Management of SARS-CoV-2 infection: recommendations of the Polish Association of Epidemiologists and Infectiologists. Annex no. 1 as of June 8, 2020

Flisiak, Robert; Horban, Andrzej; Jaroszewicz, Jerzy; Kozielewicz, Dorota; Pawłowska, Małgorzata; Parczewski, Miłosz; Piekarska, Anna; Simon, Krzysztof; Tomasiewicz, Krzysztof; Zarębska-Michaluk, Dorota

Letters to the Editor

Management of SARS-CoV-2 infection: recommendations of the Polish Association of Epidemiologists and Infectiologists. Annex no. 1 as of June 8, 2020

Robert Flisiak, Andrzej Horban, Jerzy Jaroszewicz, Dorota Kozielewicz, Małgorzata Pawłowska, Miłosz Parczewski, Anna Piekarska, Krzysztof Simon, Krzysztof Tomasiewicz, Dorota Zarębska-Michaluk

DOI: 10.20452/pamw.15424

Published online: June 26, 2020.
CC BY-NC-SA 4.0

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To the editor Supplementary material

To the editor

Due to new data from the literature and accumulated experience, it became necessary to implement some changes in recommendations for management of severe acute respiratory syndrome coronavirus 2 (SARS‑CoV‑2) infection published by Polish Association of Epidemiologists and Infectiologists on March 31, 2020.¹ Changes include both primary and supportive therapy in particular stages of the disease (Table 1). They are first of all a consequence of remdesivir registration by the United States Food and Drug Administration and European Medicines Agency that resulted in the recommendation to use this medication at an earlier stage of the disease.^2-4 In the recommendations of March 31, 2020 we included chloroquine and hydrochloroquine in the primary therapy, which was a result of no alternative registered therapeutic options and expected new data supporting effectiveness of these drugs. Due to lack of such data, these medications are listed in this annex as a supportive therapy, which is in accordance with the current summary of product characteristics for chloroquine in Poland.⁵ Additionaly, this annex includes convalescent plasma and low‑molecular‑weight heparin as a possible supportive therapy.^6,7 There is still no sufficient data supporting use of azithromycin, favipiravir, ruxolitinib, oseltamivir, opaganib, and verdinexor in the treatment of patients with SARS‑CoV‑2 infections, so we do not recommend the use of these medications.

Table 1. Recommended therapeutic management in particular clinical stages of SARS‑CoV‑2 infection including the primary and supporting therapy

Stage of the disease	Primary therapy	Supportive therapy
a Low‑molecular‑weight heparin in prophylactic or therapeutic doses according to the general rules for the management of thromboembolic complications Abbreviations: ARDS, acute respiratory distress syndrome; IL‑6, interleukin 6
Asymptomatic or mild	No need	Symptomatic
Stable	Remdesivir , administered intravenously once a day with a loading dose of 200 mg and later maintenance dose of 100 mg for 5–10 days, or (if remdesivir is not available) lopinavir / ritonavir , administered orally in a dose of 400/100 mg every 12 hours for up to 14 days	Chloroquine , administered orally usually in a dose of 250 mg (in justified cases, 500 mg) every 12 hours for 7 to 10 days (no longer than 10 days) or hydroxychloroquine , administered orally with a loading dose of 400 mg every 12 hours and maintenance dose of 200 mg every 12 hours for 10 days. Convalescent plasma Low‑molecular‑weight heparin ^a Antibiotics if necessary Symptomatic treatment
Unstable	Remdesivir , administered intravenously once a day with a loading dose of 200 mg and later maintenance dose of 100 mg for 5–10 days, or (if remdesivir is not available) lopinavir / ritonavir , administered orally in a dose of 400/100 mg every 12 hours for up to 28 days plus Tocilizumab (in patients with elevated IL‑6 concentration) administered intravenously in a dose of 8 mg/kg of body weight (maximally 800 mg) in a single dose (a 1‑hour infusion). In the absence of improvement, the second dose may be repeated after 8 to 12 hours.	Chloroquine , administered orally usually in a dose of 250 mg (in justified cases, 500 mg) every 12 hours for 7 to 10 days (no longer than 10 days) or hydroxychloroquine , administered orally with a loading dose of 400 mg every 12 hours and maintenance dose of 200 mg every 12 hours for 10 days. Convalescent plasma Low‑molecular‑weight heparin ^a Antibiotics if necessary Symptomatic treatment Oxygen therapy Intravenous rehydratation
Critical condition (ARDS)	Remdesivir , administered intravenously once a day with a loading dose of 200 mg and later maintenance dose of 100 mg for 5–10 days, or (if remdesivir is not available) lopinavir / ritonavir , administered orally in a dose of 400/100 mg every 12 hours for up to 28 days plus Tocilizumab (in patients with elevated IL‑6 concentration) administered intravenously in a dose of 8 mg/kg of body weight (maximally 800 mg) in a single dose (a 1‑hour infusion). In the absence of improvement, the second dose may be repeated after 8 to 12 hours.	Mechanical ventilation Extracorporeal membrane oxygenation in the case of refractory hypoxemia, independently of invasive mechanical ventilation Convalescent plasma Low‑molecular‑weight heparin ^a Antibiotics if necessary Symptomatic treatment Oxygen therapy Intravenous rehydratation Glucocorticosteroids: methylprednisolone administered intravenously in a dose of 1 mg/kg of body weight per day for 5 days, later 40 mg per day for 3 days, next 10 mg per day for 2 days, or dexamethasone administered intravenously in a dose of 20 mg per day for 5 days, later 10 g per day for 3 days, next 5 mg per day for 2 days.

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Author names and affiliations: Robert Flisiak, Andrzej Horban, Jerzy Jaroszewicz, Dorota Kozielewicz, Małgorzata Pawłowska, Miłosz Parczewski, Anna Piekarska, Krzysztof Simon, Krzysztof Tomasiewicz, Dorota Zarębska‑Michaluk (RF: Department of Infectious Diseases and Hepatology, Medical University of Bialystok, Białystok, Poland; AH: Department of Infectious Diseases for Adults, Medical University of Warsaw, Warsaw, Poland; JJ: Department of Infectious Diseases and Hepatology, Medical University of Silesia, Katowice, Poland; DK and MPaw: Department of Infectious Diseases and Hepatology, Faculty of Medicine, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, Bydgoszcz, Poland; MPar: Department of Infectious, Tropical Diseases and Acquired Immunodeficiency, Pomeranian Medical University, Szczecin, Poland; AP: Department of Infectious Diseases and Hepatology, Medical University of Lodz, Łódź, Poland; KS: Department of Infectious Diseases and Hepatology, Medical University of Wrocław, Wrocław, Poland; KT: Department of Infectious Diseases and Hepatology, Medical University of Lublin, Lublin, Poland; DZ‑M: Department of Infectious Diseases, Jan Kochanowski University, Kielce, Poland)

Conflict of interest: None declared.

References

Flisiak R, Horban A, Jaroszewicz J, et al. Management of SARS‑CoV‑2 infection: recommendations of the Polish Association of Epidemiologists and Infectiologists as of March 31, 2020. Pol Arch Intern Med. 2020; 130: 352‑357. | Crossref
Beigel JH, Tomashek KM, Dodd LE, et al. Remdesivir for the treatment of COVID‑19 ‑ preliminary report. N Engl J Med. 2020 May 22. [Epub ahead of print].
Food and Drug Administration issuance of emergency use authorization for potential COVID‑19 treatment. https://www.fda.gov/media/137564/download. Published May 1, 2020. Accessed June 8, 2020.
European Medicines Agency. Summary on compassionate use for Remdesivir Gilead (updated). https://www.ema.europa.eu/en/documents/other/summary‑compassionate‑use‑remdesivir‑gilead_en.pdf. Accessed June 8, 2020.
Arechin – Summary of product characteristics. http://www.urpl.gov.pl/sites/default/files/Arechin%20Charakterystyka%20Produktu%20Leczniczego.pdf. Accessed June 8, 2020.