New COVID-19-related guidance on CPR, chest imaging, hydroxychloroquine

Medical societies addressed appropriate resuscitation and chest imaging practices for patients with COVID-19, issued guidelines on treatment and management, and warned about arrhythmia risks with hydroxychloroquine and azithromycin.

The American Heart Association released interim guidance on performing cardiopulmonary resuscitation on patients with suspected or confirmed COVID-19, published by Circulation on April 9. The statement, which offers specific guidance on arrests in and out of the hospital, focuses on principles including reducing clinician exposure to COVID-19, prioritizing oxygenation and ventilation strategies with lower aerosolization risk, and considering the appropriateness of starting and continuing resuscitation.

Advice on the use of chest imaging in COVID-19 was offered by a consensus statement from the Fleischner Society, an international thoracic radiology society. The statement, published by CHEST on April 7, says that imaging is not indicated in patients with suspected COVID-19 and mild clinical features unless they are at risk for disease progression, but it is indicated in patients with COVID-19 and worsening respiratory status. It added that in a resource-constrained environment, imaging is indicated for medical triage of patients with suspected COVID-19 who present with moderate-severe clinical features and a high pretest probability of disease. An Ideas and Opinions article published by Annals of Internal Medicine on April 8 also cautioned against using CT to diagnose COVID-19, noting that the early research supporting this method of detection had many flaws.

The Infectious Diseases Society of America released guidelines on the treatment and management of patients with COVID-19 on April 11. For patients who have been admitted to the hospital with COVID-19, they recommended hydroxychloroquine/chloroquine in the context of a clinical trial. For the same population, the guidelines recommend hydroxychloroquine/chloroquine plus azithromycin, lopinavir/ritonavir, or tocilizumab only in the context of a clinical trial. COVID-19 convalescent plasma was recommended in the context of a clinical trial. Two recommendations addressed corticosteroids: The guidelines suggested against them for patients admitted with COVID-19 pneumonia, and recommended them in the context of a clinical trial for patients with acute respiratory distress syndrome due to COVID-19.

The guidelines also reviewed the evidence on other questions related to COVID-19, including treatment with HIV antivirals, lopinavir-ritonavir combined with interferon- beta or other antivirals, ribavirin, oseltamivir, intravenous immunoglobulin, or remdesivir; use of convalescent plasma for prophylaxis; and discontinuation of NSAIDs, angiotensin-converting enzyme inhibitors, or angiotensin- receptor blockers. The treatment guidelines are the first of three planned parts. Guidelines on diagnostics and infection prevention are coming soon, the society said. The authors noted either knowledge gaps or very low certainty of evidence for all seven of their recommendations.

A paper coauthored by the presidents of the American Heart Association, American College of Cardiology, and Heart Rhythm Society warned about the risks of drug interactions arrhythmias with both hydroxychloroquine and azithromycin. The paper, which was published by JACC,Circulation, and Heart Rhythm on April 10, offers recommendations on electrocardiographic monitoring for patients on these drugs.

Data on dosing of hydroxychloroquine was provided by a simulation study using prospective data from 13 ICU patients taking the drug for rheumatoid arthritis. Based on pharmacokinetic (PK) properties, the authors proposed a dosing strategy (loading dose of 800 mg once daily on day 1, followed by 200 mg twice daily for seven days) but recommended further personalization for optimal dosing. “There is an urgent need for health agencies to clarify the standard dosing regimen of [hydroxychloroquine] in order to have comparable data across clinical trials, and to avoid dubious efficacy or toxicity results due to PK profiles,” they wrote.

On April 9, the NIH announced a new clinical trial of hydroxychloroquine in patients hospitalized with COVID-19. CDC guidance updated April 7 notes that hydroxychloroquine and chloroquine are under investigation in clinical trials, but no drugs are currently approved to treat COVID-19. In a new episode of the Annals On Call podcast, posted on April 9, host Robert Centor, MD, MACP, discusses the evidence that generated interest in the potential role of hydroxychloroquine for COVID-19 treatment.

The College continues to advocate for internists and patients in areas related to COVID-19 care, including calling for open enrollment periods for the uninsured, use of the Defense Production Act to produce personal protective equipment, and immediate financial assistance to keep physician practices open. Advocacy updates regarding COVID-19 are available online.