I am sharing my COVID-19 treatment experience. I see COVID-19 patients on a daily basis in my OPD. I also see patients in the hospital Isolation ward dedicated only to COVID-19 symptomatic patients.

On weekends, I see more than a hundred patients in my village too with various diseases but commonly with respiratory symptoms. I can't believe people still ask me if COVID-19 infection is real or not.

Is COVID-19 real?

First of all, some people ask me whether this is some kind of drama or a real disease. So COVID-19 is now a pandemic and there shouldn’t be any doubt. It spreads much easier than the other flu viruses.

I don’t think getting locked up in a room will prevent you from getting the infection. I say this as recently I got a few patients who had locked themselves in a single room for so many months and acquired the disease. It can slow the spread of infection though, but I believe, everyone is going to get infected. 

Is COVID-19 a Viral Disease?

People are still debating on this topic. However, I don’t think there is any doubt about that. But since people get superimposed bacterial infections, antibiotics are commonly prescribed.

This does not make it a bacterial disease. Others are trying various drugs including antimalarials, antiparasitic, drugs like ivermectin (primarily used to treat lice infestations), and drugs to treat joint diseases. Others including doctors are advising various home remedies such as senna makki tea, vitamin C, zinc, and herbal products to boost immunity.

And on the other hand steroids and other immune suppressants are used to suppress immunity. I say COVID-19 infection has made everyone a fool or everyone is so desperate that they have started investigating non-scientific treatments.

What are the symptoms of COVID-19?

When COVID-19 is severe, it primarily affects the lungs, and patients are unable to breathe. Most patients who present to me have non-specific symptoms such as lethargy, weakness, insomnia, fatigue, sweating (cold sweats), and body aches.

Other important symptoms include fever and mild non-productive cough. Fever is usually low grade but can be high grade in some patients. Unlike other viral diseases, in which the fever settles in a week to ten days, fever in COVID-19 may persist for a longer duration.

The cough is mostly dry unless there is a superimposed bacterial infection.

Gastrointestinal symptoms are also very common. Patients present with abdominal cramps, diarrhea, bloating, and dyspepsia.

Diarrhea is usually described as an increased stool frequency rather than an increased volume as in other diarrheal diseases. Diabetic patients and hypertensive patients may notice a fluctuation in their glycemic control and blood pressure readings despite using the same previous medicines.

How do I manage my patients?

First of all, I don’t ask my patients to get COVID-19 testing. I ask only those patients to get PCR for COVID-19 who would like to avail leave from their office.

The reasons why I don’t test for COVID-19 PCR are:

• PCR testing is positive in only about 60% of the patient. So with a negative PCR, you get a sense of false satisfaction and reassurance.
• The chances of spreading the infection to your family members are higher when you have a false-negative PCR report.
• In our population, even the percentage of false-negative PCR is much higher. Either the labs are just collecting money and not doing the tests or since COVID-19 is primarily a lung disease and we are taking nasal swabs which can be negative.
• In symptomatic patients with classical radiological findings, PCR testing is not going to change the treatment.
• Negative COVID-19 PCR or Positive COVID-19 PCR, the treatment is the same. If it's being done for the purpose of quarantine, like PCR-positive patients, I think all symptomatic patients should be quarantined regardless of the PCR status.
• PCR testing is very costly. You can get complete treatment on the money that you spend on the test with so many false-negative results.
• A simple chest radiograph costs Rs. 300 – Rs.800 ($2 - $4) while PCR for COVID-19 costs Rs.7000 – Rs.9000 ($40 - $55).

If PCR testing should not be done, then how to diagnose COVID-19?

I ask for a simple chest radiograph of all the patients who have recently developed any new symptoms (not just fever and cough). I have seen, that almost a hundred percent of our symptomatic patients have an abnormal chest radiograph.

Rarely, I have asked for an HRCT (high resolution computed tomogram) chest. HRCT chest has a greater sensitivity than PCR testing. Furthermore, Radiographs also tell us the extent of the disease and the area of the lungs involved.

I ask some of my patients to go for COVID-19 PCR testing especially those who are very apprehensive and have been roaming around physicians (trusting only Dr.Google).

However, I warn these patients that the test can be falsely negative. After an abnormal chest x-ray, I advise a few inflammatory markers to decide about antibiotics and anticoagulants.

How do I treat my COVID-19 patients?

Various COVID-19 treatment guidelines have been published. The Massachusetts General Hospital guidelines and NICE guidelines can be viewed here:

• The Massachusetts General Hospital COVID 19 Treatment guidelines
• NICE COVID 19 Treatment guidelines

What I believe is that COVID-19 affects the lungs in three ways:

• Infection (Viral infection and superimposed bacterial infections)
• Inflammation
• Clot formation

Antibiotics and Antivirals:

Antiviral medications (like remdesivir) have a doubtful role but are not available everywhere, so I don’t prescribe antiviral medications.

I prescribe antibiotics based on CRP (C-reactive protein) levels and comorbid status. For very sick patients and those who can not tolerate oral medicines, I advise a fourth-generation cephalosporin (like cefepime) and azithromycin.

For those without comorbid conditions and raised CRP and those who can take oral medicines, I only prescribe azithromycin. To most young patients with a normal CRP and no comorbid conditions, I don’t prescribe any antibiotics.

For inflammation in COVID-19 infection:

I prescribe an anti-inflammatory drug to all my patients. I see people are taking round-the-clock paracetamol for fever. However, since there is inflammation, paracetamol is not going to work if you are not doing anything to reduce the inflammation.

With anti-inflammatory, fever settles within 24 hours. Furthermore, I think the use of early anti-inflammatory drugs may reduce lung fibrosis too.

For patients who remain hypoxic despite anti-inflammatory after 24 hours, I add steroids. Methylprednisolone or dexamethasone is added to the treatment regimen. In hospitalized sick patients, Actemra (tocilizumab) may be prescribed to patients with cytokine storm.

Anticoagulants in COVID-19 patients:

Lastly, for patients who have raised D-dimers, I also prescribe injectable enoxaparin 40 mg subcutaneously once daily for five days.

Although studies are coming up regarding the role of rivaroxaban in COVID-19 patients, most studies are driven by pharmaceutical companies and I have little trust. I still prescribe time-tested medicines (enoxaparin in this case).

How do my patients respond to the above treatment regimen?

With goal-directed therapy, until now, only one of my patients who were 60 years of age and had an oxygen saturation of 76% on presentation, landed in the intensive care unit for hypoxemia.

One patient had persistent hypoxemia after 3 days ranging from 88 – 90%. Except for one patient, who was hospitalized and one patient who has advised home oxygen, none of the patients required hospitalization.

Fever settled in the majority of my patients within twenty-four hours. Here is a brief summary of how my patients responded to the treatment regimen. I am planning to publish the details soon.

Age:

• The mean age of the patients: 51 years ranging from 21 to 85 years.

Gender:

• Males: 47.4%
• Females: 52.6%

Diabetes:

• 39.5%

Hypertension:

• 39.5%

IHD (ischemic heart disease):

• 7.9%

Strokes:

• 10.5%

Lung disease:

• 7.9%

Chest radiograph:

• 65.8% of the patients had bilateral consolidations with most having bilateral consolidations

Mean SPO2 on presentation:

• 93.32 % ranging from 75 to 99%.

Mean sPO2 after one week:

• 95.58 ranging from 85 to 99%

The mean difference between sPO2 at baseline and one week later:

• 2.53 +/- 4 std (P-value: 0.001)

Mean CRP:

• 10.6 (ranging from 2 - 63)

Mean D-dimers:

• 375 ranging from 40 to 1308

Hospitalization required:

• One patient was admitted to the ICU.

Death:

• None

In conclusion,

Early use of anti-inflammatory and goal-directed therapy may reduce hospitalizations and COVID-19-associated mortality. However, data is still being gathered. Logical treatment options include the use of antibiotics, anti-inflammatory drugs, and anticoagulants.