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Blog articles are provided as informational purposes only and are not intended to constitute medical advice. Medication protocols are subject to patient’s medical provider’s authorization.

 

1.  Inhalers with valved holding chambers (VHCs): use over nebulizers if clinically appropriate for your hospice patients with confirmed or suspected COVID-19.

A number of hospice COVID19 cases will still be more appropriate for nebs (e.g. if patient has severe, life-threatening respiratory symptoms, or is unable to use a chamber). The recommendations to prefer inhalers with VHCs over nebulizers is to reduce the amount of potentially infectious aerosol dispelled into the air during nebulization.1

2.  NSAIDs: use when clinically appropriate.

The WHO and FDA do not recommend against use of NSAIDs at this time, as there is not enough information to recommend against their use.2,3

News reports had echoed a March 11, 2020 letter4 in the Lancet Medical journal suggesting that a particular enzyme (ACE2) is increased by NSAIDs, which could aggravate COVID-19 symptoms. NSAIDs are known to reduce inflammation and mask fevers, but no evidence that they worsen symptoms related to COVID-19 has been demonstrated thus far. However, for other reasons, such as renal impairment, cardiovascular disease and bleeding history, NSAIDs may not be appropriate in many hospice patients.

3.  Oral Steroids: for hospice patients in particular, use when clinically appropriate.

In hospice patients with COVID-19, consider continued use of oral steroids if there is some other indication or condition supporting their use. It's likely ok to add them for acute symptom management of breathlessness, as the benefit probably still outweighs the risk in short prognosis and acute symptoms. Existing evidence is inconclusive for steroid treatment of COVID-19 patients, and especially those on hospice.

WHO and CDC recommend that corticosteroids not be routinely used in patients with COVID-19 for treatment of viral pneumonia or ARDS unless indicated for another reason (e.g., asthma or COPD exacerbation, septic shock).5 However, this does not consider the end-of-life population. 

4.  ACE inhibitors: continue if clinically appropriate

The American Heart Association, the Heart Failure Society of America, and the American College of Cardiology (ACC) issued a joint statement urging patients with cardiovascular disease diagnosed with COVID-19 to continue taking their ACE inhibitors and ARBs as prescribed.6 Evidence does not support discontinuation if infected with COVID-19, and the benefits are expected to outweigh risks. However, for other reasons, such as low blood pressure, dysphagia, or overall decline, ACE inhibitors may not be appropriate to continue in all hospice patients.

5.  Off-Label use of medications to prevent or treat COVID-19 infection: AVOID

Examples include hydroxychloroquine, chloroquine, azithromycin, quercitin, and others. No medication is currently FDA approved for COVID-19 prevention or treatment, as their safety and efficacy have not been established in clinical trials. Use of medications for COVID-19 would be off-label, and is not recommended.

The FDA recently issued an emergency use authorization (EUA) for hydroxychloroquine and chloroquine to be used from the Strategic National Stockpile (SNS), for the treatment of certain hospitalized teens and adults with COVID-19.7 EUAs enable new products or new uses for existing drugs without clinical trials, if the benefits appear to outweigh the known risks, and there are no alternatives. This EUA does not support use of hydroxychloroquine or chloroquine outside of those terms (i.e. for prevention, or in non-hospitalized patients). Regardless, most hospice patients do not meet these criteria, and goals of care do not typically align with curative treatment.

In hospice patients, including those with confirmed or suspected COVID-19, continue to carefully evaluate goals of care if considering treatment for COVID-19. We do not recommend any medications for prevention of COVID-19 at this time. We recommend reserving hydroxychloroquine, chloroquine, and other antibiotics for when the patient has an FDA-approved indication for one of these medications. However, due to widespread but unsupported off-label use and hoarding, there are now significant shortages of these medications, impacting those patients with approved indications, such as lupus and rheumatoid arthritis.

Many therapies for management of symptoms related to COVID-19 or other conditions exist. Please contact a ProCare HospiceCare clinical pharmacist at 866-264-7496 for patient-specific recommendations.

 

Written by:  Kristin Speer, Pharm.D. BCPS

 

References:

  1. Amirav I, Newhouse T. ‘RE: Transmission of Corona Virus by Nebulizer- a serious, underappreciated risk!’ CMAJ. 3 March 2020. URL: https://www.cmaj.ca/content/re-transmission-corona-virus-nebulizer-serious-underappreciated-risk
  2. WHO communication via Twitter, March 18, 2020. https://twitter.com/WHO/status/1240409217997189128
  3. FDA advises patients on use of non-steroidal anti-inflammatory drugs (NSAIDs) for COVID-19. FDA Website. Accessed April 4, 2020. URL: https://www.fda.gov/drugs/drug-safety-and-availability/fda-advises-patients-use-non-steroidal-anti-inflammatory-drugs-nsaids-covid-19
  4. Fang L et al. Are patients with hypertension and diabetes mellitus at increased risk for COVID-19 infection? Lancet Respir Med2020 Mar 11; [e-pub]. (https://doi.org/10.1016/S2213-2600(20)30116-8)
  5. Interim Clinical Guidance for Management of Patients with Confirmed Coronavirus Disease (COVID-19). CDC Website. Accessed April 4, 2020. URL: https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html
  6. Patients taking ACE-i and ARBs who contract COVID-19 should continue treatment, unless otherwise advised by their physician: Statement from the American Heart Association, the Heart Failure Society of America and the American College of Cardiology [press release]. 2020 Mar 17. (https://www.hfsa.org/patients-taking-ace-i-and-arbs-who-contract-covid-19-should-continue-treatment-unless-otherwise-advised-by-their-physician/)
  7. FDA Emergency Use Authorization For Use of Chloroquine Phosphate or Hydroxychloroquine Sulfate Supplied From the Strategic National Stockpile for Treatment of 2019 Coronavirus Disease. March 28,2020. URL: https://www.fda.gov/media/136534/download
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