Ivermectin, HCQs dropped from Health Ministry's latest COVID-19 Guidelines

New Delhi: In the light of the recent rising COVID-19 cases, the Union Ministry of Health and Family welfare has released the updated guidelines for management of COVID-19 cases in adults.

The said guidelines developed by the Indian Council of Medical Research (ICMR) and All India Institute of Medical Sciences (AIIMS) have now dropped the usage of two drugs, Ivermectin and Hydroxychloroquine (HCQ) from their clinical guideline for management of COVID-19 in mild cases.

This marks a major change from the previous guideline that was released on 19th May 2021 which recommended that these two drugs may be used in COVID-19 patients with mild disease, who do not have upper respiratory tract symptoms and without hypoxia. The current guideline still maintains that inhalation of Budesonide (given via Metered dose inhaler/ dry powder inhaler) may be used at a dose of 800mg for 5 days if the symptoms are persistent beyond 5 days of disease onset.

The guidelines details of management of COVID in mild, moderate and severe cases.Following are the details

Mild COVID-19 Infection

Patients with upper respiratory tract symptoms without shortness of breath or hypoxia are grouped under Mild infections. Patient should be isolated at home and must maintain physical distancing and strict hand hygiene. Patients with mild disease should monitor temperature and oxygen level, and should seek medical attention if experience difficult in breathing or high fever/cough for more than 5 days, the guideline notes.

Moderate COVID-19 Infection

According to the guideline, a patient is classified as a moderate case of COVID-19 if their respiratory rate is more than 24/min and SpO2 level 90%- 93% on room air. Patient may require hospital treatment at this stage. Treatment for moderate case as has been approved by ICMR:

• Oxygen Support: The targeted level of SpO2 should be 92-96%, 88-92% in case of COPD patients. The guideline recommends non-breathing facemask for oxygenation. 
• For all the patients requiring oxygen supplemental oxygen therapy awake proning method should be encourage thereby changing position every 2 hours.
• Anti-inflammatory or immune-modulatory therapy.

The guideline recommends injecting of Methylprednisolone 0.5 to 1 mg/kg in 2 divided doses for 5-10 days. In case of stable or improving conditions, this may be switched to oral route.

• Anticoagulation- Prophylactic un-fractioned heparin or Low molecular Weight heparin at conventional dose with no contraindication or high risk of bleeding.
• Things to be monitored with moderate COVID-19 pateints Work of breathing, hemodynamic instability, change in oxygen requirement, X rays and HRCT chest, only when the patient's condition worsens. Additionally, CRP and D-dimer should also be monitored every 48 to 72 hours.

Patient with Severe COVID-19 Infection

Patients with respiratory rate greater than 30/min with SpO2 less than 90% on room air are severe infection as per the guideline. At this stage, patients need to be in Intensive Care Unit. Treatment recommended by the guideline for severe infection:

• Respiratory Support-

Use of Non Invasive Ventilation in patients with work breathing low and High flow nasal cannula in case of increasing oxygen requirement are recommended. Intubation is suggested if NIV is not tolerated with high work of breathing. Conventional protocol for Acute Respiratory Distress Syndrome should be maintained while practicing ventilator.

• Anti-inflammatory- Methylprednisolone 1 to 2mg/kg IV in 2 divided doses for 5-10 days.
• Anticoagulation and thing to be monitored is same as Moderate infection treatment as listed above.
• Maintaining euvolemia and management of sepsis shock has been listed as the supportive measures by the guideline. 

Who are at high risk for Severe Disease or Mortality?

Patient aged above 60 years with comorbidities such as CVD, hypertension and CAD, diabetes, chronic lung/kidney/liver disease and cerebrovascular disease are at high risk for severe infection as per the guideline.

USE of Remdesivir and Tocilizumbab

The guideline recommend the use of Remdesivir only in patients with moderate to severe with no renal dysfunction and who are within 10 days of onset of symptoms. 200 mg IV on day 1 followed by 100 mg for next 4 days. It is restricted for patients who are not on oxygen support or home setting.

Use of Tocilizumab (Off label) may be considered if severe disease is present, raising of inflammatory markers with no improvement despite use of steroids when no active bacterial/fungal infection is found. 4-6mg/kg in 100ml Normal Saline over one hour is the dose, the guideline writes.

If you want to read the full guidelines click on the following link

https://www.icmr.gov.in/pdf/covid/techdoc/COVID_Management_Algorithm_23092021.pdf