(updated 9-28-2020)
Prophylaxis
While there is very limited data (and none specific for COVID-19), the following “cocktail” may have a role in the prevention/mitigation of COVID-19 disease.
■ Vitamin C 500 mg BID and Quercetin 250 mg daily
■ Zinc 75-100 mg/day
■ Melatonin (slow release): Begin with 0.3mg and increase as tolerated to 2 mg at night
■ Vitamin D3 1000-3000 u/day
■ Famotidine 20-40mg/day
Mildly Symptomatic patients (at home):
■ Vitamin C 500mg BID and Quercetin 250-500 mg BID
■ Zinc 75-100 mg/day
■ Melatonin 6-12 mg at night (the optimal dose is unknown)
■ Vitamin D3 2000 - 4000 u/day
■ ASA aspirin 81-325 mg/day (unless contraindicated)
■ Famotidine 40mg BID (reduce dose with renal impairement)
In symptomatic patients, monitoring with home pulse oximetry is recommended.
Ambulatory desaturation below 94% should prompt hospital admission
Mildly Symptomatic patients (on floor):
■ Vitamin C 500 mg PO q 6 hourly and Quercetin 250-500 mg BID (if available)
■ Zinc 75-100 mg/day
■ Melatonin 6-12 mg at night (the optimal dose is unknown)
■ Vitamin D3 20 000 – 60 000u single oral dose. Calcifediol 200 -500 ug is an alternative. This should be followed by 20 000u D3 (or 200ug calcifediol) weekly until discharged from hospital.
■ Enoxaparin 60 mg daily
■ Famotidine 40mg BID (reduce dose with renal impairement)
■ Methylprednisolone 40 mg q 12 hourly; increase to 80 mg q 12 if poor response
■ T/f EARLY to the ICU (Tratament failure early to the Intensive care unit) for increasing respiratory signs/symptoms and arterial desaturations.
General schema for respiratory support in patients with COVID-19
TRY TO AVOID INTUBATION IF POSSIBLE
Low-Flow Nasal Cannula
■ Typically set at 1-6 Liters/Min
High Flow Nasal Cannula
■ Accept permissive hypoxemia (O2 Saturation > 86%)
■ Titrate FiO2 based on patient’s saturation
■ Accept flow rates of 60 to 80 L/min
■ Trial of inhaled Flolan (epoprostenol)
■ Attempt proning (cooperative proning)
Invasive Mechanical Ventilation
■ Target tidal volumes of ~6 cc/kg
■ Lowest driving pressure and PEEP
■ Sedation to avoid self-extubation
■ Trial of inhaled Flolan
Prone Positioning
■ Exact indication for prone ventilation is unclear
■ Consider in patients with PaO2/FiO2 ratio < 150
SALVAGE THERAPIES
■ High dose corticosteroids; 120 -250 mg methylprednisolone q 6-8 hourly
■ Plasma exchange
■ “Half-dose” rTPA
Respiratory symptoms (SOB; hypoxia- requiring N/C ≥ 4 L min: admit to ICU):
Essential Treatment (dampening the STORM)
1. Methylprednisolone 80 mg loading dose then 40 mg q 12 hourly for at least 7 days and until transferred out of ICU. In patients with poor response, increase to 80 mg q 12 hourly.
2. Ascorbic acid (Vitamin C) 3g IV q 6 hourly for at least 7 days and/or until transferred out of ICU. Note caution with POC glucose testing.
3. Full anticoagulation: Unless contraindicated we suggest FULL anticoagulation (on admission to the ICU) with enoxaparin, i.e 1 mg kg s/c q 12 hourly (dose adjust with Cr Cl < 30mls/min). Heparin is suggested with CrCl < 15 ml/min.
Note: Early termination of ascorbic acid and corticosteroids will likely result in a rebound effect. Additional Treatment Components (the Full Monty)
4. Melatonin 6-12 mg at night (the optimal dose is unknown).
5. Famotidine 40 mg- 80 mg BID (20 -40 mg/day in renal impairment)
6. Vitamin D3 20 000 – 60 000u single oral dose. Calcifediol 200 -500 ug is an alternative.This should be followed by 20 000u D3 (or 200ug calcifediol) weekly until discharged from hospital.
7. Thiamine 200mg IV q 12 hourly
8. Atorvastatin 80mg/day
9. Magnesium: 2 g stat IV. Keep Mg between 2.0 and 2.4 mmol/l. Prevent hypomagnesemia (which increases the cytokine storm and prolongs Qtc).
10. Optional: Remdesivir, 200 mg IV loading dose D1, followed by 100mg day IV for 9 days
11. Broad-spectrum antibiotics if superadded bacterial pneumonia is suspected based on procalcitonin levels and resp. culture (no bronchoscopy).
12. Maintain EUVOLEMIA
13. Early norepinephrine for hypotension.
14. Escalation of respiratory support; See General Schema for Respiratory Support in Patients with COVID-19.
Salvage Treatments
■ Plasma exchange. Should be considered in patients with progressive oxygenation failure despite corticosteroid therapy. Patients may require up to 5 exchanges.
■ High dose corticosteroids; Bolus 250- 500mg/ day methylprednisolone
Monitoring:
■ On admission: PCT, CRP, IL-6, BNP, Troponins, Ferritin, NeutrophilLymphocyte ratio, D-dimer and Mg.
■ Daily: CRP, Ferritin, D-Dimer and PCT. CRP and Ferritin track disease severity closely (although ferritin tends to lag behind CRP).
■ In patients receiving IV vitamin C, the Accu-Chek™ POC glucose monitor will result in spuriously high blood glucose values. Therefore, a laboratory glucose is recommended to confirm the blood glucose levels
Post ICU management
■ Enoxaparin 40-60 mg s/c daily
■ Methylprednisone 40 mg day, then wean slowly
■ Vitamin C 500 mg PO BID
■ Melatonin 3-6 mg at night
Post hospital discharge
1. Consider extended DVT prophylaxis in high risk patients.
2. Consider taping course of corticosteroids (guided by CRP)
3. Omega-3 fatty acids
4. Atorvastatin 40mg daily
5. Melatonin
6. Multivitamins including B complex and Vitamin D
