Pharmacotherapy Considerations in Hospitalized Patients With COVID-19 Pneumonia

William Pruett, MD; Lee E. Morrow, MD, MSc, FCP, FCCP, FCCM, ATSF; Mark A. Malesker, PharmD, FCCP, FCCP, FCCM, FASHP, BCPS

Disclosures

US Pharmacist. 2020;45(44020):HS9-HS16. 

In This Article

Abstract and Introduction

Abstract

The role of the clinical pharmacist has expanded during the coronavirus disease 2019 (COVID-19) crisis. Pharmacists caring for hospitalized patients with pneumonia must simultaneously provide other team members with updated, COVID-19–specific best practices and ensure consistent application of evidence-based ICU practices, with responsibilities including optimizing medication shortages and keeping current with rapidly changing clinical information. It is also important for pharmacists to keep abreast of the unique pharmacotherapy challenges posed by COVID-19 pneumonia, understand the need for glycemic control and the controversial nature of anticoagulation, and be conversant with the medications used in mechanical ventilation. Objective data on COVID-19 therapy are lacking, and a definitive treatment algorithm will remain elusive so long as disagreement abounds.

Introduction

Medicine finds itself in a very peculiar place right now. Since the onset of the coronavirus disease 2019 (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2, the medical community has struggled to find effective therapies to combat this novel pathogen. Social media, mainstream media, and medical journals tout novel and/or repurposed drugs almost continuously. However, much of the information supporting these therapies is anecdotal or retrospective; limited data have been obtained from randomized, controlled trials. The formulation of decisive conclusions from the few existing clinical trials is also problematic given that sample sizes are very small, studies are from single centers, and public-health need pressures the release of preliminary results with inadequate peer review. Regardless, this process has provided accelerated access to novel therapies (remdesivir and convalescent plasma) through the FDA's Emergency Use and Expanded Access programs.

Hallmarks of our accumulating understanding of the COVID-19 pandemic include an incredibly rapid pace of new information, fragmentation of the data being shared, and frequent contradictions between new information and data released only hours or days before. In this environment, clinical disagreements are common, and healthcare worker frustration is substantial. Given the lack of objective data, inconsistent guideline recommendations, and the rapid pace at which COVID-19 therapy is evolving, clinicians routinely rely on empirical, real-time recommendations shared by peers with more extensive experience—often through online channels including critical-care blogs and virtual guidelines.[1,2] Multiple suggestions herein are not supported by rigorous data. Therefore, it is advisable for readers to view any recommendations lacking a customary citation with trepidation, as they are essentially expert opinion. This humbling observation also highlights that while expanding the understanding of COVID-19 is essential to optimizing the care of infected patients, it is equally important—perhaps more important—to adhere to long-standing, evidence-based ICU practices in treating hospitalized patients with COVID-19 pneumonia who are critically ill.

Experience gained thus far has led to two important realizations regarding pharmacists and COVID-19. First, the care of COVID-19–infected patients requiring mechanical ventilation is a resource-heavy endeavor for the pharmacy, with serious potential for shortages of commonly used medications. While the exact drugs with limited supply have varied regionally based on local practice and/or supply chains, heavily hit areas have consistently reported limitations.[3] Second, pharmacists caring for these patients simultaneously fulfill the key roles of educator and enforcer: The educator provides other team members with updated, COVID-19–specific best practices (optimizing drug dosages, suggesting alternative routes/modes of administration, and recommending therapeutic exchanges), and the enforcer ensures consistent application of evidence-based ICU practices (fostering antimicrobial stewardship, minimizing the impact of shortages, and assisting with experimental therapies). It is not uncommon for physicians and nurses who do not routinely care for critically ill patients to take on this role during surges in COVID-19 patients; in this circumstance, the educator and enforcer roles of the clinical pharmacist become imperative. To that end, rather than focusing on rapidly evolving virus-specific therapies, this article summarizes the more durable lessons concerning pharmacotherapy and reviews ICU practices that should be modified during the COVID-19 pandemic.[4]

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