covid

Question 1

COVID disease course

Answer 1

Early infection
Pulmonary phase
Hyperinflammation phase

Question 2

Early infection presentation

Answer 2

Mild sx: fever 99.6+, dry cough, diarrhea, HA
clinical: lymphopenia, increase PTT, increased D-dimer and LDH(mild)

Question 3

Pulmonary phase presentation

Answer 3

Sx: SOB, hypoxia PaO2/FiO2 ≤ 300 mmhg
clinical: abnormal chest img, transaminitis, low-normal procalcitonin

Question 4

Hyperinflammation phase presentation

Answer 4

Sx: ARDS, SIRS/shock, cardiac failure
Clinical: elevated inflammatory markers (CRP, LDH, IL6, D-dimer, ferritin)
(+) troponin, NT-proBNP elevation

Question 5

Severity of illness determines treatment

Answer 5

Pre-exposure prophylaxis
Symptomatic treatment
Hypoxic illness
Significant oxygen demand
Mechanical ventillation

Question 6

Oral antivirals stage of illness

Answer 6

Symptomatic Treatment

Question 7

Remdesivir stage of illness

Answer 7

Symptomatic Treatment + Hypoxic Illness

Question 8

Corticosteroids stage of illness

Answer 8

Hypoxic illness + Significant oxygen demand + mechanical ventillation

Question 9

IL-6 antag and Kinase inhibitors stage of illness

Answer 9

Significant oxygen demand + mechanical ventillation

Question 10

Anticoagulants stage of illness

Answer 10

Middle, for hospitalized patients
- Therapeutic dose LMWH if D-dimer 4x ULN and no increased bleed risk
- prophylaxis dose LMWH for everyone else

Question 11

Eligibility for remdesivir

Answer 11

Hospital
for high risk severe covid (≤ 94%) +/- on supplemental O2 (non-invasive)
FDA approved

Question 12

Eligibility for Dexamethasone

Answer 12

Hospital
hypoxic illness

Question 13

Eligibility for IL-6 antagonist

Answer 13

Hospital
systemic inflammation (CRP >75)
increasing O2 need/NIV/MV/ECHO
Already receiving systemic GC and need extra O2

Question 14

Eligibility for Kinase inhibitor

Answer 14

Hospital
Severe covid, elevated inflammatory, on systemic GF and high flow O2/non-invasive vent
Possible mortality benefit in MV pt

Question 15

Eligibility for Molnupiravir

Answer 15

Used if no other tx options available (alt)
Adults (18+), ambulatory, mild-mod disease

Question 16

Eligibility for Paxlovid

Answer 16

Preferred oral antiviral option
12 y/o + and at least 40kg
mild-moderate covid, ambulatory
w/ 1 risk factor for developing severe covid
sx within 5 days of onset

Question 17

Disqualification for oral antivirals

Answer 17

Hospitalization for COVID
Use longer than 5 days
Pre/post exposure prophylaxis

Question 18

Disqualification for Remdesivir

Answer 18

eGFR < 30 ml/min
Severe disease

Question 19

Disqualification for immunosupressants

Answer 19

Fighting serious bacterial infection
Using another immunosupressant agent
Concerns for infection/thrombosis

Question 20

Drugs that have FDA approval for COVID

Answer 20

Remdesivir (IV)
Baricitnib (PO)

Question 21

Eligibility for Lovenox (LMWH)

Answer 21

Non-ICU
D dimer 4x ULN (>2000)
+ VTE prophylaxis when necessary

Question 22

Anticoagulation severity is associated with

Answer 22

Increased PT, INR, TT
Decreased apTT

Question 23

Neutralizing Mab stage of illness

Answer 23

Pre-exposure prophylaxis
No longer used due to strain mutation
Evushield (tixagevimab + cilgavimab)

Question 24

Paxlovid quick facts

Answer 24

Protease inhibitor
Not FDA approved
Nirmatrelvir = CYP3A4 inducer (req. ritonavir to boost fx)
Renal elimination (lower dose for impairment)
EPIC-HR = most benefit in high risk pt group

Question 25

Molnupiravir quick facts

Answer 25

RNA-dependent RNA polymerase mutator
NOT FDA approved
Low DDI, not eliminated renal/hepatic
Broad spec activity, high barrier to resistance
ADR: diarrhea, nausea, dizziness

Question 26

Remdesivir quick facts

Answer 26

Nucleoside base: interfere RNA-dependent RNA polymerase + template incorporation
FDA APPROVED SINCE 10/22/20
IV only, hospital use
LD then MD for 5-10 days
RENAL elimination
well tolerated
ADR: ALT/AST elevation, phlebitis, nonspecific sx

Question 27

Corticosteroids quick facts

Answer 27

Used in covid because COVID is super hyperinflammatory
short course ADR
- hyperglycemia, agitation/confusion, adrenal supression, risk of infx

Dexamethasone 5mg IV or PO QD x 10 days or hospital DC
or equivalent

Question 28

Tocilizumab, Sarilumab (IL-6 antag) quick facts

Answer 28

Binds to IL-6, prevents signal transudction
Hospitalized pt w/ severe-critical dx + elevated systemic inflammation markers (CRP>75)
AVOID if fighting bacterial infx
ADR: many
- elevated ALT/AST
- neutropenia
- thrombocytopenia
- infection

Question 29

Kinase inhibitor quickfacts

Answer 29

Prevent phos/activation of STATs (modulates JAK-STAT)
RENAL dose adjustment
Reduce dose if given w/ OAT3 inhibitors (probenecid)
Possible mortality benefit when given w/ SOC