NICE Guidance: Managing COVID-19 in the Community

Dawn O'Shea

March 29, 2021

The National Institute for Health and Care Excellence (NICE) has produced new guidelines on the management of people in the community with COVID-19, as part of a new suite of COVID-19 guidelines. This replaces the previous sets of rapid guidance. Here's a summary of key information:

Care planning

  • Put treatment escalation plans in place and sensitively discuss treatment expectations and care goals with the patient, their families and carers.

Managing cough

  • Encourage people with cough to avoid lying on their backs, if possible, because this may make coughing less effective.

  • Use simple measures first, including advising people more than one year of age with cough to take honey.

  • Consider short-term codeine linctus, codeine phosphate tablets or morphine sulfate oral solution in people aged ≥18 years to suppress coughing if it is distressing. Seek specialist advice for people under 18 years.

Managing fever

  • Advise people with COVID-19 and fever to drink fluids regularly and that fluid intake needs can be higher than usual.

  • Advise people to take paracetamol or ibruprofen if they have fever and other symptoms that antipyretics would help treat. Continue treatment only when fever and other symptoms are present.

Managing breathlessness

  • Identify and treat reversible causes of COPD obstructive pulmonary disorder and asthma.

  • When significant medical pathology has been excluded or further investigation is inappropriate, the following may help to manage breathlessness as part of supportive care:

    • keeping the room cool,

    • encouraging relaxation and breathing techniques,

    • changing body positioning, and

    • encouraging people who are self-isolating alone to improve air circulation by opening a window or door.

  • If hypoxia is the likely cause of breathlessness:

    • consider a trial of oxygen therapy, and

    • discuss with the person, family or carer possible transfer to and evaluation in secondary care. 

Managing mental health

Treatments for anxiety, delirium and agitation

  • Anxiety or agitation and able to swallow:

    • Lorazepam 0.5 mg to 1 mg four times a day as required (maximum 4 mg in 24 hours).

    • Reduce the dose to 0.25-0.5 mg in older people or those who are debilitated (max 2 mg in 24 hours).

    • Oral tablets can be used sublingually (off-label use).

  • Anxiety or agitation and unable to swallow:

    • Midazolam 2.5 mg to 5 mg by subcutaneous injection every 2-4 hours as required.

    • If needed more than twice daily, a subcutaneous infusion via a syringe driver may be considered, starting with midazolam 10 mg over 24 hours.

    • Reduce dosage to 5 mg over 24 hours if estimated glomerular filtration rate is <30 mL/minute.

  • Delirium and able to swallow:

    • Haloperidol 0.5-1 mg at night and every two hours when required.

    • Increase dose in 0.5 mg to 1 mg increments as required to a maximum of 10 mg daily or 5 mg daily in older people.

    • The same dose of haloperidol may be administered by subcutaneous injection or subcutaneous infusion of 2.5 mg to 10 mg over 24 hours.

    • Consider a higher starting dose (1.5 mg to 3 mg) if distress is severe or causing immediate danger to others.

    • Consider adding a benzodiazepine if the person remains agitated.

  • Delirium and unable to swallow:

    • Levomepromazine 12.5-25 mg as subcutaneous injection as a starting dose and then hourly as required (use 6.25-12.5 mg in older people).

    • Maintain with subcutaneous infusion of 50-200 mg over 24 hours, increased according to response (doses >100 mg over 24 hours should be given under specialist supervision).

    • Consider midazolam alone or in combination with levomepromazine if the person also has anxiety. Note: at the time of publication (March 2021), midazolam and levomepromazine did not have UK marketing authorisation for this indication or route of administration.

Managing medicines

This article originally appeared on Univadis, part of the Medscape Professional Network.

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