SUMMARIZED CLINICAL

INFORMATION ON COVID-19
FOR ALBAY PHARMACISTS
Prepared By:

Lorenzo C. Llamas, Jr., RPH

Albay Pharmacists Association, Inc.
Purpose

 This serves as a reliable and concise reference on

Coronavirus Disease 2019 for pharmacists and the
pharmacy workforce. This presentation also encompasses
on measures to reduce the risk of infection, preparedness
in the pandemic, promotion of good hygiene and
counselling guide for pharmacists/workforce to patients.
Outline
 Background
 Mode of Transmission
 Risk Factors
 Signs and Symptoms
 Clinical Course
 Diagnostic Testing
 Clinical
Management of Adult Patients with
Suspected or Confirmed COVID-19 Infection
 Pharmacy-mediated Activities
Background
 COVID-19 (Coronavirus Disease 2019) is a
respiratory tract infection caused the SARS-CoV-2
first isolated in Wuhan, China in Dec. 2019.

 As of 30 June 2020, there are >10,000,000

reported cases worldwide and is the cause of
death in >500,000 individuals.
 Background
Virion Spherical, 50-200 nm in
diameter, helical nucleocaspid
Genome ssRNA, linear, non-segmented
positive-sense, 29kbp (kilo
base pairs)
Proteins S (spike) E (envelope) M
(membrane) N (nucleocaspid)
Replication Cytoplasm, particles mature by
budding into endoplasmic
reticulum and Golgi
Other high frequency of
recombination, difficulty to
Characteristics grow in cell culture
Modes of Transmission
 Droplet spread
 Person-to-person among close contacts (about 1.8m)
 Occur mainly via respiratory droplets produced when an
infected person coughs or sneezes and inhaled into the lungs
 Aerosol spread
 Coughing and airway management procedures (oxygenation,
intubation, ventilation) can generate aerosols containing smaller
virus particles suspended in air
 RISK OF EXPOSURE TO HEALTH CARE WORKERS
 Fomites – touching of surfaces
 Airborne – indoor/crowded places
RISK FACTORS
 Older patients (>65 yrs old)
 Presence of co-morbidities:
 a. Chronic respiratory diseases
 b. Cancer
 c. Cardiovascular diseases
 d. Cerebrovascular disease
 e. Immunocompromised state
 f. Diabetes
 g. Decreased renal/hepatic function h. Hypertension
Signs and Symptoms
COMMON LESS COMMON
FEVER MUSCLE ACHE
DRY COUGH DIARRHEA
SHORTNESS OF BREATH RHINORRHEA
SORE THROAT HEADACHES
FATIGUE VOMITING
ANOREXIA
LOSS OF TASTE AND
SMELL
Clinical Course
Phase Duration
Incubation Within 14 days following exposure,
symptoms occurring 4-5 days after
exposure

Varies in severity
Period of Illness
***Dyspnea (shortness of breath) 8 days after illness onset (5-13D)
***Acute Respiratory Distress 17-29% of hospitalized patients with
Syndrome a median time of 8 days after
symptoms onset

Recovery Mild: around 2 weeks

Severe: 3-6 weeks
 Disease Severity Classification
Classification Signs and Symptoms

Mild Fever, cough, fatigue, anorexia, myalgias, sore throat, nasal

congestion, headache, diarrhea, nausea and vomiting, loss of
smell (anosmia) or loss of taste (ageusia) preceding the onset of
respiratory symptoms NO signs of pneumonia or hypoxia

Moderate With signs of Non-severe pneumonia (e.g. fever, cough,

dyspnea, RR <30/minute; spO2 >92% on room air (NV for oxygen
saturation at 94-100%)
Severe Severe Pneumonia or severe acute respiratory infection, as
follows: Fever, cough, dyspnea, RR >30 breaths/minute, severe
respiratory distress
Critical Onset within 1 week of known clinical insult (pneumonia) or new
or worsening respiratory symptoms, progressing infiltrates on
CXR or chest CT, with respiratory failure not fully explained by
cardiac failure or fluid overload
 Disease Severity Classification (reference:
WHO Interim Clinical Guidance May 2020)
Classification Management
Mild Home isolation for 14 days with instructions or send to community
quarantine facility.
Admit if elderly or with unstable/uncontrolled co-morbid
conditions.
Give symptomatic treatment and supportive care as needed.
Empiric antibiotics NOT needed
Moderate Admit to a COVID-19 designated room/unit
Severe Refer to INTERIM GUIDANCE ON THE CLINICAL MANAGEMENT OF
ADULT PATIENTS WITH SUSPECTED OR CONFIRMED COVID-19
INFECTION
Critical Refer to INTERIM GUIDANCE ON THE CLINICAL MANAGEMENT OF
ADULT PATIENTS WITH SUSPECTED OR CONFIRMED COVID-19
INFECTION
Clinical Course of COVID Patients among
Survivors and non-Survivors
Diagnostic Testing
Benefits

 Proper allocation of personal protective equipment

 Prevention of nosocomial spread and subsequent
community transmission
 Guidance in treatment decisions and enrolment in
clinical trials
Diagnostic Testing

1. Real-time reverse transcription-polymerase chain

reaction (RT-PCR)
2. Rapid Tests based on Antigen Production
3. Detection of Antibodies to SARS-CoV-2
Pharmacy-mediated Activities
 Preventive measures (Risk Management Plan)
 Advice to the Community
 Recommendations
 Referral and isolation
 Home care for mild and asymptomatic patients
 Pharmacy as information source
 Infection control
 Cleaning and Disinfection
RT-PCR
 The currently WHO-recommended “stand-alone” test to
confirm COVID-19 infection as it detects the viral RNA in
respiratory secretions and in stool samples.
 Table below is the sensitivity and specificity of RT-PCR based
on type of sample
 Nasopharyngeal (NP) specimens rather than oropharyngeal or
saliva specimens are preferred for swab-based SARS-CoV-2
testing.
False Negative on RT-PCR
 False negative results of RT-PCR assays may be due
to inadequate sample and inappropriate timing of
sample collection in relation to symptom onset.
 On the day of symptom onset, the median false-
negative rate was 38%. This decreased to 20% on day
8 (3 days after symptom onset) then began to
increase again, from 21% on day 9 to 66% on day 21.
 The false-negative rate was minimized 8 days after
exposure, 3 days after the onset of symptoms on
average.
Rapid Tests based on Antigen Production
 NOT CURRENTLY RECOMMENDED BY THE WHO TO
CONFIRM COVID-19 INFECTION/CASE
 detects the presence of viral proteins (antigens)
expressed by the COVID-19 virus in a sample from the
respiratory tract of a person.
 Factors Affecting Accuracy and Precision:
 Onset of illness
 the concentration of virus in the specimen
 quality of the specimen collected from a person and how it is
processed, and
 the precise formulation of the reagents in the test kits
Rapid Tests based on Antigen Production
 False-positive results could occur if the antibodies on the
test strip also recognize antigens of viruses other than
COVID-19 (e.g. cross-reaction).
 Rapid antigen tests can potentially be used as an
alternative to RT-PCR assay for the diagnosis of
symptomatic patients during the first week of illness.
 Negative results from an antigen test should be confirmed
with an RT-PCR test prior to making treatment decisions to
prevent undue transmission.
Detection of Antibodies to SARS-CoV-2
 Not recommended as stand-alone tests for the diagnosis of
COVID-19.
 These tests are also not recommended for mass testing and
clearance for work of asymptomatic people due to its low
sensitivity and high false negative rates.
 Laboratory based immunoassays such as chemiluminescence
assay (CLIA) and enzyme-linked immunosorbent assay (ELISA)
are the preferred tests for antibody determination.
 Best done on the third week onwards from the onset of
symptoms.
Ancillary Tests
Complete blood count Metabolic panel: creatinine, sodium,
potassium, calcium, albumin,
magnesium
Inflammatory markers: lactate Prothrombin and D-dimer
dehydrogenase (LDH), Ferritin, C-
reactive protein (CRP) and
procalcitonin
Arterial blood gas (ABG) measurement Blood cultures if super-infection is
suspected

Respiratory tract specifimen for Sputum

influenza testing

Chest X-Ray CT scan (plain)

ECG
Medication Therapy Management:
General Notes (as of 20 July 2020)
 Chloroquine and Hydroxychloroquine have been discontinued by
the WHO in the solidarity trial
 There is NO current evidence to recommend any specific agent
for SARS-2-CoV in patients with suspected or confirmed
infection.
 Symptomatic treatment is recommended for mild cases
 Considerations for the use of investigational drugs:
 Record ALL prescriptions of the investigational drugs to be used for
compassionate use(chloroquine, hydroxychloroquine, lopinavir-ritonavir,
tocilizumab, remdesivir)
 Chloroquine and Hydroxychloroquine are STILL NOT RECOMMENDED FOR
USE AS PROPHYLAXIS FOR COVID-19.
Specific Drugs for Symptomatic
treatment
 Antipyretics
 Paracetamol may be used instead unless it is
contraindicated.
 If patients are taking NSAIDs for a chronic condition,
encourage adherence to prescribed regimen and monitor
accordingly.
 Antitussives
 Insufficient evidence on the clinical antitussive property of
dextromethorphan for patients with cough associated with
URTI
Specific Drugs for Symptomatic
treatment
 Ascorbic Acid (Vit. C) and Zn
 BOTH ARE INSUFFICIENT IN EVIDENCE FOR USE AS ADJUNCT
IN COVID-19
 Limit intake of Vit. C to 500 mg/day due to increased risk of
oxalate kidney stone formation.
 Excessive use of Vit C may also encourage hoarding and
deprive patients with a greater need for ascorbic acid (e.g.
those who are malnourished or have scurvy).
 Excessiveuse of Zinc is associated with copper deficiency,
neutropenia, and anemia
Specific Drugs for Symptomatic
treatment
 ACEInhibitors and Angiotensin II Receptor
Blockers:
 Patients
are advised NOT to change their current
medications unless told so by their physicians
 Thereis lack of evidence that patients taking ACEIs
or ARBs are of higher risk of susceptibility in SARS-
CoV-2 infection
 Continue
the routine use until new evidence
becomes available
 Specific Drugs for Symptomatic
treatment
 Corticosteroids (Dexamethasone)
 Not recommended for viral pneumonia
 short-course therapy[10 days]
 adjunct treatment on COVID19 patients who require oxygen
support and on mechanical ventilation only (COPD, shock)
 May delay viral clearance from the respiratory tract and blood
 May increase rate of hyperglycemia, psychosis, and avascular
neurosis
 Nebulized bronchodilators may risk virus spread - Metered Dose
Inhalers are preferred if there are equivalents.
 Drugs under Investigation/Study
 Remdesivir
 Investigational drug for Ebola, MERS, SARS
 MOA: inhibit viral replication either by competitive inhibition
of the viral polymerase or by DNA chain termination
 Reported to have activity against SARS-CoV-2
 Compassionate use for severe COVID-19 cases only; not for
mild to moderate COVID except on clinical trial
 Ifavailable, dose: 200mg IV x 1, then 100mg IV once daily for
10 days NOT TO BE USED with Chloroquine/Hydrox
ychloroquine, and Lopinavir/Ritonavir
 DRUGS UNDER INVERSTIGATION
that are No Longer Recommended
 Lopinavir-Ritonavir
 No evidence indicating clinical improvement, reduced mortality, or
reduced viral RNA found in the throat in patients with serious
COVID-19
 Chloroquine and Hydroxychloroquine
 BOTH DISCONTINUED BY THE WHO SOLIDARITY CLINICAL TRIAL
 NOT TO BE USED AS PROPHYLAXIS FOR SUSPECTED COVID-19
INFECTION
 Tocilizumab and Favipiravir
 Not recommended for routine use in COVID-19 except in the
context of a clinical trial
 PREGANANCY and BREASTFEEDING
 No evidence yet that pregnant women present different signs/symptoms
 No evidence yet of vertical transmission
 Monitor pregnant women on history of contact
 Gravida with suspected infections, also including those who might need
isolation, should have access to obstetrics, fetal medicine care
 Infants born to mothers with suspected or confirmed infections should be
fed according to feeding guidelines and still implementing measures on
infection prevention and control.
 Mothers should practice respiratory hygiene
 Mothers should perform hand hygiene contact with the baby
 Disinfect and clean surfaces frequently
Pharmacy-mediated Activities

 Preventive Measures
 Recommendation for Outpatient Care
 Pharmacy as an information resource
 Infection control: hand washing and hand rubbing
 Infection control: other precautions
 Preventive Measures
 Pharmacists and the pharmacy workforce can play a key role
in preventing the spread of coronavirus SARS-CoV-2 by:
 Understanding the nature of the disease, how it is transmitted, and
how to prevent it from spreading further;
 Informing, advising and educating the community;
 Supplying appropriate products;
 Encouraging individuals and families with suspected cases of
SARS-CoV-2 acute respiratory disease to seek treatment from
healthcare facilities that possess the appropriate environment
and equipment to manage such patients.
 ADVICES TO THE COMMUNITY
 Avoid large gatherings and closed crowded spaces;
 Maintain physical distancing of at least 1 metre
radius from any individual
 Perform hand hygiene frequently, using alcohol-based
hand rub if hands are not visibly soiled or soap and
water when hands are visibly soiled;
 Ifcoughing or sneezing cover the nose and mouth with
a flexed elbow or paper tissue, dispose of the tissue
immediately after use and perform hand hygiene;
 Refrain from touching the mouth, nose and eyes
before washing their hands.
 ADVICES TO THE COMMUNITY
 Wear a medical mask and seek medical care if
experiencing fever, cough and difficulty breathing, as
soon as possible or in accordance with local protocols;
 Follow
the advice below regarding appropriate mask
management.
Pharmacy as Information Resource
Pharmacy as Information Resource
Pharmacy as Information Resource
Infection control: hand washing and
hand rubbing
 Pharmacies raise awareness about the importance
of frequent and appropriate hand washing and by
stocking or preparing alcohol-based hand
sanitizer.
 Hand hygiene is essential for preventing the
spread of the virus, and use of either soap and
running water or an alcohol-based hand sanitizer.
 TheWHO recommends that hand rub formulations
should have an alcohol content of 80% ethanol or
75% isopropyl alcohol.
 References
 Philippine Pharmacists Association “Clinical Information on COVID-
19 for Pharmacists” (as of 13 July 2020)
 Tortora, Gerard J. “Microbiology: An Introduction, 9th Edition”
Pearson Education, Inc. © 2007
 International Pharmaceutal Federation, “FIP Health Advisory
CORONAVIRUS SARS-CoV-2 OUTBREAK: Information and interim
guidelines for pharmacists and the pharmacy workforce” © 2020
 PSMID, et al., “INTERIM GUIDANCE ON THE CLINICAL MANAGEMENT
OF ADULT PATIENTS WITH SUSPECTED OR CONFIRMED COVID-19
INFECTION” © 2020