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NICE Coronavirus Guidelines - Article Outdated!

Recently, recommendations for treating coronavirus infection were released by NICE (National Institute of Health and Care Excellence). The rules are summarised here. These guidelines go into further criteria and therapy alternatives while advising hydroxychloroquine for COVID-19 patients.

NOTE: This article is outdated. See CORONAVIRUS TREATMENT UPDATE at the end!

Clinical syndromes linked to COVID-19 infections are defined as follows:

Mild illness
- Patients with uncomplicated viral infection of the upper respiratory tract may experience vague symptoms like:
  - Nasal congestion
  - Dyspnoea
  - Cough (with or without sputum production)
  - Headache
  - Fever
  - Fatigue
  - Sore throat
  - Malaise
  - Muscle pain
  - Anorexia
- Additionally, patients may have diarrhea, vomiting, and nausea.
- Patients who are elderly or immunosuppressed could have unusual symptoms.
Pneumonia:
- Adults who have pneumonia but don't show symptoms of severe pneumonia (see below) or need oxygen.
Severe Pneumonia [Ref]:
- Teenagers or adults who have a fever or any of the following respiratory diseases:
  - Respiratory rate greater than 30 breaths/min
  - SpO2 93% on room air or less
  - Severe respiratory distress
- Chest imaging may reveal or rule out several pulmonary problems even though the diagnosis is determined on the basis of clinical evidence.
Acute respiratory distress syndrome (ARDS):
- It starts within a week after respiratory symptoms that are either new or getting worse.
- Bilateral opacities on chest imaging (radiograph, CT scan, or lung ultrasound) cannot be accounted for by volume overload, nodules, lobar, or lung collapse.
- Cardiac failure or fluid overload do not entirely explain pulmonary infiltrates and respiratory failure.
- If not even a single risk factor is observed, objective tests like an echocardiogram should be carried out to rule out hydrostatic causes of infiltrates and edema.
Oxygenation impairment is used to grade ARDS severity:
- Mild ARDS:
  - PaO2/FiO2 is over 200 and below 300 mmHg (with PEEP or CPAP of 5 cmH2O or more, or non-ventilated)
- Severe ARDS:
  - PaO2/FiO2 is less than 100 (with PEEP of 5 cmH2O or more, or non-ventilated).
- Moderate ARDS:
  - PaO2/FiO2 is greater than 100 and less than 200 mmHg (with PEEP of 5 cmH2O or more, or non-ventilated)

Note: In the absence of PaO2, SpO2/FiO2 315 mmHg indicates ARDS (including in non-ventilated patients).

Sepsis:
- Signs of organ dysfunction include:
  - Fast heart rate
  - Low blood pressure
  - Altered mental status
  - Low oxygen saturation
  - Difficult or fast breathing
  - Reduced urine output
  - Cold extremities
  - Skin mottling
  - Weak pulse
  - Laboratory evidence of:
    - Coagulopathy
    - Raised lactate
    - Hyperbilirubinaemia
    - Thrombocytopenia
    - Acidosis
- Septic Shock:
  - Serum lactate concentration of more than 2 mmol/L.
  - Despite volume resuscitation, there is still hypotension, necessitating the use of vasopressors to keep the mean arterial pressure (MAP) above 65 mmHg.

[Ref: Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China. J Am Med Assoc 2020 (in press) https://doi.org/10.1001/jama.2020.2648]

NICE Coronavirus Management guidelines for COVID-19 infections:

Home Care:
- Patients may stop home isolation when a test-based approach is utilized if there is:
  - Fever reduction without using medicines to lower fever
  - Decreased respiratory symptoms (cough, shortness of breath
  - At least two consecutive nasopharyngeal swab samples that were tested using the COVID-19 molecular assay yielded negative results at intervals of at least 24 hours.
- When a non-test-based approach is utilized, patients may stop being isolated at home if the following conditions are satisfied.:
  - At least 7 days have passed from the onset of symptoms and at least 72 hours have gone since the onset of symptoms, which is defined as the resolution of fever without the use of fever-relieving medications and improvement in respiratory symptoms (cough, shortness of breath)
Home Management:
- Patients with minor infections must be effectively isolated in an outpatient environment, home care is appropriate.
- The prevention of transmission to others should be a priority.
- Patients should be closely watched for signs of clinical decline because an immediate hospital stay might be necessary.
- Patients with minor symptoms should be isolated and kept away from home pets and other people.
- When presenting in front of healthcare facilities and when in a room with other individuals, they should wear a facemask.
- It's crucial to clean regularly touched surfaces.

NICE Coronavirus Guidelines for Hospital Care of COVID-19 infection:
- Severe COVID-19 infections may necessitate hospitalization and oxygen assistance for patients.
- To effectively control infection, such patients must be managed.
- Intubation with mechanical ventilation will be required if patients experience acute respiratory distress syndrome.
- People suffering from refractory hypoxia may benefit from ECMO (extracorporeal membrane oxygenation).
- High-flow oxygen and non-invasive positive pressure ventilation in these methods should be regarded as aerosol-generating treatments that call for particular separation safeguards for their safety.
NICE Coronavirus Critical Care Guidelines for COVID-19 infections:
- Regardless of their COVID-19 status, all patients who are admitted to the hospital should have their frailty examined.
- Decisions concerning critical care admission for patients who are COVID-19 positive should be based on medical necessity and take into account the possibility that the patient will recover to an outcome that is acceptable to them and within a time frame commensurate with the diagnosis.
- When decision-support tools are available, patients, caregivers or advocates, and families should be included in discussions regarding risks, benefits, and expected outcomes so that they can, to the greatest extent feasible, make educated treatment decisions.
NICE Coronavirus guidelines on Dialysis in COVID-19 infected patients:
- Dialysis for COVID-19 suspected people should be evaluated to determine whether it can be postponed until the patient's COVID-19 status is known.
- Additionally, it should be confirmed that the necessary transportation services are offered by learning what the present transportation providers are willing to offer and whether there are any substitutes in the event that the current providers refuse to transport COVID-19-infected patients.
- In order to prevent patients' conditions from getting worse, NICE also suggests that outpatient transportation services bring patients to their dialysis appointments on time.
NICE Coronavirus guidelines on Systemic cancer treatments
- The degree of immunosuppression associated with various medications and cancer types, as well as any other patient-specific risk factors, must be considered when prioritizing patients for therapy.
- Consideration should be given to administering medicine in various and less immunosuppressive regimens, in different locations, or via a different mode of administration where alterations to standard care are required due to system demands.
- Additionally, they must weigh the possibility of cancer not receiving the best possible care against the possibility of contracting COVID-19 due to immunosuppression and developing a serious illness.
Chloroquine use in COVID-19 patients - NICE Coronavirus Guidelines statement:
- The National Health Commission of China's therapy recommendations includes the use of chloroquine, which has been linked to apparently slowed illness progression and shorter symptom duration.
- However, there are no available published data. [Ref]
Hydroxychloroquine (NICE Coronavirus Guidelines recommend HCQ)
- Hydroxychloroquine (200 mg three times a day for 10 days) was connected to a higher rate of undetectable viral RNA on nasopharyngeal specimens on day 6 in comparison to no specific therapy (70 vs 12.5 percent ).
- Azithromycin appeared to have an additional advantage in this trial when used in conjunction with hydroxychloroquine, however, there are methodological issues with the study's control groups, and it is unclear what the clinical justification for employing azithromycin is. [Ref]
Uncertainty about NSAID use
- Some specialists believe that using NSAIDs early in the development of the disease may negatively impact how the ailment develops.
- These have been based on anecdotal reports of a few young individuals who took NSAIDs early in the course of an infection and experienced severe sickness.
- The likelihood that the patient's immune response may be hampered by the anti-inflammatory effects of NSAIDs is also concerning.
- To lower fever, use acetaminophen (paracetamol) rather than NSAIDs.
- The WHO and the European Medicines Agency (EMA) do not, however, advise against using NSAIDs when clinically essential.
Limited role for corticosteroids
- The WHO and CDC advise avoiding using corticosteroids in COVID-19 pneumonia patients unless there are further reasons (eg exacerbation of COPD).
- Those who have the Middle East respiratory syndrome coronavirus (MERS-CoV) infection have been shown to have a higher risk of influenza-related death and a slower rate of viral clearance when taking corticosteroids.
- There was considerable evidence for both short- and long-term deleterious consequences, despite the fact that it was commonly employed in the management of severe acute respiratory syndrome (SARS).
Lopinavir/Ritonavir:
- Researchers in China have published the results of an open-label, randomized clinical trial employing lopinavir and ritonavir for the treatment of COVID-19 in 199 infected adult patients.
- The primary outcome, time to clinical improvement, showed no differences. [Ref]
Remdesivir:
- Remdesivir is being tested in a number of randomized trials to determine its effectiveness in treating moderate or severe COVID-19.
  It exhibits activity against SARS-CoV-2, SARS, and MERS-CoV in animal trials as well as in vitro.
- In a case report of a US patient with COVID-19, the compassionate use of remdesivir through an experimental new medication application was detailed.
  We await any potential clinical effects of the medication on COVID-19. [Ref]
Tocilizumab for Cytokine-release syndrome:
- Tocilizumab, an IL-6 inhibitor, is recommended for patients with severe COVID-19 and increased IL-6 levels, according to the National Health Commission of China's treatment recommendations.
- A clinical trial is being conducted.
NICE CORONAVIRUS GUIDELINES SUMMARY:
- Once COVID-19 is diagnosed, identify which syndrome and decide on home or hospital care.
- Take each syndrome into consideration.
- As a medicine to reduce fever, use paracetamol.
- Use hydroxychloroquine for most patients.
- Avoid corticosteroids and NSAIDs.

NOTE: CORONAVIRUS TREATMENT UPDATE!

The COVID-19 epidemic was just getting started when the story was published. In terms of how COVID-19 is treated, a lot has changed. It has been determined that the use of hydroxychloroquine and chloroquine in COVID-19 patients (for the treatment and prophylaxis) is ineffective and perhaps dangerous.

Corticosteroids and dexamethasone, in particular, have been found to reduce mortality in moderate to severe COVID-19 infections after the RECOVERY TRIAL. Dexamethasone is currently being incorporated into guidelines worldwide.