Episode 484: Top takeways for hospital pharmacists from the NEJM editors discussion on treating Covid-19

In this episode, I’ll discuss a recent discussion hosted by 2 editors of NEJM on treating Covid-19.

On March 5th Doctors Eric Rubin and Lindsey Baden, two editors for the New England Journal of Medicine, published a discussion on the treatment of patients with the Covid-19 virus. Although the number of confirmed cases is low in the US at the time of this recording, it is likely to increase and the topic is weighing on the minds of many of us, so in this episode I will share the 4 points they made that are relevant to hospital pharmacists.

1. The phenotype of this disease may be different than previously thought. Of the most significantly ill patients – the ones that may end up in our ICU with respiratory illnesses – only about half had a fever on presentation. The available data on the phenotype of this disease is still murky but it is likely to clarify rapidly in the next week or so as more cases are analyzed.

2. Good supportive care is our only treatment option at this point, and knowing the diagnosis doesn’t do anything to change patient management.

3. The transmission dynamic based on available data seems similar to influenza, so expect standard “respiratory precautions” to be used when caring for these patients in an inpatient environment.

4. There will be a great temptation amongst clinicians to want to use existing medications that have in vitro or theoretical reports of activity against Covid-19. These include chloroquine, lopinavir-ritonavir, ACE inhibitors, and IVIG. These “off-the-shelf ” options are attractive to clinicians because they are already familiar with their use, dosage, and side effects.  However, at this point, it is premature to think that they actually work.

A few points about treatment that the editors didn’t mention:

1. There is a serious risk using an ACE inhibitor to the effectiveness of supportive care. Blood pressure in a patient in shock is much harder to maintain if they are on a concomitant ACE inhibitor.

2. Both the WHO and CDC recommend not using steroids in patients with Covid-19 unless there is another compelling reason. This is based on the negative or neutral effects of using steroids in patients with SARS, MERS, and influenza.

3. In the first US case discussed in NEJM clinicians were able to obtain the antiviral remdesivir on a compassionate use basis from the manufacturer Gilead. Requests for compassionate use must be made to Gilead by the patient’s treating physician, however, pharmacists are often in a place to help facilitate this request.  Currently, Gilead maintains a webpage with the status of remdesavir, and they provide an email address, coronavirus.response@gilead.com, to initiate the process of making a compassionate use request.

To access my free download area with 20 different resources to help you in your practice, go to pharmacyjoe.com/free.

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If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.

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