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

General Recommendations

Medication administration should be consolidated to minimize the number of times nursing staff must enter a COVID-19–infected patient's room. This lessens personal protective equipment (PPE) consumption and reduces the infection potential for healthcare workers. For medications being delivered via continuous infusion, consideration should be given to compounding larger bags than would typically be used and/or maximally concentrating medications to reduce the frequency of bag exchanges. Ready-to-use dosage forms should be used whenever possible because medications cannot be removed from a COVID-19 room to be reused elsewhere.

It is generally accepted that the delivery of medications via nebulizer is an aerosol-generating procedure and is associated with an increased risk of COVID-19 transmission in nonintubated patients.[5,6] Accordingly, it is recommended that inhaled therapies be delivered to nonintubated COVID-19–infected patients via metered-dose inhaler (MDI) whenever practical, and clinicians should be reminded that one nebulized treatment is typically equal to roughly six to eight puffs on a conventional MDI.[7] In the intubated patient, aerosolization via nebulizer is not a concern and medications should be given via in-line nebulization in order to preserve MDIs for use elsewhere.[8]

Acute kidney injury (AKI) and elevations in liver-function tests are common in critically ill patients, including those with COVID-19 pneumonia. This means that pharmacokinetic consultation may be required to assist with dosage adjustments for medications with renal and/or hepatic metabolism or clearance. In this setting, certain medications should be avoided whenever possible; both nonsteroidal anti-inflammatory drugs and vancomycin are discouraged because they contribute to AKI.[9]

Caution is warranted with medications that are known to prolong the QT interval. Although several of these agents are often necessary or recommended for use in COVID-19–infected patients, the astute clinician will periodically perform ECGs and assess for therapeutic substitutions if or when indicated.

Many COVID-19 patients develop an overreactive immune response—the so-called cytokine storm—that leads to dramatic increases in lactate dehydrogenase, ferritin, erythrocyte sedimentation rate, C-reactive protein, and d-dimer; a hypercoagulable state; and poorer clinical outcomes.[10] Experts encourage caution in the prescribing of therapies with the potential to worsen the cytokine storm, and this is one rationale behind the recommendation for a restrictive blood-transfusion strategy.

The role of ACE inhibitors and angiotensin receptor blockers (ARBs) is controversial in COVID-19 patients. One early hypothesis was that ACE inhibitors and ARBs increase ACE2 expression by epithelial cells in the lung and that these receptors are the entry site for pathogenic coronarviruses.[11] A subsequent curated literature review suggested that ACE2 may paradoxically protect against acute lung injury and that taking an ACE inhibitor or ARB might be protective.[12] Without convincing data that these agents help or hurt during COVID-19 infections, multiple major professional societies endorse the continuation of these agents in patients previously taking them who have no contraindications to ongoing use (e.g., AKI, hyperkalemia).[13,14]

The major cause of death in COVID-19 patients is the development of acute respiratory distress syndrome (ARDS). Because the complications of ARDS are exacerbated by volume overload, a restrictive fluid strategy is uniformly endorsed. The guidelines that specifically address this topic recommend that fluids be given as frequent, small boluses, with reassessments made often via point-of-care ultrasound.[15,16] In line with this rationale, hypotonic fluids, starches, and gelatins should be avoided; medications should be maximally concentrated; and medications should be given by IV push whenever possible, as opposed to infusing in a larger volume.

Finally, to date, no agent studied for postexposure prophylaxis has shown efficacy against COVID-19. Accordingly, pharmacists should be prepared to educate clinicians that, unlike the customary practice for influenza, postexposure prophylaxis is not currently endorsed for COVID-19.

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