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Medication Information for COVID-19As literature continues to evolve regarding COVID-19, medication-related questions have come up from practicing providers and others. It is important to note that because COVID-19 is a novel virus, there is very limited evidence to support which treatment is better than another. However, this FAQ outlines currently available information. As we all know, information is changing rapidly, so please check back for updates frequently.Should steroids be used in the treatment of COVID-19? No, not typically. Per the CDC, “Corticosteroids should be avoided, because of the potential for prolonging viral replication as observed in MERS-CoV patients, unless indicated for other reasons.1-4 Corticosteroids are not routinely recommended for viral pneumonia or ARDS and should be avoided in COVID-19 unless they are indicated for another reason (e.g., COPD exacerbation, refractory septic shock following Surviving Sepsis Campaign Guidelines).”Source: References:Zumla A, Hui DS, Perlman S. Middle East respiratory syndrome. Lancet. 2015 Sep 5;386(9997):995-1007. doi: 10.1016/S0140-6736(15)60454-8. Epub 2015 Jun 3. Review.Arabi YM, Mandourah Y, Al-Hameed F, Sindi AA, Almekhlafi GA, et al; Saudi Critical Care Trial Group. Corticosteroid Therapy for Critically Ill Patients with Middle East Respiratory Syndrome. Am J Respir Crit Care Med. 2018 Mar 15;197(6):757-767.Russell CD, Millar JE, Baillie JK. Clinical evidence does not support corticosteroid treatment for 2019-nCoV lung injury. Lancet. 2020 Feb 6; S0140-6736(20)30305-6.Metlay JP, Waterer GW, Long AC, Anzueto A, Brozek J, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-e67.Should ibuprofen and other NSAIDs be used in the treatment of COVID-19? While the CDC has not provided any guidance on this topic, a recent article from the British Medical Journal examined this question. In it, the authors stated that “there was good evidence that prolonged (COVID-19) illness or the complications of respiratory infections may be more common when NSAIDs are used—both respiratory or septic complications and cardiovascular complications.”5 In addition, it states, “ibuprofen’s anti-inflammatory properties could “dampen down” the immune system, which could slow the recovery process.” However, more research is needed. “For covid-19, research is needed into the effects of specific NSAIDs among people with different underlying health conditions. In the meantime, for treating symptoms such as fever and sore throat, it seems sensible to stick to acetaminophen as first choice.” It is important to ensure that no contraindications to acetaminophen are present for patients initiating this medication. ReferenceDay, M. COVID-19: Ibuprofen should not be used for managing symptoms, say doctors and scientists. BMJ. First published as 10.1136/bmj.m1086 on March 17, 2020. Available from: Should ACE inhibitors and ARBs be discontinued for patients with the COVID-19?No, not at this time. Currently there are no experimental or clinical data demonstrating beneficial or adverse outcomes with background use of ACE inhibitors, ARBs or other RAAS antagonists in COVID-19 or among COVID-19 patients with a history of cardiovascular disease treated with such agents. The HFSA (Heart Failure Society of America), ACC (American College of Cardiology), and AHA (American Heart Association) recommend continuation of RAAS (renin-angiotensin-aldosterone system) antagonists for those patients who are currently prescribed such agents for indications for which these agents are known to be beneficial, such as heart failure, hypertension, or ischemic heart disease. In the event patients with cardiovascular disease are diagnosed with COVID-19, individualized treatment decisions should be made according to each patient's hemodynamic status and clinical presentation. Therefore, be advised not to add or remove any RAAS-related treatments, beyond actions based on standard clinical practice.6ReferenceHFSA/ACC/AHA Statement Addresses Concerns Re: Using RAAS Antagonists in COVID-19. Available from: is the current evidence available to use hydroxychloroquine to treat COVID-19 patients?The FDA has not approved any drugs for use in the treatment of coronavirus. Because COVID-19 is a novel virus, there is very limited evidence to support which treatment is better than another. An optimized dosing projection for hydroxychloroquine was published in the Chinese literature.7 In it, authors stated, “Hydroxychloroquine was found to be more potent than chloroquine at inhibiting SARS-CoV-2 in vitro. Hydroxychloroquine sulfate 400 mg given twice daily for 1 day, followed by 200 mg twice daily for 4 more days is recommended to treat SARS-CoV-2 infection.” In addition, in the French literature, a small open-label non-randomized trial was published assessing hydroxychloroquine and azithromycin.7 French confirmed COVID-19 patients were included; six patients were asymptomatic, 22 had upper respiratory tract infection symptoms and eight had lower respiratory tract infection symptoms. Twenty cases were treated with hydroxychloroquine 600 mg/day (200mg three times daily) and showed a significant reduction of the viral carriage at D6-post inclusion compared to controls, and much lower average carrying duration than reported of untreated patients in the literature. Azithromycin (500mg on day 1 followed by 250mg per day for the next four days) added to hydroxychloroquine was significantly more efficient for virus elimination. It is important to note that both hydroxychloroquine and azithromycin can cause QT prolongation and have a known risk of Torsades de Pointes (TdP).9 When taken together, this risk can increase.10 Ensure that patients are clinically appropriate for this therapy and appropriate ECG monitoring is implemented. Currently, there are additional studies ongoing and recommendations will likely evolve as more data comes out.ReferencesYao X, Zhang M, Cui C, et al. In vitro antiviral activity and projection of optimized dosing design of hydroxychloroquine for the treatment of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Published by Oxford University Press for the Infectious Diseases Society of America. Downloaded from by guest on 14 March 2020. Gautret P, Lagier J, Parola P, et al. Hydroxychloroquine and azithromycin as a treatment of COVID-19: results of an openlabel non-randomized clinical trial. Available from: Credible Meds. Risk categories for drugs that prolong QT and induce Torsades de Pointes (TdP). Available from: Clinical Pharmacology. Drug Interaction Report: hydroxychloroquine and azithromycin. Retrieved from is the current status of Gilead’s compassionate use program for remdesivir?The CommonSpirit IRBs have issued guidance on how to enroll in clinical trials for remdesivir. (DH link; CHI link) Recently, Gilead has updated their website regarding access to remdesivir outside of clinical trials.11 “Gilead is currently in the process of transitioning the provision of emergency access to remdesivir from individual compassionate use requests to expanded access programs. This approach will both accelerate access to remdesivir for severely ill patients and enable the collection of data from all participating patients. These programs are currently under rapid development in conjunction with national regulatory authorities worldwide.Due to overwhelming demand over the last several days, during this transition period we are unable to accept new individual compassionate use requests, with the exception of requests for pregnant women and children less than 18 years of age with confirmed COVID-19 and severe manifestations of disease. We are focused now on processing previously approved requests and anticipate the expanded access programs will initiate in a similar expected timeframe that any new requests for compassionate use would have been processed.” ReferenceGilead. Emergency access to remdesivir outside of clinical trials. Available from: What is the latest literature for using lopinavir-ritonavir (Kaletra) for COVID-19?In a recent trial published in the New England Journal of Medicine, hospitalized adult patients with severe COVID-19 saw no benefit with lopinavir–ritonavir treatment beyond standard care.12 The randomized, controlled, open-label trial enrolled hospitalized adult patients with confirmed SARS-CoV-2 infection, which causes the respiratory illness Covid-19. Patients were randomly assigned in a 1:1 ratio to receive either lopinavir–ritonavir (400 mg and 100 mg, respectively) twice a day for 14 days, in addition to standard care, or standard care alone. A total of 199 patients with laboratory-confirmed SARS-CoV-2 infection underwent randomization; 99 were assigned to the lopinavir–ritonavir group, and 100 to the standard-care group. Treatment with lopinavir–ritonavir was not associated with a difference from standard care in the time to clinical improvement (hazard ratio for clinical improvement, 1.24; 95% confidence interval [CI], 0.90 to 1.72). Mortality at 28 days was similar in the lopinavir–ritonavir group and the standard-care group (19.2% vs. 25.0%; difference, ?5.8 percentage points; 95% CI, ?17.3 to 5.7). Lopinavir–ritonavir treatment was stopped early in 13 patients (13.8%) because of adverse events.ReferenceCao B, Wang Y, Wen D, et al. A trial of lopinavir–ritonavir in adults hospitalized with severe Covid-19. NEJM. March 18, 2020. DOI: 10.1056/NEJMoa2001282 Available from: How should breathing treatments (e.g., albuterol, ipratropium) be administered to patients with COVID-19?Per the CDC, being present in the room for procedures that generate aerosols or during which respiratory secretions are likely to be poorly controlled (e.g., nebulizer therapy) on patients with COVID-19 is considered high-risk.13 For patients with COVID-19, metered dose inhalers (MDI) should be used. Centers for Disease Control and Prevention. Interim U.S. guidance for risk assessment and public health management of healthcare personnel with potential exposure in a healthcare setting to patients with coronavirus disease (COVID-19). March 7, 2020. Available from: questions, please contact the System P&T Co-Chairs:Karen McConnell, PharmD, System Director of Clinical Pharmacy ServicesKarenMcConnell@Bruce Bethancourt, MD, CMO Dignity Health Medical GroupBruce.Bethancourt@Ben Chaska, MD, System SVP Physician Enterprise Operations Midwest/Fargo Divisions BenjaminChaska@ Prepared by: Karen McConnell, March 23, 2020 ................
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