DOCS RELYING ON HCQ, ANTIBIOTICS

Administered orally, HCQ and azithromycin have worked; efficacy of plasma therapy needs to be tested by Indian experts

NEW DELHI : Indian doctors are depending on a combination of antimalarial drug and an antibiotic to treat people hospitalised in isolation wards and ICUs in the absence of a specific treatment for Covid-19.

NEW DELHI: Indian doctors are depending on a combination of a tried and tested antimalarial drug and an antibiotic to treat people hospitalised in isolation wards and intensive care units in the absence of a specific treatment for the coronavirus disease (Covid-19).

“It is not a miracle therapy, but this is all we have. All patients in isolation wards are given a combination of hydroxychloroquine (HCQ) twice a day and azithromycin once a day for five days, and it has been tolerated well. No adverse reactions have been reported,” said Dr Yatin Mehta, chairman, Institute of Critical Care and Anaesthesiology, Medanta-the Medicity, where 15 Covid-19 patients are currently being treated, of whom three are in ICU.

Medanta also treated 14 Italians infected with the disease; 13 being discharged last month, and one, a 78-year-old woman died.

Hydroxychloroquine and chloroquine are oral prescription drugs that have been used for treatment of malaria and certain inflammatory conditions for over a century. Both drugs are undergoing clinical trials for pre-exposure or post-exposure prophylaxis of Sars-CoV-2 infection, the virus that causes Covid-19, and treatment of patients with mild, moderate, and severe symptoms of Covid-19.

“Hydroxychloroquine is not mean to be taken by healthy people as a prophylaxis to prevent infection, only Covid-19 patients are being given a combination of this drug along with the antibiotic azithromycin for treatment. Antivirals have been withdrawn by ICMR as they didn’t show much benefit,” said Dr RR Gangakhedkar, chief, epidemiology, ICMR.

The majority of Covid-19 patients have mild to moderate illness, with symptoms of cough, fever and tiredness, with around 5% developing severe pneumonia and acute respiratory stress syndrome (ARDS), which is marked by worsening respiratory symptoms within one week of known clinical infection.

In India, around 2% of Covid-19 cases are in ICU, according to ICMR, with a little more than 100 being on ventilator support across India to treat ARDS, which makes it difficult for a patient to breathe without oxygenation. “All patients with ARDS are monitored closely for signs of clinical deterioration, such as rapidly progressive respiratory failure and sepsis, and apply supportive care interventions immediately,” said Dr Mehta.

The signs of ARDS include worsening respiratory symptoms within one week of known clinical infection and chest imaging, including X-rays, CT scan or lung ultrasound, showing bilateral opacities, not fully explained by effusions, lung collapse, or nodules.

Intensive management is needed if the patient is a smoker or has cardiovascular disease and lung diseases, like asthma and chronic obstructive respiratory disease, which puts them at a higher risk of severe disease and complications. “In patients with chronic diseases, prescription medication is continued,” said Dr Mehta.

With some hospitals in the US and Italy reporting unusually high death rates of 65% to 80% of Covid-19 patients despite ventilator support, compared to 40-50% for other severe acute respiratory infections, there’s a global debate on whether ventilating patients could be doing certain patients more harm than good.

“Covid-19 causes death by respiratory failure and cardiac arrest, just like other severe pneumonias, the difference is lack of immunity, greater severity of disease and relatively less lung damage. These are lungs not difficult to ventilate but there is relatively more hypoxia. A possibility is clots in blood supply to lung, but no one is fully sure,” said Dr Anurag Agrawal, director, CSIR Institute of Genomics and Integrative Biology, New Delhi.

“If you see the published data of good quality - mostly Italian – you see two subtypes of patients. The first present with typical ARDS needing high PEEP (positive end-expiratory pressure is the pressure in the lung), and second with normal mechanics and increased dead space.

The second group may have micro-thromboembolism (clots obstructing blood flow), but nobody is sure yet as there are not enough autopsies being done for obvious reasons,” added Dr

Agrawal.

Some clinicians are recommending oxygenating patients through nose tubes or other devices, while some are adding nitric oxide to improve oxygen and blood flow to the least damaged parts of the lungs.

“What does one do? You have to oxygenate. Our experience in treating Covid-19 patients found non-invasive ventilation wasn’t very effective and HFNC (highflow nasal cannula) didn’t work as well as mechanical ventilation,” said Dr Mehta.

Some hope came from the Indian Council of Medical Research on Sunday announcing protocols for convalescent plasma therapy trials in the country. “Convalescent plasma is an experimental procedure for Covid-19 patients. Hospitals and institutions planning to provide this modality of treatment should do so in a clinical trial with protocols, which are cleared by the institutional ethics committee,” the ICMR said in a statement on Sunday.

Convalescent therapy involves drawing blood packed with antibodies against SarsCov-2, the virus that causes Covid-19, from people who have recovered.

Platelets that carry antibodies are separated from other blood components like red blood cells, white blood cells and platelets, and given to Covid-19 patients to reinforce their immunity to fight infection.

While studies from China have shown it raised lymphocyte counts, improved liver and lung function, and reduced inflammation, lung lesions and other severe symptoms within a week, clinical trials to study the safety and efficacy of convalescent plasma therapy on Indian patients is still needed before it’s approved for treatment.

“The disease is four months old and till we have a vaccine or treatment specifically targeting the Sars-CoV2 virus, we have to use all the tools we have on hand to save lives,” said Dr Mehta.