The story so far: The Union Health Ministry has revised its guidelines for the treatment of COVID-19 patients , particularly for the use of steroids, with doctors reporting a worrying rise in medical complications, such as mucormycosis , due to the abuse of drugs and therapies during treatment. The new protocol advises doctors to drop from usage medicines such as ivermectin, doxycycline and hydroxychloroquine to treat mild COVID-19 cases. The revised guidelines, issued on May 27, recommend the use of antipyretics for fever and antitussives for cold in asymptomatic and mild cases.
What are the complications being reported?
Mucormycosis causes black lesions on the nasal bridge or the upper inside of the mouth, which can quickly become more severe, leading to blurred or double vision, chest pain, breathing difficulties, and coughing of blood. COVID-19 patients with diabetes and a weakened immune system are particularly prone to this fungal attack.
Doctors point out that it is clear that the virus affects not just the respiratory system but other organs as well, including the liver and kidneys. “Long COVID-19 is also seen among recovered patients well into three months and beyond. People with co-morbidities are more vulnerable and irrational use of drugs can have extreme adverse effects on the outcome with COVID-19,” they say.
Which drugs have been dropped from the list?
For patients with mild symptoms, the Ministry dropped from its recommendations several drugs that were being used widely for treatment until now. For example, the Ministry has removed hydroxychloroquine, ivermectin, azithromycin, doxycycline, zinc and favipiravir from its list of recommended drugs for treating patients with mild infection. Plasma therapy, which was previously used extensively, has also been dropped from the list.
The Ministry also dissuaded medical practitioners from prescribing unnecessary tests, such as CT scans. For asymptomatic cases, the guidelines said no medication is required, while medications for other co-morbid conditions should be continued. The new protocol calls for a healthy balanced diet with proper hydration, while advising patients and their families to stay connected and engage in positive talks through phone, video calls, etc.
In mild cases, the guidelines recommended self-monitoring for fever, breathlessness, oxygen saturation or worsening of any symptoms. People may take antipyretics or antitussives for symptomatic relief, and may inhale budesonide at a dose of 800 mcg twice a day for five days for cough, the guidelines said. “No other COVID-19-specific medication required. Patients may have to be investigated further if symptoms persist or deteriorate,” the document states.
What do the guidelines specify on medicines?
The Ministry has also revised its policy on Remdesivir, stating that it can be given only to “select moderate/severe hospitalised COVID-19 patients” on supplemental oxygen. The Ministry noted that this is a reserve drug approved under Emergency Use Authorisation based only on limited scientific evidence globally. It further stated that the drug is not to be prescribed for patients with mild symptoms who are under home care or at COVID Care Centres, and that doctors are advised to exercise extreme caution in using this reserve/experimental/Emergency Use Authorisation drug.
The Ministry said the advisory and revised guidelines are aimed at stopping the misuse of drugs and therapies which cost a lot and have limited availability, along with the potential to cause harm.
In the case of Remdesivir, particularly, the government said that the drug should be taken on advice by senior faculty members or specialists directly involved in a patient’s care. “It should be procured and provided by the hospitals only; the patient’s attendants/relatives should not be asked to procure Remdesivir from the retail market,” the Ministry said.
On Tocilizumab, the guidelines said that it is an immunosuppressant drug and that it has been approved for use as an off-label drug only in severe and critically ill patients. The document notes that steroids are harmful in asymptomatic and mild cases of COVID-19. It points out that steroids are to be prescribed only in patients who are hospitalised with moderately severe and critical symptoms and are to be administered at the “right time, in the right dose and for the right duration”.
What do the guidelines say for asymptomatic patients?
For asymptomatic and mild cases, the guidelines suggest a six-minute walk test. Patients should walk for six minutes with a pulse oximeter attached to a finger. If oxygen saturation falls below 94% or if the reading varies from three to five percentage points, or if the patient feels unwell (lightheaded, short of breath), admission to a hospital for observation may be required.
Has anything been suggested for children with COVID-19?
The government has issued comprehensive guidelines for the management of COVID-19 among children under 18 years of age, in which Remdesivir has not been recommended and rational use of HRCT (high-resolution computed tomography) imaging has been suggested. Also, the guidelines note that steroids are harmful in asymptomatic and mild cases of infection. Mask is not recommended for children below five years of age. However, children aged between six and 11 years may wear a mask, but only under the supervision of parents and the consulting doctor, the guidelines said.
For asymptomatic infection among children, the guidelines recommend no specific medication and advise following appropriate measures (wearing a mask, following strict hand hygiene, physical distancing) and a nutritious diet. The guidelines say that for mild infection, paracetamol at 10-15mg/kg/dose may be given every four to six hours for fever; throat-soothing agents and warm saline gargles in older children and adolescents have been recommended for cough.
Doctors have noted that a high percentage of children who got infected and were hospitalised during the second wave of infections had either co-morbidities or low immunity. They added that healthy children with mild illness recovered without the need for hospitalisation.