Treatment of COVID-19 in patients hospitalised due to COVID-19

Please note that the prescribing process is different according to patient’s age.

Children under 4 weeks of age AND/OR UNDER 3kg

Remdesivir should be considered in COVID-19 pneumonia with low flow oxygen support and be recommended by one of the paediatric remdesivir leads (Dr Shelley Segal, Prof Andrew Pollard, Dr Dominic Kelly, Dr Stephane Paulus). Use must be approved via the Gilead Sciences Ltd compassionate use scheme (BlueTeq form is NOT required under this scheme).

The prescriber will need to complete the Gilead Sciences Ltd electronic request form on rdvcu.gilead.com The prescriber will need to inform Gilead Sciences Ltd that stock is required for the patient but that OUH stock will be used to commence the treatment to prevent delays. For the pharmacy contact details section of the form, please get in touch with the ward pharmacist or the on call pharmacist if the request is made out of hours. Pharmacists should refer to the Remdesivir screening guide on sharepoint for further information on the screening process.

If the application has been successful, Gilead will contact the prescriber to inform them. The prescriber should document this into the patient’s EPR record.

Patients at least 4 weeks old and at least 3kg

Check whether your patient should be given remdesivir -all of the criteria listed below should be met:

SARS-CoV-2 infection is confirmed by polymerase chain reaction (PCR) test or where a multidisciplinary team (MDT) has a high level of confidence that the clinical and/or radiological features suggest that COVID-19 is the most likely diagnosis 

AND 

Hospitalised specifically for the management of COVID-19 symptoms 

AND 

Requiring low-flow supplemental oxygen (except for immunocompromised patients - see below)

AND 

Presented to hospital not more than 10 days since symptom onset (see exemptions below)

AND 

Estimated glomerular filtration rate (eGFR) at least 30 ml/minute (see exemptions below)

AND 

Alanine aminotransferase (ALT) below 5 times the upper limit of normal at baseline 

Exemptions

• Patients with end-stage renal disease on haemodialysis are exempt from the eGFR treatment threshold above.
• For significantly immunocompromised patients, who should be discussed with Paediatric ID:
  • A course of remdesivir can be extended to a maximum of 10 days
  • The criterion on time between symptom onset and treatment initiation does not apply
  • The criterion on the need for supplemental oxygen requirement does not apply

See more detail at NHS Interim Clinical Commissioning Policy

Patients re-admitted with COVID-19 (and meeting the eligibility criteria above, with the exception of the requirement on the timing from symptom onset) are permitted a second course of up to 5 days upon readmission.

Discuss cases outside of these criteria with Paediatric ID.

Prescribing remdesivir

• Initiation: the decision to initiate treatment with remdesivir should be made by the admitting care consultant. Remdesivir should be prescribed using the relevant EPR powerplan. A BlueTeq form will need to be completed by one of the Paediatric ID consultants or Trust Remdesivir leads.
• Monitoring: the use of remdesivir should be reassessed daily. Daily LFTs and U&Es should be performed.
• Discontinuation: Remdesivir should be discontinued in patients who develop:
  • ALT 5 times or more the upper limit of normal during treatment with remdesivir, or, ALT elevation accompanied by signs or symptoms of liver inflammation or increasing conjugated bilirubin, alkaline phosphatase or INR
  • adverse reactions thought to be hypersensitivity
  • other adverse reactions thought to be due to remdesivir (complete yellow card, found here).
• Also consider stopping remdesivir if:- 
  • the patient clinically improves and no longer requires supplemental oxygen 72 hours after commencement of treatment; or 
  • the patient continues to deteriorate despite 48 hours of sustained mechanical ventilation

Children under 4 weeks old AND/OR with a body weight under 3kg

Day 1: 2.5mg/kg remdesivir as a single dose (maximum 200mg) iv

Day 2 onwards: 1.25mg/kg remdesivir (maximum 100mg) iv OD for further 4 days.

The usual total duration of treatment is 5 days, but it may be extended up to 10 days for severely immunocompromised patients (MDT decision only).

Children at least 4 weeks old and with a body weight between 3kg and 40kg

Day 1: 5mg/kg remdesivir as a single dose (maximum 200mg) iv

Day 2 onwards: 2.5mg/kg remdesivir (maximum 100mg) iv OD for further 4 days.

The usual total duration of treatment is 5 days, but it may be extended up to 10 days for severely immunocompromised patients (MDT decision only).

Children with a body weight 40kg or over

Day 1: 200mg remdesivir as a single dose iv

Day 2 onwards: 100mg remdesivir iv OD for a further 4 days.

The usual total duration of treatment is 5 days, but it may be extended up to 10 days for severely immunocompromised patients (MDT decision only).

Corticosteroids should be considered for use in children over 44 weeks gestational age with severe or critical COVID-19. For preterm babies with a gestational age under 44 weeks discuss with Paediatric ID team before initiating hydrocortisone (dosing below).

Please ensure, where appropriate, that PPI for gastric protection is prescribed while the patient is on corticosteroid.

Children over 44 weeks gestational age

Preferred

• Dexamethasone 150 micrograms/kg (as dexamethasone base, max 6mg) iv or po OD for 10 days.

Alternative

• Prednisolone 1mg/kg (max 40mg) po OD for 10 days.

Children 44 weeks gestational age or under 

Preferred

• Discuss with Paediatric ID team before initiating hydrocortisone.
• Hydrocortisone: 500 micrograms/kg iv or po every 12 hours for 7 days then 500 micrograms/kg OD for 3 days

Adolescents aged 16 years and older

Refer to the OUH COVID 19 thromboprophylaxis guideline

Children and adolescents under 16 years of age

• VTE prophylaxis may be considered on a case by case basis.
• Consider anti-embolism stockings (TEDs) in adolescents aged 12 years and older.

Children under 12 years of age with a body weight less than 50kg: 100units/kg (max 2500units) subcut OD

Children over 12 years of age with a body weight over 50kg: 5000units subcut OD

Adjust dose if eGFR is less than 30mL/min/1.73m²

The duration of VTE prophylaxis should be based on individual basis on specialist advice.

Baricitinib

Consider baricitinib for children and young people aged 2 years to 18 years in hospital with COVID-19 who:

• COVID-19 infection is confirmed microbiological testing or where MDT has a high level confidence that the clinical and/or radiological features suggest that COVID-19 is the most likely diagnosis, and
• have viral pneumonia syndrome, and
• need supplemental oxygen or respiratory support for the treatment of COVID-19, and
• are having or have completed a course of corticosteroids such as dexamethasone, unless they cannot have corticosteroids, and
• have no evidence of infection (other than SARS-CoV-2) that might be worsened by baricitinib.

To be prescribed ONLY on Paediatric ID advice and requires a BlueTeq form.

Exclusion criteria

Baricitinib should not be administered in the following circumstances:

• Known hypersensitivity to baricitinib;
• Patient is aged 9 years or over and eGFR less than 15 mL/min/1.73m² OR Patient is aged 2 years upto 9 years and eGFR less than 30 mL/min/1.73m2; ^*
• Receiving dialysis or haemofiltration;*
• Absolute neutrophil count (ANC) less than 0.5 x 10⁹ cells/L;  (Use with caution when (ANC) between 0.5-1 x 10⁹ cells/L)* 
• Active or latent tuberculosis;
• Pregnancy or breastfeeding.

* Note that these criteria are taken from RECOVERY trial and differ to the Summary of Product Characteristics for baricitinib

It is good practice to screen for blood borne virus including HIV, hepatitis B and C prior to starting baricitinib. Doses can be given whilst result are pending. In case of positive result discuss with Micro/ID. 

Cautions:

 Dosing:

eGFR should be calculated using Bedside Schwartz formula: Estimated GFR (mL/min/1.73 m2)= 35 × height (cm) / serum creatinine (micromol/l)

• Co-administration of an Organic Anion Transporter 3 (OAT3) inhibitor with a STRONG inhibition potential e.g. probenecid: discuss with pharmacy and in patients aged 9 years old or over baricitinib dose to be halved to 2mg OD.
• Patients already receving barictinib for other indications: discuss with pharmacy

Important information:

Baricitinib tablets can be dispersed in water prior to oral or enteral tube administration.

Unlicensed Use: This use of baricitinib is off-label. A routine use unlicensed medicine form has been completed for this use of baricitinib.

Discharge letter: Record that baricitinib has been given, together with the dose and date of administration

Interactions: Speak to pharmacy. A useful resource is University of Liverpool COVID-19 Drug Interactions website

Only to be given as part of clinical trials