COVID-19: Adult in-patient: Drug management following POSITIVE LFT / PCR test (Guidelines)

Extract from NICE NG191, section 4.3, box 1

Dosage in adults:

• Continue corticosteroids for up to 10 days unless there is a clear indication to stop early, which includes discharge from hospital or a hospital-supervised virtual COVID ward.
• Dexamethasone (licensed indication)
  For people able to swallow and in whom there are no significant concerns about enteral absorption, prescribe tablets.
  ONLY use intravenous administration when tablets or oral solutions are inappropriate or unavailable.
  • 6 mg orally, once a day for 10 days (three 2 mg tablets or 15 mL of 2 mg/5 mL oral solution)
  • OR 6 mg intravenously once a day for 10 days (1.8 mL of 3.3 mg/mL ampoules [5.94 mg]).

Suitable alternatives (currently unlicensed)

• Prednisolone: 40 mg orally once a day for 10 days.
• Hydrocortisone: 50 mg intravenously every 8 hours for 10 days (0.5 mL of 100 mg/mL solution; powder for solution for injection or infusion is also available); this may be continued for up to 28 days for people with septic shock.

Dosage in pregnancy

• Follow Royal College of Obstetrics and Gynaecology guidance.

For more information on the management of children, follow the Royal College of Paediatrics and Child Health National guidance: the management of children in hospital with viral respiratory tract infections (2023).:

Nirmatrelvir / ritonavir (Paxlovid):

• Clinical evidence suggests that nirmatrelvir plus ritonavir is effective at treating mild COVID-19 compared with standard care.

Remdesivir:

• For adults in hospital, remdesivir can improve how long adults needing low-flow supplemental oxygen live compared with standard care, but the evidence is highly uncertain.
• NICE evaluation committee concluded that there was NO clinical trial evidence available for remdesivir in the context of the current endemic setting with a widely vaccinated and naturally immune population and the Omicron variant.
• The committee concluded that significant uncertainty remained in terms of generalisability of the trial evidence for remdesivir.

Renal disease and renal dialysis

Infectious Diseases & Renal Specialists in NHS Highland recommend using:

• For dose adjustment for nirmatrelvir / ritonavir, see Liverpool guidance: Dosing of Paxlovid in Renal Disease:
  • PDF: Guidance for Paxlovid dosing in renal disease and patients on dialysis note: if link to pdf does not work, go back to "Prescribing Resources" page, click on the drop-down box for nirmatrelvir/ritonavir and accessing the 4^th resource on the list.

• To support NO dose adjustment for remdesivir, see Liverpool guidance: COVID-19: Dose recommendations for Patients with Renal Impairment

Note: this advice is at variance with manufacturer’s recommendations and is therefore off-label.

Swallowing difficulties

• For administering COVID-19 oral antiviral therapy for patients with swallowing difficulties, see Liverpool guidance: Administration in swallowing difficulties

Prescribing information

• For Hospital Pharmacy supply of oral COVID antiviral medication, use pre-prepared hospital prescription forms to reduce waste by supplying the whole course of treatment.
  • Hospital prescription form for Paxlovid^®
  • Hospital prescription form for molnupiravir
• Prescribe on HEPMA as Protocol > Paxlovid then choose standard dose or reduced dose (for renal impairment)
• For in-patient areas with paper drug charts, follow example below:

Baricitinib (JAK1 & JAK2 inhibitor)

• This is unlicensed and use should be discussed with Infectious Diseases before prescribing.
• NICE NG191 has limited information

Tocilizumab

If tocilizumab has been administered then the following is essential handover communication on discharge

• Low clinical threshold for identification and management of infection must be used.
• CRP level may be a less reliable marker of active infection and procalcitonin may be negative.

All handovers of clinical care must explicitly mention that an IL-6 inhibitor has been given and the date of administration. This includes:

• Between hospitals if patients are transferred
• Between levels of care and clinical teams within hospitals
• Between hospitals and primary care

Clinicians MUST ensure the GP is aware the patient has received an IL-6 inhibitor and provide information to the patient to such effect:

• Supply the manufacturer’s patient information leaflet

The following standard text should be added to the hospital discharge letter:

• Your patient received tocilizumab on ....../....../......
• Immune function will be suppressed for the next 3 months.
• Clinical assessment is required to diagnose and manage infection as inflammatory markers will be unreliable

CRP: C‑reactive Protein
EMC: Electronic Medicines Compendium
IL‑6: Interleukin‑6
IV: Intravenous
JAK: Janus Kinase
LFT: Lateral Flow Test
mL: Millilitre
mg: Milligram
NICE NG: NICE Guideline
NICE: National Institute for Health and Care Excellence
PCR: Polymerase Chain Reaction
SMPc / SPC: Summary of Product Characteristics