Kettering Health COVID-19 Therapeutics Guidelines

The following agents are available for treatment of COVID-19 patients within Kettering Health facilities. This list is adapted from the NIH and IDSA treatment guidelines. Where possible, order questions have been built into EPIC to guide appropriate utilization of the various agents. As of 9/19, tocilizumab is not available. Baricitinib can be used as a substitute with approval from the on-call physician (Drs. Gregg, Lytle, and Weinstein). In general, the anti-viral agents are most effective early in disease and the anti-inflammatories are most effective later in disease.

The Guidelines can be found here:

Figure 1: Stages of COVID-19 Disease Progression Credit: Journal of Heart and Lung Transplant

1. Dexamethasone (Anti-inflammatory)
   • Recommended for all COVID-19 patients requiring supplemental oxygen.
   • Dose: 6 mg IV or po for 10 days
   • Corticosteroids are not recommended for patients who do not require supplemental oxygen.
   • Equivalent dosing of methylprednisolone or prednisone is acceptable.

2. Remdesivir (Anti-viral)
   • Recommended for hospitalized patients admitted within 10 days of symptom onset who are requiring low flow oxygen.
   • Can also be given to patients requiring higher levels of support including BIPAP and heated high-flow nasal cannula. 
   • Remdesivir is not recommended by either the IDSA or NIH guidelines for patients on invasive mechanical ventilation or ECMO. It can be considered for patients intubated within the preceding 24-48 hours.
   • Dose: 200 mg IV on day 1, followed by 100 mg IV daily x 4 days
   • Not recommended in patients with GFR <30 ml/min unless benefit outweighs risk.
   • Contraindicated in patients with LFTs > 10x ULN
3. Baricitinib (Must receive approval) (Anti-inflammatory)
   • Recommended in select patients with rapidly progressive respiratory over a 48-hour period.
   • Must be on oxygen with an FiO2 > 40% or HHFNC at >30 L/min or on invasive mechanical ventilation.
   • Must have at least one elevated inflammatory marker.
   • Dose must be adjusted for renal insufficiency; pharmacy will do this per protocol.
   • Exclusion criteria:
     • Active tuberculosis or an uncontrolled acute bacterial infection
     • Significant immunosuppression
     • Hemodialysis or eGFR < 15 ml/min
     • ALT > 5x ULN
     • Absolute neutrophil count < 500 cells/uL
     • Absolute lymphocyte count < 200 cells/uL
     • Hemoglobin < 8g/dL

4. Convalescent plasma (Anti-viral)
   • Large studies have failed to show benefit of convalescent plasma for most patients with COVID-19.
   • Plasma may be considered for patients admitted within 3 days of symptom onset only.
   • Dose: 1 unit of high-titer plasma.
5. Monoclonal antibodies (Anti-viral) (casirivimab/imdevimab and bamlanivimab/etesevimab)
   • Given in Infusion Clinic via referral and in Emergency Departments – patients must not be requiring oxygen for their COVID-19 infection.
   • Inpatient administration is permitted only for patients who are not requiring supplemental oxygen (or no increase flow rate among those on chronic O2).
   • Criteria for utilization:
     • COVID-19 positive with symptoms for fewer than 7 days
     • And pregnant or 2 of the below risk factors are present:
       • Age > 65
       • BMI > 35
       • Chronic kidney disease (Stage 4 and above, ESRD)
       • Diabetes on insulin or oral hypoglycemic agent
       • Age > 55 with COPD, Interstitial Lung Disease, Cystic Fibrosis, or Pulmonary Fibrosis
       • Age > 55 with hypertension, coronary artery disease, or congestive heart failure
       • Immunosuppressive condition: solid organ transplant, advanced AIDS, active chemotherapy, end-stage liver disease, use of biologics for underlying disease, TNF alpha inhibitor for RA or Crohn’s, chronic high dose steroids
     • At the present time, prophylactic treatment is not offered
6. AVICOVID-2 Clinical Trial – KH Main Campus only
   • Inhaled vasointestinal peptide (VIP) analog
   • Randomized, double-blind, placebo-controlled trial
   • Contact KH Research staff for screening
   • Inclusion criteria:       
     • COVID-19 + within the last 7 days
     • Patients requiring low-flow supplemental oxygen, full code, no terminal underlying condition
     • RA O2 sat < 94%, or RR > 30, or PaO2/FiO2 <300
   • Exclusion criteria:
     • Critical COVID-19 requiring HHFNC oxygen, invasive mechanical ventilation, ECMO, multi-organ dysfunction, MAP < 65 mm of Hg
     • Immunosuppressive therapy for transplant or other high mortality disease
     • MI within last 6 months or troponin > 0.5
     • PE/DVT within 3 months
     • New diagnosis of atrial fibrillation within 3 months (older, well-controlled afib allowed)
     • Watery diarrhea requiring 1L + of IV fluids