Health Tips

At the time of writing, Malaysia is undergoing another nationwide lockdown, with the latest daily statistics of 6,440 COVID-19 cases and 74 deaths. 

Meme credit to The Rakyat Post

Nobody is a big fan of the movement control order (MCO), yet it is necessary, as our healthcare system has already stretched to its limits. To cope with the sudden surge of cases, the Ministry of Health has recently appointed UKM's Specialist Children's Hospital (HPKK) as a COVID-19 hospital, through the power granted by the Emergency Ordinance 2021. 

Whenever we mentioned the situation of COVID-19 in hospitals, we would imagine a team of doctors and nurses wearing full PPE and a COVID-19 patient with many tubes attached to the body. 

In this article, we give you a simplified overview on how the frontliners treat COVID-19 patients in hospitals.

Clinical staging of COVID-19

If your PCR swab test turns out to be positive, the next thing a healthcare professional would do is to stratify the severity of your condition based on your symptoms:

• Stage 1: No symptoms (asymptomatic)

• Stage 2: With symptoms but no pneumonia (inflammation of lungs)

• Stage 3: With symptoms and pneumonia

• Stage 4: With symptoms, pneumonia and require supplemental oxygen

• Stage 5: Critically ill with signs of organ damage

COVID-19 patients who are in stage 1,2 and 3 are considered having mild disease. Patients who are in stage 4 and 5 often progress to a more severe state of needing oxygen supplementation and ICU beds. 

What causes the deterioration of COVID-19 patients?

Photo by Fusion Medical Animation on Unsplash

We all understand that COVID-19 is a matter not to be taken lightly, as it can cause long-lasting complications (called ‘long covid’) or even death. In COVID-19 patients who deteriorate into worse state, the reasons are known to be the following:

1. A rapidly worsening pneumonia and may be accompanied by damage to other organs. This is known as the cytokine release syndrome (CRS), or commonly known as ‘cytokine storm’. It is a serious, widespread inflammation throughout the whole body system that happened as a result of an overwhelming immune response to the virus.

2.  Viral effect of SARS-Cov-2, the virus that causes COVID-19.

3. Underlying medical conditions, such as high blood pressure, diabetes, kidney disease and asthma

4. COVID-19 complications such as thromboembolism (formation of blood clots in lungs and/or legs) and organizing pneumonia (a type of lung injury).

5. Older age

Medical treatment for COVID-19 patients in hospitals

In general, all COVID-19 patients would receive treatments for their symptoms (e.g. medications to reduce fever, reduce phlegm etc.), optimal nutritional support, maintenance of fluid and electrolyte balance. These are important to prevent COVID-19 from worsening and start impacting other vital organs, such as the kidneys.

There are some common medications used in treating COVID-19 in the hospitals. However, it’s important to note that no specific treatment for COVID-19 infection is currently approved. Below are medications that, to our best current evidence, may reduce the severity of COVID-19. 

Favipiravir

Favipiravir is an antiviral medication. It mainly targets the influenza virus and a range of RNA-based viruses, such as SARS-Cov-2. According to a randomized, comparative, open-label, multicenter, phase 3 clinical trial, favipiravir may be a safe and effective treatment in mild-to-moderate COVID-19. 

• Favipiravir is available as 200mg tablets (Brand name: Avigan®)

• The dose of favipiravir for adults is 1800mg twice daily on day 1 with at least 4 hours between doses. Then 12 hours after the administration of the second dose, the treatment is followed by 800 mg twice daily from day 2 to 5.

• The use of favipiravir is avoided in patients with severe kidney disease, pregnancy and breastfeeding.

• Favipiravir should be taken with meals, and it is generally safe with minimal side effects.

Tocilizumab

Tocilizumab works differently than favipiravir. Remember we mentioned in severe cases of COVID-19 the patient would experience a ‘cytokine storm’ in which the body is in a state of serious inflammation that could potentially damage the organs? Tocilizumab is an interleukin-6 (IL-6) inhibitor that can reduce such widespread inflammation in serious COVID-19 cases. IL-6 is one of the ‘key culprits’ that set the cytokine storms in severe COVID-19 cases. According to this study published in The New England Journal of Medicine, IL-6 inhibitors such as tocilizumab improves survival in critically-ill COVID-19 patients.

• Tocilizumab is available in an 80mg/4ml injection vial and it is stored in the fridge. It is not available as tablets.

• The dose of tocilizumab for adults is 8mg per kg as a single dose only (maximum 800mg). It is usually used in combination with steroids.

• Tocilizumab is administered as a single dose via IV infusion over 1 hour.

• The use of tocilizumab is avoided in patients with pregnancy, ongoing infections (TB, invasive fungal or bacterial infections), and GI perforation.

• Tocilizumab may lead to side effects such as low white blood cells, low platelets, infusion-related reactions and elevated liver enzymes. If you’re on tocilizumab, your healthcare provider would closely monitor your blood test profile to make sure these don’t happen.

Steroids

E.g, dexamethasone, methylprednisolone, prednisolone 

Steroids are not only useful in reducing inflammation, but they’re also low in cost and easy to access, hence they’re a good choice when it comes to treating severe COVID-19 cases, especially those with cytokine storms. 

• Dexamethasone and prednisolone are available in pills, whereas methylprednisolone is only available as an injection.

• Steroids are widely used in hospitals, but they do come with their fair share of side effects. For instance, steroids use may lead to lower immunity (hence higher risk of infections), high blood sugar level, high blood pressure, electrolyte disturbance, body swelling and osteoporosis. Nonetheless, the goal of steroids treatment in COVID-19 cases is to reduce the cytokine storm while exposing the patient to as few side effects as possible.

Blood thinners for reducing blood clots

E.g. enoxaparin, fondaparinux, rivaroxaban

Remember the blood clot issues with AstraZeneca’s COVID-19 vaccines? The fact is, the risk of getting blood clots when you have COVID-19, especially at stage 4 and 5, is even higher! As a result, current evidence suggests that all patients in stage 4 and 5 should receive standard prevention (called prophylaxis in hospital setting) of blood clots. 

Besides preventing blood clots, patients who recovered from COVID-19 are also given rivaroxaban for 3 months as treatment for pulmonary embolism, i.e. blood clots in lungs.

Other treatments

• Metered-dose inhaler (MDI) salbutamol therapy – This is a bronchodilator therapy that aims to open up the airways and improves breathing among COVID-19 patients

• Self-proning – Some hospitals started to let COVID-19 patients who require supplemental oxygen do a trial of self-proning. It is a protocol in which patients roll onto their stomachs or sides by themselves, thereby improving oxygenation and eliminating the needs of using early intubation.
   
  Image credit http://www.emdocs.net/covid-19-awake-repositioning-proning/

• Oxygen supplementation – If self-proning does not improve the oxygen level, patients may be put on oxygen supplementation either through low flow nasal cannula (LFNC) or high flow nasal cannula (HFNC). 

• Intubation – In severe cases where a patient's oxygen level is still low despite the aforementioned oxygen supplementation, the doctors have no choice but to sedate the patient and intubate the patient to a ventilator.

• Antibiotics – Antibiotics DO NOT kill SARS-Cov-2, but they’re used when there is suspicion of other bacterial infections that happen alongside with COVID-19.

On top of those treatments, doctors and nurses would also closely monitor the vital signs, oxygen saturation and progressions of COVID-19 patients– such monitoring can be in the form of blood tests and/or imaging tests.

Do not use these medications without medical supervision

Now, if you have the urge to buy the medications we mentioned as an attempt to prevent/treat COVID-19, hold your horses.

Using these medications without medical supervision not only do guarantee its effectiveness, but it’s actually dangerous. These medications have their own specific side effects and different dosing based on one’s kidney function. It’s best to leave the medical treatment of COVID-19 to the experts. The best you can do right now is follow the SOPs and stay at home to prevent yourself from contracting the disease in the first place.

Prevention is better than cure

It has been more than a year since the world entered the pandemic, and the medical community has become more knowledgeable about the disease. Yet, the virus is also constantly evolving – with the latest emergence of delta variants with higher transmissibility. At the time of writing, Malaysia has lost more than 4,300 lives to COVID-19, and the number is bound to increase every day. Hence, we should not let our guard down yet, until the curve is flattened. Let’s stay at home for our medical frontliners, and get vaccination when it's your turn.

A word from Doc2Us

If you have any enquiries related to COVID-19 and its vaccines, you can consult our COVID-19 Task Force, which consists of professional doctors and healthcare professionals, for FREE! 

You can access free COVID-19 virtual health advisory by downloading the Doc2Us app on http://onelink.to/doc2us or use our web chat https://web.doc2us.com/. Alternatively, go to MySejahtera app> Digital Health> Virtual Health Advisory, and click on Doc2Us.

For more information about COVID-19 vaccination programme in Malaysia, visit https://www.vaksincovid.gov.my/

Disclaimer: COVID-19 is a novel disease. The information and scientific evidence of its development and vaccines are changing as we speak. Some content of this article may be outdated in the future. We encourage you to always speak to a healthcare professional you trust for the latest updates on COVID-19 and its vaccines.

Read more:

A guide to what to do if you think you might have Covid-19

Does the brand of COVID-19 vaccines matter?

Should you receive Covid-19 vaccine if you have a drug allergy?

Side effects of Covid-19 vaccine: should you be worried? 

What you need to know about the COVID-19 vaccine

Should pregnant women take COVID-19 vaccine?

Blood clots and COVID-19 vaccines, explained

Please adhere to your COVID-19 vaccination appointment, here's why

References

1. Ministry of Health Malaysia - Annex 2e: Clinical Management Of Confirmed Covid-19 Case In Adult And Paediatric

2. Hospital Kuala Lumpur - Therapeutic Management of COVID-19: DRUG SUMMARY - Updated June 2021

3. UpToDate - COVID-19: Critical care and airway management issues

Cover image credit: Photo by Mufid Majnun on Unsplash

Written by

Ms Joyce Toh