COVID/Omicron - What's your treatment protocol now?

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So, it's been 2 years or so and I know most of us are bored by COVID/Omicron. BUT, it might be helpful to update each other on how we are treating COVID/Omicron patients nowadays. What's your protocol? Are you offering any therapeutics... and to whom?
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No change compared to Delta.

If sick, give 6mg decadron IV and admit. Hospitalist takes it from there.
If not sick, but is a generally sick person: DC home with instructions to call PCP for possible monoclonals (we don't do that in my ED).
If not sick: DC. Drink fluids, take NSAIDS, go away.
 
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I don't expect much change. It's basically just steroids and immunomodulators on this end, which shouldn't be variant-specific.

We've not ever had monoclonals, doubt molnupiravir will meet final MedSafe approval, will probably see first doses of nirmatrelvir arrive in a month or two.
 
Admitted a 6yo to the PICU with MIS-C last night.

I must admit, this is getting old.
 
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Regeneron (casirivimab and imdevimab) and Eli Lilly (bamlanivimab) are not effective against Omicron. And right now I'm assuming everybody has Omicron because it's penetrance is like 85-90% last I checked.

There is very little treatment, if any, that I offer. My workflow:

Code: 
if (symptoms sound like COVID) {
   if (SpO2 > 90% RA or if borderline, exertional SpO2 > 90% RA) {
      // there is basically nothing I do for definitive treatment in this group, e.g. no MABs
      // 99 of 100 people in this group get discharged, and the one that doesn't must fight to be admitted

      - reciteShpeel("there is nothing to do.  Hope you don't get sick.  
        You are putting up the good fight.  COVID is at least 10x worse than flu.  
        You are going to do fine.  Don't see Grandma or Grandpa over the next week.  
        No, you can't have ivermectin.");
  
      if (random number between 1-100 is > 3) {
         - reciteShpeel("Please consider getting vaccinated after you recover from this.");
      }

      // however there are special subpopulations that I might do something:
  
      if (vitals are out of whack for routine COVID infection) {
         - they still prob. have COVID, but I consider PE, bacterial PNA, etc.  workup accordingly
      }
      else if (age > 70ish) {
         - I usually send CXR and basic labs, but mostly for show. People can't fathom 
         - going to the doctor and doing nothing.  I still don't treat though.
      }
      else if (super demented or bedbound w/ poor protoplasm) {
         - send basic labs and CXR
         - reciteShpeel("Oh your demented, mute mother is dehydrated!");
         - give 1L LR
         - give ofirmev
      }

      - send COVID Rapig Ag test
      - +/- supportive care meds (Toradol, tylenol, zofran, promethazine, etc).
      - discharge immediately, callback if (+), do not callback if (-).  
   }
   else {
      // here SpO2 < 90%
      // you get admitted
  
      - BMP, Mg, CBC, LFTs, Lactate, BCx x2, Ferritin, C-RP
      - CXR
      - COVID PCR test
      - supportive care meds if needed
      - ADMIT
   }
}
 
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That's amazing

I wonder if I can integrate that into EPIC somehow and it just orders everything I need and the chart auto-signs itself before I even see the patient
 
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I had such good formatting on this too and have modified my code several times...but it continues to do left justify all lines.

EDIT: fixed it
 
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For me, no difference w/ regard to omicron than prior, with the notable exception that the MaB's that I have currently have access to are ineffective against this variant.

Outpatient management (typically no or minimal ED w/u. Wish I could get the others here to stop wasting time ordering labs and CTs on these people):
--for the young, non-coomorbid: test and gtfo ("someone might give you a call if the test comes back positive, “¯\_(ツ)_/¯
--for the comorbid (esp if unvaxxed): offer fluvoxamine +/- inhaled budesonide. Will switch to Paxlovid or molnupiravir as these become available (choice will depend on age and potential med interactions. Although honestly, just read the molnupiravir study and it's frankly unimpressive as a therapy. Does anyone have a link to the paxlovid study? I can't find it, maybe it hasn't been published yet?)

Pt's getting admitted:
--mildly unwell, hypoxic but stable on low flow 02: 6 mg dexamethasone (usually PO). Usually .5 mg/kg sc enoxaparin (should start having convo w/ hospitalist regarding therapeutic anticoagulation). Rarely order abx or advanced imaging.
--moderately unwell, eg HFNC, escalating 02 needs in ED: methylprednisolone 125 mg vs low dose dex, depending on whether I think hospitalist will consider advanced immunomodulators. Enoxaparin as above. Consider abx or CT if clinical picture and CXR don't fit w/ typical covid, which is uncommon.
--severely unwell, eg on PPV (noninvasive or invasive). As above but spend way too long arguing w/ RT about vent management
 
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RustedFox said:
This coding thing must be some programming joke that I'm too cool to understand.
Click to expand...

The best line of code above is

Code: 
if (random number between 1-100 is > 3) {
      - reciteShpeel("Please consider getting vaccinated after you recover from this.");
}

Which is my way of poking fun at those who are not vaccinated
 
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Often nothing and a lot of reassurance.

Inhaled budesanide 400mcg BD for 14 days if they would meet inclusion criteria for the PRINCIPLE trial (age greater than 65 or greater than 50 with a risk factor for disease progression).

Refer for sortrovimab if they're unvaccinated and would meet inclusion criteria for the COMET-ICE trial (including age greater than 55).

SpO2 less than 92% at rest gets a CXR, usual bloods including baseline procalcitonin, PO/IV dexamethasone 6mg and likely admission. High suspicion for mimics with very late or very early decompensation.

From the intensive care point of view, I have been tremendously disappointed with remdesivir, tocilizumab, and baricitinib. There might be a role for early remdesivir as per the PINETREE trial, but I think once good-going lung infiltrates develop, your only hope is steroids, good organ support, and time.

Not at all impressed with fluvoxamine. Needs more research.
 
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Are you guys recommending treatment based on information from ongoing trials?
PRINCIPLE?
COMET-ICE?

Or have these trials been completed.

Basically...at this stage of the game...I do what my hospital asks me to do. I'm not going to keep up to date with all of these trials, and whether they are appropriately powers or good trials or are valid or whatever.

The reason why I don't get a CXR with SpO2 91-93% is it's not going to change my management. I send them home. It doesn't matter if the CXR is normal or abnormal with multifocal fluffy patches of consolidation. I don't send these patients home with antibiotics either especially if they tested positive for COVID.
 
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I do CXR for admitted patients to keep the hospitalist happy and for patient satisfaction reasons only (after explanation why the CXR won't actually change management)

I think we have 100 pills of paxlovid for our entire health system, so I think you have to be 100 YO unvaccinated with CHF and Obese and HIV (or a rich donor I guess) to probably meet criteria as I don't think I can even order it.

If hypoxic, but oxygen is only 2 L and reasonablly well appearing, I will have shared decision making of going home with home O2, home heatlh, and decadron script. Most people take this.

If greater than 2 L at rest, I admit and remdesivir on top of decdaron if they meet criteria.

MAB (sotromivab) referral requirements varies so much week by week at this point depending on supply, it's hard for me to keep track. But right now I think it's 4 days of symptoms or less + high risk + unvaccinated for our system.
 
thegenius said:
Are you guys recommending treatment based on information from ongoing trials?
PRINCIPLE?
COMET-ICE?

Or have these trials been completed.

Basically...at this stage of the game...I do what my hospital asks me to do. I'm not going to keep up to date with all of these trials, and whether they are appropriately powers or good trials or are valid or whatever.

The reason why I don't get a CXR with SpO2 91-93% is it's not going to change my management. I send them home. It doesn't matter if the CXR is normal or abnormal with multifocal fluffy patches of consolidation. I don't send these patients home with antibiotics either especially if they tested positive for COVID.
Click to expand...

These trials have been completed. They form the basis of our treatment guidelines. Knowing the inclusion criteria keeps me from slipping into indication creep. The criteria are also part of our treatment protocols.
 
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turkeyjerky said:
For me, no difference w/ regard to omicron than prior, with the notable exception that the MaB's that I have currently have access to are ineffective against this variant.

Outpatient management (typically no or minimal ED w/u. Wish I could get the others here to stop wasting time ordering labs and CTs on these people):
--for the young, non-coomorbid: test and gtfo ("someone might give you a call if the test comes back positive, “¯\_(ツ)_/¯
--for the comorbid (esp if unvaxxed): offer fluvoxamine +/- inhaled budesonide. Will switch to Paxlovid or molnupiravir as these become available (choice will depend on age and potential med interactions. Although honestly, just read the molnupiravir study and it's frankly unimpressive as a therapy. Does anyone have a link to the paxlovid study? I can't find it, maybe it hasn't been published yet?)

Pt's getting admitted:
--mildly unwell, hypoxic but stable on low flow 02: 6 mg dexamethasone (usually PO). Usually .5 mg/kg sc enoxaparin (should start having convo w/ hospitalist regarding therapeutic anticoagulation). Rarely order abx or advanced imaging.
--moderately unwell, eg HFNC, escalating 02 needs in ED: methylprednisolone 125 mg vs low dose dex, depending on whether I think hospitalist will consider advanced immunomodulators. Enoxaparin as above. Consider abx or CT if clinical picture and CXR don't fit w/ typical covid, which is uncommon.
--severely unwell, eg on PPV (noninvasive or invasive). As above but spend way too long arguing w/ RT about vent management
Click to expand...
fluvoxamine?
 
Are your labs regularly reporting variant type ? Mine does not

That being said for sick inpatients on supplemental O2 we use a combo of dex, rem +/- baricitinib +/- toci
 
So there IS a recent change in the NIH recommended inpatient treatment—
www.covid19treatmentguidelines.nih.gov

Antithrombotic Therapy | COVID-19 Treatment Guidelines

Read about the use of drugs to reduce blood clot formation in people with COVID-19.
www.covid19treatmentguidelines.nih.gov

The punchline is that they recommend in patients admitted on low flow oxygen (floor admissions) if their DDIMER is Elevated, they should be on THERAPEUTIC dosed Lovenox while upstairs, NOT prophylactic dose. This does NOT hold true for ICU admissions, who should only be on prophylactic dose unless they develop actual DVT/PE.

I did this a couple times on Monday with my admissions, and just got very confused calls from pharmacy and hospitalist about what in the world I was doing :). It is rather brand new advice.

Otherwise I mostly do what people about say—
—Super well appearing, D/C with symptomatic management.
—Moderately well appearing, some comorbities. But oxygenating fine. I often get a portable chest X-ray, if they are old I often get basic labs (mostly to check renal function). Home w/ symptomatic care after an ambulatory trial to ensure their 02 doesn’t drop massively.
—Well appearing but a ****-ton of baseline issues and advanced age… I can refer via our system to a centralized sortrovimab center, with extremely limited amount available. Mostly with these its encourage them to drink and to come back If(when) they get worse in a few days.

I have found a lot of reasonably well appearing people I see with normal vitals that I’m sending home DO have asthma, and have mild/moderate flare and I do burst these with steroids.

I also am seeing at least 1 visit a day for such severe sore throat that they aren’t taking POs… I typically do for these the same I’d do for any pre-COVID sore throat, with various analgesics, 1x dose decadron orally, and a pep talk about hydration.

As far as people that look sick, or have Oxygen levels <92% on arrival, I do tend to load the boat and get everything— CBC, CMP, DDIMER, CRP, Troponin, Portable chest X-ray, EKG. I typically do not get ferritin, ESR, or pBNP. Since I’m 85% sure I’m admitting them when I meet them, I want to get all that info… and you do find the occasional NSTEMI, and I believe there is some inpatient prognostic value to knowing the CRP and/or DDIMER incredibly elevated. I given them 6mg IV Decadron, and sometimes 8mg if they look ICU level on arrival. Otherwise its largely supporting care.
 
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The kitchen sink said:
Are your labs regularly reporting variant type ? Mine does not

That being said for sick inpatients on supplemental O2 we use a combo of dex, rem +/- baricitinib +/- toci
Click to expand...
My understanding is the most recent data for remdesivir shows no benefit. Our hospitalist do not routinely use it anymore.

The data to support IL-6 inhibitors (toci and baricitinib) only shows benefit (although fairly significant--I recall ~35% reduction in mortality) in patients on high levels of support (basically HFNC, NPPV, intubated + MV).

Im not sure why you would use both Baricitinib and tocilizumab (basically one or the other). We use which ever one we have in stock at the moment (frequently fluctuates).

The only treatment I am sure of is decadron 6mg PO for hypoxic patients (or solu-medrol IV if unable to take PO).

I differ to the hospitalist what to do with AC. Some get a dimer and pending the level do therapeutic lovenox (policy seems to shift frequently) vs. get CTPA inpatient to determine if truly a PE (I no longer do this in the ER for throughput issues because we are being crushed by covid volume).

Generally running these patients "dry" (little IV fluids, some lasix).

I refer some borderline outpatients for sotromivimab. Tho ultimately a different group of people make the final decision in our system who actually gets it as supply is limited. I presume all cases now are omicron and other mabs are useless.

We do not have paxlovid/molnupiravir available in our city yet. Data on paxlovid looks strong, I'm looking forward to using it when available.

For non hypoxic patients going home I offer them whatever Rx for supportive care for the symptoms bothering them the most (cough suppressant, decongestants, etc.) but I make it clear these will not actually "cure" the underlying covid infection, only help symptoms. For many of these patients that don't feel strongly they just get a pulse oximeter and return precautions. Many do come back hypoxic few days later.
 
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RoyBasch said:
My understanding is the most recent data for remdesivir shows no benefit. Our hospitalist do not routinely use it anymore.

The data to support IL-6 inhibitors (toci and baricitinib) only shows benefit (although fairly significant--I recall ~35% reduction in mortality) in patients on high levels of support (basically HFNC, NPPV, intubated + MV).

Im not sure why you would use both Baricitinib and tocilizumab (basically one or the other). We use which ever one we have in stock at the moment (frequently fluctuates).

The only treatment I am sure of is decadron 6mg PO for hypoxic patients (or solu-medrol IV if unable to take PO).

I differ to the hospitalist what to do with AC. Some get a dimer and pending the level do therapeutic lovenox (policy seems to shift frequently) vs. get CTPA inpatient to determine if truly a PE (I no longer do this in the ER for throughput issues because we are being crushed by covid volume).

Generally running these patients "dry" (little IV fluids, some lasix).

I refer some borderline outpatients for sotromivimab. Tho ultimately a different group of people make the final decision in our system who actually gets it as supply is limited. I presume all cases now are omicron and other mabs are useless.

We do not have paxlovid/molnupiravir available in our city yet. Data on paxlovid looks strong, I'm looking forward to using it when available.

For non hypoxic patients going home I offer them whatever Rx for supportive care for the symptoms bothering them the most (cough suppressant, decongestants, etc.) but I make it clear these will not actually "cure" the underlying covid infection, only help symptoms. For many of these patients that don't feel strongly they just get a pulse oximeter and return precautions. Many do come back hypoxic few days later.
Click to expand...
The data for the new oral antivirals looks pretty good, but they have a shocking number of significant drug interactions. I've written for it once so far in a patient who was on no medicines otherwise, but I think this thing is going to be a pain in the butt to try and figure out who it's safe for.
 
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RoyBasch said:
My understanding is the most recent data for remdesivir shows no benefit. Our hospitalist do not routinely use it anymore.

The data to support IL-6 inhibitors (toci and baricitinib) only shows benefit (although fairly significant--I recall ~35% reduction in mortality) in patients on high levels of support (basically HFNC, NPPV, intubated + MV).

Im not sure why you would use both Baricitinib and tocilizumab (basically one or the other). We use which ever one we have in stock at the moment (frequently fluctuates).

The only treatment I am sure of is decadron 6mg PO for hypoxic patients (or solu-medrol IV if unable to take PO).

I differ to the hospitalist what to do with AC. Some get a dimer and pending the level do therapeutic lovenox (policy seems to shift frequently) vs. get CTPA inpatient to determine if truly a PE (I no longer do this in the ER for throughput issues because we are being crushed by covid volume).

Generally running these patients "dry" (little IV fluids, some lasix).

I refer some borderline outpatients for sotromivimab. Tho ultimately a different group of people make the final decision in our system who actually gets it as supply is limited. I presume all cases now are omicron and other mabs are useless.

We do not have paxlovid/molnupiravir available in our city yet. Data on paxlovid looks strong, I'm looking forward to using it when available.

For non hypoxic patients going home I offer them whatever Rx for supportive care for the symptoms bothering them the most (cough suppressant, decongestants, etc.) but I make it clear these will not actually "cure" the underlying covid infection, only help symptoms. For many of these patients that don't feel strongly they just get a pulse oximeter and return precautions. Many do come back hypoxic few days later.
Click to expand...
Generally agree. In my post I meant to say either or tocilizumab not +/-
 
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VA Hopeful Dr said:
The data for the new oral antivirals looks pretty good, but they have a shocking number of significant drug interactions. I've written for it once so far in a patient who was on no medicines otherwise, but I think this thing is going to be a pain in the butt to try and figure out who it's safe for.
Click to expand...
Depending on the interaction in question, would you discontinue the chronic med paxlovid interacts with so the patient can take paxlovid and then resume a few days after they finish treatment and clear the paxlovid?
 
RoyBasch said:
Depending on the interaction in question, would you discontinue the chronic med paxlovid interacts with so the patient can take paxlovid and then resume a few days after they finish treatment and clear the paxlovid?
Click to expand...
Probably would depend on the meds in question.
 
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Remdesivir to anyone on O2 or initially <94% and within 7 days of symptom onset. Not ordering if they get intubated.
Dexamethasone to anyone requiring supplemental oxygen or intubation.
Tocilizumab or Baricitinib to anyone intubated or on HFNC and heading that direction, + elevated inflammatory markers (D-dimer for us)

For those stable for discharge we do not have Sotrovimab in-house, and I honestly wouldn't know who to recommend the oral antivirals for given supply issues and that being human is essentially a "risk factors" for disease progression.
 
mild: dc with Tessalon if I am in a good mood and they aren’t a jerk
Hypoxemia: usually CTA, procal, dimer, decadron, hospitalist does remdesivir upstairs

Family of 6 all wanting a covid test: do everything I can to make them feel bad for abusing the ER and not being vaccinated, and GTFO as soon as possible

Conspiracy theorists: give supra-equine doses of ivermectin, betadine gargles TID, PICC line for bleach q24h, and lasix to facilitate drinking their own urine
 
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I just do whatever the hospital protocol is for the week which depends also on what we have in stock.

In the end I dont get the impression anything wete doing is helpful. By the time they get to me, they either die in a werk or two or end up with a trach and goto trach peg land. Pretty damn rare that they then around and we actually extubate them.
 
panscan said:
mild: dc with Tessalon if I am in a good mood and they aren’t a jerk
Hypoxemia: usually CTA, procal, dimer, decadron, hospitalist does remdesivir upstairs

Family of 6 all wanting a covid test: do everything I can to make them feel bad for abusing the ER and not being vaccinated, and GTFO as soon as possible

Conspiracy theorists: give supra-equine doses of ivermectin, betadine gargles TID, PICC line for bleach q24h, and lasix to facilitate drinking their own urine
Click to expand...

You CTA every hypoxic covid? Holy ****. Seems very unnecessary.
 
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Rekt said:
You CTA every hypoxic covid? Holy ****. Seems very unnecessary.
Click to expand...
Agreed…this is really what medicine has come to expect and ask for unfortunately…9 out of 10 are negative for PE and most are non diagnostic due to body habitus
 
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Rekt said:
You CTA every hypoxic covid? Holy ****. Seems very unnecessary.
Click to expand...
Either we do it in the ER, or they do it in the ICU.

Most of my hypoxemic COVID patients have enough comorbidities to look for something else in addition to COVID.
 
thegenius said:
Seems like every COVID PNA with o2 requirements have markedly elevated dimers. Like over 10-15.
Click to expand...
I don't order any dimers on any covid patients or possible covids. Puts yourself into some useless box of getting a CTA.

I base my CTA off a multitude of factors. Most covid patients I see, and we see a ridiculous amount, aren't tachycardic regardless of how severe their hypoxia is. If there is an unresponsive tachycardia (antipyretics, ibuprofen, + LR) that slightly increases my concern. Or a "double sickening" component of acutely worsening dyspnea/DOE. Concerning pleuritic component that isn't it just hurts when I cough. Then plus all the normal risk factors.
 
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Rekt said:
I don't order any dimers on any covid patients or possible covids. Puts yourself into some useless box of getting a CTA.

I base my CTA off a multitude of factors. Most covid patients I see, and we see a ridiculous amount, aren't tachycardic regardless of how severe their hypoxia is. If there is an unresponsive tachycardia (antipyretics, ibuprofen, + LR) that slightly increases my concern. Or a "double sickening" component of acutely worsening dyspnea/DOE. Concerning pleuritic component that isn't it just hurts when I cough. Then plus all the normal risk factors.
Click to expand...
Agreed. Getting a dimer on a covid patient is almost never indicated in the ED in my mind. Getting a CTA on all covid patients is bats*** insane to me. If the hospitalist wanted to do that, I'd tell them that they can obviously do whatever they want once the patient is admitted but that doing it in the ED isn't indicated (absent some other reason to scan them as well described by @Rekt above). If they really push back, you can just offer to give the patient 1mg/kg lovenox before they go up while waiting for their inpatient CTA.

There's defensive medicine and there's sheer idiocy. Getting a CTA on every admitted covid patient is the latter.
 
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BoardingDoc said:
Agreed. Getting a dimer on a covid patient is almost never indicated in the ED in my mind. Getting a CTA on all covid patients is bats*** insane to me. If the hospitalist wanted to do that, I'd tell them that they can obviously do whatever they want once the patient is admitted but that doing it in the ED isn't indicated (absent some other reason to scan them as well described by @Rekt above). If they really push back, you can just offer to give the patient 1mg/kg lovenox before they go up while waiting for their inpatient CTA.

There's defensive medicine and there's sheer idiocy. Getting a CTA on every admitted covid patient is the latter.
Click to expand...

I rarely if ever get dimers for Covid pts, but I do order crp and ferritin largely for the inpatient to follow because they want that. But I don’t wait to admit them. Yet as it turns out, those two come back quickly at my hospital
 
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On the critical care side, steroids, steroids, and more steroids for the most part. At least Dex 6 daily, more likely BID for any sort of mechanical ventilation. Depending on the course there's often a pulse dose component somewhere. At the main hospital I'm at we're using a lot of Olumiant if the kidney function isn't terrible. At the other, one of the critical care attendings is swearing by plasma exchange for cytokine storm (from what I can find, lots of case series, but no randomized controlled trials).


In regards to the ED workup, I honestly don't care. The hospital wants a CRP before Olumiant is started, but those come back quickly. I honestly don't care about ferritin or dimers (most people get started on theraputic anticoagulation anyways, including all of the Olumiant patients). My unscientific preference for monitoring inflammation is CRP... but I can always start tracking that in the next day's AM labs anyways.
 
BoardingDoc said:
Agreed. Getting a dimer on a covid patient is almost never indicated in the ED in my mind. Getting a CTA on all covid patients is bats*** insane to me. If the hospitalist wanted to do that, I'd tell them that they can obviously do whatever they want once the patient is admitted but that doing it in the ED isn't indicated (absent some other reason to scan them as well described by @Rekt above). If they really push back, you can just offer to give the patient 1mg/kg lovenox before they go up while waiting for their inpatient CTA.

There's defensive medicine and there's sheer idiocy. Getting a CTA on every admitted covid patient is the latter.
Click to expand...
If they're hypoxemic and the chest x-ray doesn't seem consistent with it or they're not wheezing, then I'll get a CTA. Our intensivists and hospitalist monitor d-dimers. If the dimers become elevated, they empirically start them on a NOAC. Our normal is <500. I think they start NOAC's around 1000, but don't quote me on that.
 
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some of my colleagues spend a lot of time and energy worrying about getting people Paxlovid. it’s never really available around here from what I’ve seen so I don’t really bother. am I a bad person/doctor?
 
I’m not using it, but as another poster mentioned, fluvoxamine seems to show real promise, with good results in RCTs. Frankly, I’m surprised it’s not getting more attention…
 
bravotwozero said:
I’m not using it, but as another poster mentioned, fluvoxamine seems to show real promise, with good results in RCTs. Frankly, I’m surprised it’s not getting more attention…
Click to expand...

Not for lack of trying by some ID docs. A prof from my former university who has expertise in clinical trials is advocating its use. There’s at least as much evidence in support of it as other stuff that got approved. There was an ID journal club discussing it on twitter and the biggest concern in that group was how generalizable the main study was. They had to change a definition from hospitalization to something like observation in ED greater than x hours because there were no more beds to admit people to. So there was some confusion and concern about that.

A good portion of the group would like to see more trial data (trial going on in the US still) but would use it if other better studied options were not available to them. (this was before omicron).
 
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