intravenously as a single dose

sarilumab: children: consult specialist for guidance on dose; adults: 400 mg intravenously as a single dose

Plus – monitor comorbidities during hospital stay

Consider – treatment of co-infections

Plus – monitor comorbidities during hospital stay

Plus – continue the patient's inhalers as prescribed for asthma or COPD if appropriate

Treatment recommended for ALL patients in selected patient group

The overall aim for continuing inhaled corticosteroids is to reduce the risk of an exacerbation of asthma or COPD.[916]
There is no evidence that inhaled corticosteroids are related to COVID-19 infection in people with asthma.[917] There is also no evidence they increase the risks associated with COVID-19 in people with COPD.[915]

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.[912][915][918]
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.[918]

Plus – monitor comorbidities during hospital stay

Plus – weigh up risks versus benefits of prescribed cardiovascular or kidney medication

Treatment recommended for ALL patients in selected patient group

Despite concern about the possible increased risk of infection or more severe disease in patients prescribed ACE inhibitors or angiotensin-II receptor antagonists, a living systematic review found high-certainty evidence that the use of these drugs is not associated with severe disease.[923][924]
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.[925][926][927][928]

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 ill (based on expert opinion).

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.

Seek advice from the patient’s cardiology or nephrology team if they have complex conditions (e.g., on renal replacement therapy or immunosuppressive therapy).

Plus – monitor comorbidities during hospital stay

Plus – review current treatment for depression

Treatment recommended for ALL patients in selected patient group

Ask the patient which medications they are taking for their depression. Alternatively, review their primary care records for relevant information (if available).

Drug-drug interactions and their associated adverse effects of particular relevance to patients with COVID-19 include sedation, cardiotoxicity (QT prolongation), and respiratory depression.[899]

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.[977]
The severity of symptoms of discontinuation may vary, but it may be unpleasant and may complicate the management of the acute medical condition.[978]

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.[977][979] Consider this issue for all medications prescribed in patients with COVID-19 as well as any experimental therapies (see the Emerging section).

Practical tip

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.[979]

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.[984][985]
- 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.

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.

Plus – monitor comorbidities during hospital stay

Consider – experimental therapies

Plus – monitor comorbidities during hospital stay

Consider – plan for discharge and rehabilitation

Coronavirus disease 2019 (COVID-19)

Treatment algorithm

Comorbidities in pregnancy and in children

Be aware of any comorbidity-associated risk of clinical deterioration and severe disease

Check baseline kidney function and monitor closely

Support patients with known depression

NSAIDs in patients with chronic kidney disease, heart failure, or asthma

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

Take the patient’s comorbidities into account when considering experimental therapies

Practical tip

Practical tip

Practical tip

People with type 1 diabetes

People with type 2 diabetes

Practical tip

Comorbidities in pregnancy and in children

Be aware of any comorbidity-associated risk of clinical deterioration and severe disease

Check baseline kidney function and monitor closely

Continue to monitor fluid balance particularly closely

Support patients with known depression

Management in the community setting

Management in the hospital setting

NSAIDs in patients with chronic kidney disease, heart failure, or asthma

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

Take the patient’s comorbidities into account when considering experimental therapies

Management of a patient with delirium

Practical tip

Practical tip

Practical tip

Hyperglycaemia during the ongoing hospital admission

Practical tip

Hypoglycaemia during the ongoing hospital admission

Practical tip

Practical tip

Practical tip

Comorbidities in pregnancy and in children

Be aware of any comorbidity-associated risk of clinical deterioration and severe disease

Baseline neurological assessment

Oxygen therapy in patients with asthma

Oxygen therapy in patients with COPD

Practical tip

Assess fluid status and manage fluid balance particularly closely

Patients with CKD