BENGALURU: Mutations in the SARS-CoV-2 and the surge in infections during the second wave have forced changes in treatment protocols that have not only caused confusion among the medical fraternity, but also caused side-effects and severe fungal infections among patients, leading to loss of lives.
More than 16 months since Covid-19 was first reported in Wuhan, China, a handful of vaccines and no proven treatment have led to the medical fraternity doing its optimal – even adding to its repository drugs like Remdesivir and Tocilizumab with no proven capability of curing the disease or reducing mortality.
The Indian Council for Medical Research (ICMR) recently updated its treatment protocol, dropping the much-hyped Convalescent Plasma Therapy. Amidst this chaos, the medical fraternity was faced with just one crucial question: How to treat Covid patients at home and in hospitals, and when to prescribe steroids, the misuse of which is known to be dreadful?
“Mutations are continuously occurring and variants are being seen bringing in more transmissibility and hence, increase in the number of cases. The ICMR has continued to treat with some medications that the WHO had recently advised against. But that is not dangerous if used judiciously and under the guidance of medical health professionals. It is based on vast experience and evidence of cure among Indian patients that these repurposed drugs are being used,” pointed out Dr Manjunath C N, director of Sri Jayadeva Institute of Cardiovascular Sciences and Research.
The WHO norms have said there is no evidence of Remdesivir’s impact on mortality, patient’s need for mechanical ventilation, or any important outcome. However, there have been real-life Indian case studies showing that it reduced hospital stay, say experts. Dr Nagaraja C, Director, Rajiv Gandhi Institute of Chest Diseases, says, “It is not a life-saving drug, but it has shown evidence of reducing the number of days a patient stays in the hospital. The patient recovers quickly and goes back home sooner.
This helps as beds become available for other patients faster. So, definitely, this medicine does have its advantages. It is part of the national protocol, but only as an experimental and investigational therapy. It is not related to reducing mortality.” At present, none of the drugs being used in India for the treatment of Covid are new.
Dr Ravindra Mehta, renowned pulmonologist, Apollo Hospitals, says for Covid-19, ‘right treatment for the right symptom at the right time’ is the magic bullet. When there is no ‘magic bullet’ drug, he says a combination of drugs has worked. But, many cases have not been diagnosed at the right time, and patients have also been self-medicating out of the fear of having to get admitted in hospital, often resulting in worsening scenarios.
Dr Jayanthi CR, Dean, Bangalore Medical Research College & Institute, Victoria Hospital, says, “Different medicines have different effects on people. Doctor’s advice is needed while taking medicines and Remdesivir and Ivermectin haven’t been proven as the ultimate medicine against Covid. Also, some prescriptions doing the rounds say steroids can be started on day 5 and people are blindly doing that. People could not only have side-effects like black fungus, but also lose their lives.” In this scenario, the best approach is for patients to keep track of symptoms and follow the doctors’ advice to follow a robust schedule at home or when admitted to hospital, if needed.
One step at a time
Dr Mathew Varghese, Consultant Orthopaedic Surgeon, St Stephen's Hospital, Delhi, who is known as a 'warrior' against the Polio and whose video on Covid timeline and management of the virus went viral, started taking notes on every single patient, their relatives and primary contacts to understand how the disease was spreading. He noticed a pattern in the way the virus worked in each individual's body. During the 2nd wave, he managed patients with timely treatment, realising many did not need hospitalisation. According to him, the timing of the very first symptom is the most important to note. Dr Varghese explains the ideal treatment method in stages:
THE VERY FIRST STEP
Normally, people reveal significant symptoms like a fever or loss of taste and smell as their first day. But that's not the case. They would have had an itchy throat or a bodyache which they would have attributed to some other physical strain or change in weather. "The day the symptom was first experienced is Day 1 of the onset of disease in the patient," he says. The incubation period for SARS-CoV-2 is five days (+/- 2 days) for the onset of symptoms from the day of viral entry into the body.
DAY 1-3: This is the time when a patient is in the incubation phase and viremia shows symptoms in the body. That is when the patient is most infectious in transmitting the virus to others. This is also when the body begins to generate antibodies and fever sets in.
Treatment: If it’s only fever, then take paracetamol and nothing else to be done about it. Do not take steroids at this time, as it can multiply the virus and worsen the disease. About 80 per cent of people get better by this time.
Warning signs: Watch out for these symptoms now — increase in fever, onset of settled fever, cough which is deep, but no phlegm, breathlessness. If symptoms persist, hospitalisation may be required.
Day 4-5: Crucial days, as it can take a dangerous turn. It is not because of the virus, but due to antibodies in your own body, which are supposed to kill the virus but attack your own cells. Reason: Some cells have proteins on their surface which mimic the virus’ structure, especially the spike protein. This often happens in the lungs. The antibodies go and attack the lung’s blood vessels and clotting occurs. This clogs blood vessels, which, in turn, obstructs the oxygen exchange and lung saturation dips. This causes problems in breathing. Pathology is not because of the virus but the body’s reaction to the presence of the virus. It is not pneumonia, but clotting of blood veins which cause the problem. If you allow this to continue, then you will need to be given oxygen. A patient needs to anticipate this so that it can be treated.
Treatment: At this stage, the patients should not take paracetamol if one has fever, bodyache or/and, sore throat as it suppresses the symptoms and conceals Covid-19 taking a dangerous turn. It is now that steroids and anticoagulants are given together.
Days 5-6: The patient, at this stage, is put on steroids to prevent a cytokine storm. But only steroids will not stop it. It needs to be combined with anticoagulants. The combination prescription has to be started even before diagnosing clotting of the blood vessels. Patients should not do this on their own as steroids suppresses immunity, and therefore can be a double-edged sword as various infections take over. Diabetic patients in this situation need to be in touch with their doctors for further treatment.
Treatment: The anticoagulant should be taken for 3 weeks and the steroid for 10 days. Most patients have good outcomes. Monitoring oxygen levels with an oximeter at home is not the right thing to do as, by then, the lungs would already be damaged. And invariably it can lead to a catastrophe. The instrument is useful for doctors in hospitals, but do not sit at home with it.
Day 7: Patients feel better with steroids. Fever is gone. But in immuno-compromised patients, especially the elderly, they start getting fever on the 4th day of their steroid regimen. It isn’t the virus which is coming back but immunity which is suppressed that allows the normal bacteria in the lungs to attack the body and cause bacterial infection/pneumonia. It is at this stage that the patient needs antibiotics. They should not be taken in the early stages, as it encourages antibiotic resistance. Doxycycline & azithromycin are useless in early stages.