CPT2: Covid

Question 1

What type of virus is coronavirus?

What does it cause?

Incubation period?

Originated from?

Other severe conronavirus outbreaks?

Spread by?

Answer 1

• Belongs to family of RNA single-stranded viruses known as coronviridae – pathophysiology on following slide
• Usually result in mild infection similar to a cold
• Incubation period around 2 weeks
• •Other severe coronavirus outbreaks – MERS, SARS
• Believed to have originated through cross-species transmission though exact origin is unknown
• Spread from person-to-person by respiratory droplets through sneezing and coughing

Question 2

What is the pathology of Covid-19?

Answer 2

1. SARS-Cov-2 enters and infects alveolar type II cells and replicates
2. Infection of these cells leads to release of pro-inflammatory cytokines which cause an immune response. Mild symptoms e.g. cough. fever, body aches may occur
3. Macrophages release IL-1, IL-6 and TNF-a. IL-6 causes vasodilation allowing more immune cells to travel to the alveolus. It also increases capillary permeability leading to plasma leackage which leaks into the intersitial fluid and alevolus
4. Neutrophils release reactive oxygen species and proteinases which destroy the infected cells.
5. These dead cells combine with plasma to form protein-rich plasma which accumulates in the alveolus leading to shortness of breath and pneumonia. Accumulatoin of fluid and dilation of surface lining of the alveolar causes alveolar collapse. This decrease gas exchange and can lead to hypoxaemia and acute respiratory distress syndrome.
6. If the immune system goes into overdrive the inflammation can spread into the systemic circulation and lead to cytokine storm/ systemic inflammatory response system. This can lead to systemic shock where BP drops so low organs are not perfused. Leads to multi organ failure and death

Question 3

Life-cyle of Covid-19

Answer 3

1. Spike protein on the surface of SARS-CoV-2 uses the ACE2 receptor to gain entry to the host cell.
2. The virus releases its RNA.
3. RNA is translated into polypeptides.
4. Some polypeptides form RNA-dependent RNA polymerase, which is needed to make more RNA.
5. Other polypeptides are cleaved by proteases to produce viral proteins.
6. Proteins and RNA are assembled into a new virion
7. New virion is released from the host cell.

Question 4

1. What does shielding mean?
2. What does self-isolate mean?
3. What does quarantine mean?
4. What does social distancing mean?

Answer 4

1. •Shielding: protecting vulnerable by staying at home with not contact with any other household – e.g. immunosuppressed, respiratory disease, diabetes
2. the act of quarinting, isolating or separating oneself or itself from others is suspected and has contagious disease
3. If a person or animal is in quarantine, they are being kept separate from other people or animals for a set period of time, usually because they have or may have a disease.
4. Mainatinig a suitable distance from other households to avoid spread or contraction of a contageious disease

Question 5

Signs and symptoms

Answer 5

• Main issue with asymptomatic individuals who may spread disease
• Individuals may have wide range of symptoms including fever, cough, headaches and sore throat
• Anosmia – loss of sense of smell or taste
• Children – also diarrhoea and nausea

Question 6

Transmission risk?

Answer 6

• Related to viral load – higher load, higher transmission risk
• Highest is just before symptom onset
• Consider extensive environmental contamination
• Consider other modifying immune facts which may influence clinical outcome

Question 7

How is the active disease tested for?

Problems?

Answer 7

• Viral RNA tests test for current virus
• Usually nasopharyngeal swab required
• Still much debate/lack of evidence over sensitivity and specificity
• No GOLD standard to compare to

Question 8

What is AB testing used for?

What is taken to do this?

Problem with this?

Answer 8

• Serology blood tests
• Testing for antibodies to determine if patient has been infected in the past
• However, antibodies disappear from the blood over time

Question 9

How is AB testing carried out?

Answer 9

Question 10

Difference between home and lab based AB testing

Problems?

Answer 10

• Lab based – may quantify antibodies present
• Home based – these do not quantify antibodies present but only provide a positive or negative answer
• Still issues with specificity and sensitivity – may cause more harm due to false positives and false reassurances
• As things are none are absolutely reliable – none likely to be a “game changer!”

Question 11

What 2 AB tests is there?

Answer 11

Main tests currently available in UK:

• Abbott SARS-COV2 assay – detect IgG
• RochElecsys assay – detects both IgM and IgG

Question 12

Anti-virals that may be useful

Answer 12

1. Bemcentinib: selectively inhibits AXL kinase activity, which blocks viral entry and enhances the antiviral type I interferon response. (UK prioritised trials: ACCORD-2)
2. Chloroquine and hydroxychloroquine - (no longer): block viral entry by inhibiting glycosylation of the ACE2 receptor, increasing endosomal pH (which also affects virion release), and blocking release of the viral genome. They also have immunomodulatory effects
3. Lopinavir (boosted with ritonavir): inhibits proteases and, therefore, could inhibit 3-chymotrypsin-like protease, which plays a crucial role in viral replication of SARS-CoV-2.
4. Remdesivir: inhibits RNA-dependent RNApolymerase, and therefore interferes with RNAreplication.

Question 13

Immunomodulatorys that be may helpful?

Answer 13

https://www.pharmaceutical-journal.com/download?ac=1080202

Question 14

What is the main trial ongoing in the UK?

What do the MHRA aim ti do?

Answer 14

• RECOVERY – Randomised Evaluation Of COVID-19 Therapy – UK participating
  
  • To date supportive care best improves outcomes
• MHRA – to launch COVID-19 related website for public to report side effects of medication, vaccines, medical equipment

Question 15

Effectiveness of hydroxychloroquinine?

Answer 15

•Hydroxycholoroquine – possibly increases the risk of death? This arm of the study has been withdrawn

Question 16

Describe the effecg effectiveness of the following:

1. Rendonavir
2. Convalescent blood
3. Lopinavir with Ritonavir

Answer 16

1. Remdesevir – in UK available from Early Access to Medicines Scheme (EAMS). Controversy about way data from trials presented and whether it will reduce mortality
2. Convalescent blood – involves administration of plasma of patients who have had disease; ; very limited evidence that effective
3. Lopinavir with ritonavir – stopped since evidence shows that this combination is not effective

Refer back to https://www.pharmaceutical-journal.com/download?ac=1080202 for modes of action

Question 17

Which drug has shown greatest improvement?

Mechanism

When should/ shouldnt it be used?

Answer 17

• Dexamethasone – possibly the only drug that has shown lower mortality
• reduce the host’s inflammatory response to SARS-CoV-2 in the lungs.
• 6 mg dexamethasone 8-26% mortality
• ONLY effective in patients with hypoxemia and requiring oxygen or ventilation and not in those with milder disease; do NOT use in non-severe illness since here risks outweigh benefits
• Hydrocortisone, methylprednisolone and predisolone also shown to be effective – possibly a class effect

Question 18

Vit D useful?

Answer 18

• Claims that Vitamin D effective are based on a SR which concluded that Vitamin D supplementation reduced risk of acute respiratory infection
• Vitamin D augments innate viral responses and reduces inflammation
• No evidence on outcomes in COVID
• Regardless of infection, all public should be encouraged to take 10 micrograms daily

Question 19

Pallatative care

Answer 19

• Palliative care – may be a shift to administer these by a family member at home rather than doctor or nurse
• Need for patient education
• Principles of palliative care managed in COVID-19 are similar to those in other terminal illnesses
• However agitation and anxiety may be greater

Question 20

Vaccines in clinical trials?

Answer 20

• Six SARS-COV2 vaccines candidates in clinical trials
• Some at a more advanced stage than others

Question 21

When conducting a remote consultation what should be noted?

Answer 21

Patients with suspected COVID-19 should be advised NOT to visit pharmacy

a) Always check if breathlessness
b) If person is well enough to remain at home, self isolate for 7 days from start of symptoms
c) If person in a household, all member should self isolate for 14 days
d) Plenty of fluids and rest
e) Check for red flag symptoms of pneumonia that need hospital referral

Question 22

What are red flag symptoms for pneummonia?

Answer 22

Check for red flag symptoms of pneumonia that need hospital referral:

• Severe SOB at rest or difficulty breathing
• Coughing up blood
• Blue lips or face
• Feeling cold and clammy with pale or mottled skin
• Collapse or fainting
• Becoming difficult to rouse
• Little or no urine output

Question 23

Pharmacists responsibilities and opportunities

Answer 23

• Ensuring that pharmacists and all staff have right protection when dealing with patients
• Potentially need to risk assess staff – e.g. from BAME backgrounds, pregnancy, high risk chronic disease, immunosuppression
• Involvement in public health campaigns e.g. handwashing, sharing rooms, ventilation
• An opportunity to promote smoking cessation
• Providing right information to patients on social media platforms
• Looking at alternative ways of connecting with patients including deliveries
• Dealing responsibly with increased workloads and stress

Question 24

Problems with masks

Answer 24

Lip-reading and masks:

• People who lip read may not be able to understand
• Block lip movements
• Block facial expressions
• Muffle high pitched sounds

Question 25

Clear face masks effective?

Answer 25

•Use of masks with transparent window are just as safe?

Only one approved in healthcare settings – Safe ‘N’ Clear

Conflicting advise as to whether use of transparent face

shields as effective as masks

Question 26

Over 2/3 of people over 70 have element of hearing loss. Ways of improving?

Answer 26

• •Face patient
• •Get their attention prior to starting
• •Raise volume of voice
• •Check for understanding
• •Use of post-it notes
• •White boards
• •Smart phones and tablets – speech to text transcription
• •Google live translate
• •Cardmedic – communication flashcards
• •Consider virtual consultation allowing masks to
• be taken off

Question 27

Communication in the acute setting?

Answer 27

• Use of video calls with families
• Writing names and pinning photos on PPE
• May be presence of loud equipment that may further muffle voices and sounds

Question 28

Pharmacists and provision of advice on appropriate antimicrobial prescribing

Answer 28

• Review appropriateness of antibiotic prescribing – expanded antibiotic use reported despite the fact that only around 10% of patients have bacterial or fungal infection
• Use of broad spectrum antibiotics unnecessarily with potential increase in antibiotic use
• Increased invasive procedures e.g. ventilators leading to increased risk of AMR organisms, intubation
• Media reports about efficacy of azithromycin
• Telehealth and potential increase in antibiotic prescribing

Question 29

Unasnwered COvid quaesios

Answer 29

• Pregnancy – is there no greater risk to pregnant women compared to non-pregnant?
• NSAIDS e.g. ibuprofen – do NSAIDs exacerbate the respiratory symptoms and increase severity of COVID-19 infections?
• Do ACEI and angiotensin receptor blockers predispose people to worse symptoms?
• Long-COVID – what is this? What are the symptoms and what do primary care practitioners need to look out for?