A quick reference guide for when patients with comorbidities are unwell with Covid-19

Some patients are eligible for treatment with nMAB or antivirals

Chronic Lung Disease

This information is sourced from (NHSE pulse oximetry guidance page 6) and (NHSE acute Covid guidance page 3)

Interpreting oxygen saturations in patients with known low baseline oxygen saturations

COPD

This information is sourced from the PCRS and NICE guidelines on managing Covid-19 and COPD

Treatment of Covid-19 in patients with COPD:

• Tell patients not to start a short course of oral corticosteroids and/or antibiotics for symptoms of Covid‑19 e.g. fever, dry cough or myalgia
• Evidence suggests that bacterial co-infection occurs in less than about 8% of people with Covid-19
• However you should have a low threshold for considering further review with imaging and bloods
• If a person has suspected or confirmed secondary bacterial pneumonia, start antibiotic treatment as soon as possible
• Start a course of oral corticosteroids if clinically indicated (a significant increase in breathlessness that interferes with daily activities). NICE currently recommends 30mg prednisolone for 5 days

Asthma

This information is sourced from the PCRS and the BMJ

Treatment of Covid-19 in patients with asthma:

• Remember to manage asthma actively with usual management. The risk of inadequately treating an asthma attack is highly likely to be worse than the risk from Covid-19 (Covid-19 can trigger an asthma attack)
• Consider history and examination features helping distinguish asthma exacerbation from Covid-19 e.g. wheeze, diurnal variation, improvement with inhalers and absence of fever

Diabetes

This information is sourced from the PCDS

Treatment of Covid-19 in patients with diabetes:

• Consider SICK day rules in people with diabetes who are unwell with Covid 
• Remember SADMAN rules for medications that you should think of stopping in people with intercurrent illness that could cause AKI or DKA (including SGLT2 inhibitors)
• Covid-19 can trigger new-onset diabetes in previously healthy people

Click here to read more on Covid-19 infection in people with diabetes

Older/immunocompromised people

This information is sourced from the UK Health Security Agency

• Covid can present with atypical symptoms, such as delirium and reduced mobility

Patients with adrenal insufficiency 

This information is sourced from the Society for Endocrinology

Treatment of Covid-19 in patients with Primary (eg Addisons) or secondary (eg previous high dose steroid treatment) adrenal insufficiency:

• May have atypical presentations (eg no fever, no CRP rise)
• Should not suddenly stop steroids
• Need larger than usual steroid doses and slightly different sick day rules

Other medications

This information is sourced from the PCDS

• Remember SADMAN rules for medications that you should think of stopping in people with intercurrent illness that could cause AKI or DKA (SGLT2 inhibitors/ ACEI/ Diuretics/ Metformin/ ARBs/ NSAIDs)

Patients treated with clozapine

This information is sourced from the Specialist Pharmacy Service

For patients on clozapine with Covid-19 symptoms recommendations are:

• Continue clozapine but take a blood sample immediately to determine WCC; neutrophil count; and clozapine plasma concentration
• If the patient is suspected of having a serious clozapine-related ADE (adverse drug effects) then stop clozapine and investigate appropriately

Symptoms of Covid-19 can mimic clozapine related ADEs: notably, myocarditis and neutropenic sepsis:

• Myocarditis: clozapine related myocarditis is more likely to occur within the first 6 weeks of treatment. Therefore after the initial period, the likelihood of any myocarditis being clozapine related reduces
• White cell count: Covid-19 can cause a reduction in WCC but does not appear to affect neutrophil levels, whilst clozapine does. Therefore if neutrophil levels are stable, continue clozapine