JOURNAL OF THE INDIAN MEDICAL ASSOCIATION, VOL 118, NO 06, JUNE 2020
View of the Expert • Moderate disease : 0.5 to 1 mg/ kg methylprednisolone for 3 days in two divided doses • S e v e r e disease : 1 to 2 mg/ kg methylprednisolone for 5 to 7 days in two divided doses The decision of whether to shift to dexamethasone from Prof Manish Soneja MPS, given the RECOVERY trial partial data released yesterday, needs to be taken after reviewing the details.
The Covid-19 pandemic rages on in the World. With more than eight million people affected and more than 450 thousand dead, the end is still nowhere in sight. India is still in the ascending limb of the epidemic curve and physicians of India are at the forefront of this struggle to quell the scourge. At this juncture, we thought it worthwhile to listen to Prof Manish Soneja, one of the foremost infectious disease experts in India. He is currently working at AIIMS, New Delhi, one of the premier medical institutions of the country. In the first week of June, 2020, members of the Editorial Committee of JIMA held an online interview with Dr Soneja. The transcript of that interview is presented here, exclusively for the readers of JIMA.
QUESTIONNAIRE 1. Are you using steroids in COVID-19 patients? If so, for which indication? What is the regimen, dose and duration of therapy? What is the result? The use of corticosteroids in COVID-19 has generated considerable debate.There was a valid concern based on studies showing lack of benefit and possible harm in SARS-CoV 1 and other viral pneumonia. However, the results of these studies had significant indication bias and the dose of steroids used was high. Although, still in press release, the results of RECOVERY trial, one of the largest trials on COVID-19 management, are encouraging with a significant mortality benefit in both ventilated patients and those who are on oxygen. At present, our protocol is to use corticosteroids in carefully selected patients with progressive moderate and severe COVID-19 with the premise that a major part of pathophysiology at this stage is mediated by aberrant cytokine response with viral cytopathic effects being predominant in the early stages of illness. • Dose : Low to moderate dose for short duration without tapering
Editorial note : The RECOVERY trial is an exciting development in Covid-19 landscape. Readers are requested to go through the results very carefully. Also, be on the lookout for similar trials which will be published in the future.
2. Are you using Anticoagulants in COVID-19 patients? What is the dosage and duration of therapy? What is the anticoagulant regimen advised in such patients post discharge? Anticoagulation is being used in moderate and severe COVID-19 illness provided there are no contraindications. The regimen currently being used is: • Moderate disease: Prophylactic dose of UFH or LMWH (e.g., Enoxaparin 40 mg SC OD) • Severe disease: High dose prophylactic UFH or LMWH (eg, Enoxaparin 40 mg or 0.5mg/kg SC BD), if no contraindications are present • Weight based dosing is preferred in patients who are overweight Decision on administering therapeutic anticoagulation (as a form of prophylaxis) is individualized based on patient factors. 17
