Coronavirus Infection

Coronavirus Infection D R. C HI NAZOR E GB UONU (PHARMD. , R P H. ) WES T C OAS T UNI V ERS I TY S C HOOL OF PHARMAC Y TEAC HI NG C ERTI FI C ATE PROGRAM MENTO RS : DR OFS TAD & DR S U L EE Coronavirus infection (Covid-19) is an acute respiratory disease caused by SARS-CoV-2. SARS-CoV-2 is a novel coronavirus related to SARS-CoV. Introduction Transmission is through person-to-person (by both symptomatic and asymptomatic persons), through close contact (within 6 feet), and via respiratory droplets. Transmission can also occur through droplets and formites from infected persons. 3 Caused pandemic in 2019. Outbreak is believed to have started from Wuhan, China. Epidemiology Virus spread is quick and rapid. Affected mostly adults. About 700M+ confirmed cases of COVID-19 including 6,927,088 deaths worldwide reported by World Health Organization (WHO) as of May 7, 2023. 4 Pathogenesis SARS-CoV-2 infects cells in a similar manner to other virulent coronaviruses. Early in infection, SARS-CoV-2 infects nasal and bronchial epithelial cells and pneumocytes. - inflammatory response is initiated, which recruits T cells, monocytes, and neutrophils. Later stages of infection, viral replication accelerates, and epithelial-endothelial barrier integrity is compromised.. - SARS-CoV-2 can cause direct and indirect endothelial cell damage and thrombo-inflammation Dysregulated inflammatory response ("cytokine storm"). - further recruits monocytes and neutrophils, which w jinfiltrate airspaces, causing a • Alveolar interstitial thickening. 2 • Increased vascular permeability. • Pulmonary edema. 3 5 Risk Factors Close (< 6 feet). 2 People with comorbidity. 3Prolonged (≥ 15 minutes) contact with person. With symptomatic COVID-19 between 48 hours prior to symptom onset. Positive COVID-19 test without symptoms between 48 hours of specimen collection. 6 Mild-severe symptoms may arise 2-14 days after exposure Common symptoms include Clinical presentation • fever or chills • cough • shortness of breath or difficulty breathing • fatigue • muscle or body aches • headache • new loss of smell or taste • sore throat • congestion or runny nose • nausea or vomiting • diarrhea 7 Diagnosis NIH guideline recommends: • Nucleic Acid Amplification Testing (NAAT) with a sample collected from upper respiratory tract (nasopharyngeal, nasal mid-turbinate, anterior nasal, or oropharyngeal sample) should be used to diagnose acute COVID-19. - Antigen testing may be used if NAAT is not practical or unavailable. • Intubated and mechanically ventilated adults with suspected COVID-19 - Obtaining lower respiratory tract samples recommended if initial upper respiratory tract sample is negative - When obtaining lower respiratory samples, endotracheal aspirates recommended over bronchial wash or bronchoalveolar lavage samples. • In asymptomatic persons with previous SARS-CoV-2 infection, NAAT should not be used within 90 days of previous infection, except in healthcare workers. 8 Covid-19 Treatment GOAL Reduce transmission 2 Provide symptoms relief 3 Prevent progression to severe disease, hospitalization or death Factors Affecting Treatment Selection I Clinical efficacy and the availability of the treatment option Oh 2 The feasibility of administering parenteral medication. 3 Potential for significant drug-drug interaction u Time from symptom onset In-vitro activities of the available products against the currently circulating SARS-CoV-2 variants gBYE and sub variants. bit 10 Supportive treatment • All patients would require supportive treatment to provide symptoms relief. a analgesics, or antitussives for fever, headache, myalgias, and cough. • Use of antipyretics, • Patients should be advised to drink fluids regularly to avoid dehydration. • Rest is recommended as needed during the acute phase of COVID-19 Ambulation and other forms of activity should be increased according to the patient’s tolerance. me walkor • move rend • Patients should be educated about the variability in time to symptom resolution and complete recovery - Others Includes: • Respiratory management of hypoxemia and acute respiratory distress syndrome (ARDS.) • Hemodynamic support for sepsis and septic shock. • Anticoagulation for thromboprophylaxis or management of coagulopathy. • Use of dexamethasone or other corticosteroid is NOT recommended in the absence of other indication. 11 Therapeutic treatment Decision to treat inpatient or outpatient would depend on the following: • Patients with mild illness (absence of viral pneumonia and hypoxia) often do not require hospitalization. Notenoughor • Patients with moderate illness may require hospitalization based on comorbidities and risk for clinical progression • Risk factor for clinical progression includes • z• • • s• • z 6 Immunocompromised patient (organ transplant, cancer) Cerebrovascular disease/heart conditions Obesity Chronic lung disease Chronic kidney injury Aged >50 years especially those aged >/= 65 years. 12 Non hospitalized patient with mild to moderate Covid-19 with no oxygen requirement a ▪ Provide supportive therapy. 2 ▪ Do Not administer corticosteroid in the absence of another indication. 3 ▪ For Patients at risk of progressing to severe Covid-19 Drug Dose Duration Adverse reaction a Paxlovid (Ritonavir 300mg/100mg PO 5 days boster nirmatrelvir 2x daily 2 Remdesivir 200mg IV day. 100 3 days mg IV daily DDI Treatment Pearls Bad taste, diarrhea Strong CYP3A4 and PGP inhibitor Use with 5 days of sx onset Do not use Crcl <30ml/min LFT abnormality, bradycardia, hypotension, infusion reaction Use with 7 days of sx onset Chlọroquine and hydroxychlorquine may diminish efficacy 13 Question KJ is a 55 years old male with COVID-19 infection. He started his symptoms started 2 days ago. His PMH – diabetes, dyslipidemia, DVT and GERD. Current medication includes glipizide 5 mg QD, atorvastatin 80 mg QD, Eliquis 5mg BID and Tums. The clinician plans to start KJ on Paxlovid 300mg/100mg BID for 5 days. Which of the following KJ medications should the clinician be concerned with? Select all that applies A. Eliquis Apixiban B. Tums C. Atorvastatin D. Glipizide Hospitalized patient with Covid-19 • If patients does not require supplemental oxygen – follow the same treatment guideline for nonhospitalized patient. 3M • Patients requiring minimal conventional Oxygen (2-6 L oxygen) - Give Remdesivir within 10 days of symptom onset plus Dexamethasone - 6mg IV dose once daily for 10 days or until pt is discharge or no longer requiring steroid - No additional benefit for doses greater than 6 mg - Moderate CYP3A4 inducer - Side effect includes hyperglycemia, fluid retention, dermatologic, leukocytosis, adrenal suppression. - Therapeutic dose of heparin (indicated for non pregnant patients with D-dimer levels above the ULN limit who do not have increased bleeding risk). For all other patients, Give prophylactic dose of Heparin unless contraindicated. sooounits soevery8,1hr 19 Treatment of non hospitalized Children Provide supportive treatment to ALL children (Aged < 12 and 12 – 17 years) presenting with symptoms regardless of their risk factors. High Risk Aged 12 – 17: Initiate Paxlovid with 5 days of symptoms onset OR Remdesivir within 7 days of symptoms onset. Aged < 12 years: Paxlovid is contraindicated and there is insufficient evidence to the use of Remdesivir. Intermediate Risk There is insufficient evidence to recommend either for or against the use of any antiviral therapy. Low Risk Provide supportive therapy. 21 Multisystem Inflammatory Syndrome in Children Rare acute inflammatory syndrome reported in children several weeks following acute SARSCov-2 infection Symptoms include - Fever >38.0 2 - Laboratory evidence of inflammation (ESR, CRP, lymphopenia, d-dimer, procalcitonin) 3 of single or multi-organ dysfunction (shock, cardiac, respiratory, renal or - Evidence neurological disorder) Management - - Immunomodulatory therapy (IVIG) and systemic steroid. Combination of these medications has been reported to lead to a faster and more resolution of fever than IVIG alone. Https://emergency.cdc.gov/han/2020/han00432.asp. 22 Infection Control • General community guidance for infection control includes • • • • • • • • wearing a mask in indoor public places with high community transmission (N95 or equivalent preferred) avoiding close contact (within 6 feet) avoiding crowds and poorly ventilated spaces testing to prevent spread cleaning hands often covering coughs and sneezes cleaning and disinfecting frequently touched surfaces daily monitoring health • Mask use around others for 10 days is recommended for persons with close contact with infected person. • Isolation is recommended for persons with confirmed or probable COVID-19 regardless of vaccination status. 23 Prevention Through Vaccination • Vaccination is the most effective way to prevent COVID-19. • All COVID-19 vaccines prompt our bodies to recognize and help protect us from the virus that causes COVID19. • Currently, there are two types of COVID-19 vaccines for use in the United States: mRNA, and protein subunit vaccines. • FDA approved and authorized the 2024-2025 mRNA Covid-19 vaccine(Pfizer & Moderna) in August 22, 2024. These vaccines target SARS-CoV-2 strain called KP.2 (a descendants of the Omnicron strain). • FDA authorized Novavax COVID-19 vaccine, Adjuvanted 2024-2025 formula under EUA on August 30, 2024. approved for 12 years and older. • Everyone ages 6 months and older should get a 2024-2025 COVID-19 vaccine. Especially for patients ages 65 and older, at high risk for severe COVID-19, or have never received a COVID-19 vaccine. • • The COVID-19 vaccine helps protect from severe disease, hospitalization, and death. Vaccine protection decreases over time, so it is important to stay up to date with your COVID-19 vaccine. Gmonth andabbie 24 Summary • COVID-19 is an acute respiratory disease caused by SARS-CoV-2. • Risk increases with < 6 feet distance in persons infected with the virus. • Treatment of all infected persons should include supportive treatment. • Treatment of infected patients is also based on the severity of disease and oxygen requirement. • Infection control should include the use of mask and keeping 6 feet distance from infected persons. • Covid-19 vaccines are available to help prevent the spread of covid-19 infection. 26