COVID-19: Key to caring for a patient with COVID-19 is constant monitoring, treatments backed by evidence

Key to caring for a patient with COVID-19 is constant monitoring

Our knowledge about COVID-19 has come a long way since the first days of the pandemic. Today, we are very fortunate to have vaccines. Paired with healthy behaviors like mask wearing and social distancing, vaccines are the most effective way to prevent severe illness, hospitalization, and death.

For people who do get the disease, Intermountain Healthcare physicians and teams also have a growing toolkit of treatments to fight back. There is no one-size-fits-all approach; each step in the treatment process must be customized to each patient, addressing changes in their condition in real-time.

“Our goal is to find the treatments that are supported by evidence to help each patient get better, and get better faster,” said Brandon Webb, MD, an infectious diseases specialist at Intermountain. The approach is working. “Because of vaccines and breakthroughs in treatment, we’re seeing fewer patients who need to be admitted to the hospital, and more people who survive.”

Following are some of the evidence-based ways the doctors, advanced practice providers (APPs), nurses, pharmacists and respiratory therapists at Intermountain are saving lives from COVID-19.

For patients in early stages of COVID-19, the goal is to slow the virus

Good science vs. questionable info 
Shoppers looking for a car know there’s a difference between a Mercedes and a Mitsubishi, but the story is more complicated when looking at treatments for COVID-19. Every week, we get conflicting messages on social media, in news reports, and from well-meaning friends. How do we know which information to trust?

The answer is research. Good research.  

Intermountain Healthcare is committed to using only treatments supported by the best evidence. Our team of nationally and internally recognized experts carefully examines the data to determine which treatments are safe and effective. Intermountain has also been a national leader in conducting clinical trials that have led to important breakthroughs in how to treat COVID-19. Participating in clinical trials also provides patients a safe way to receive treatments that have not yet been proven to work.

What does good research look like?
The best research appears in reputable journals like the New England Journal of Medicine and relies on key practices and factors, including:
● Evaluating a broad cross-section of people representing different age groups, genders, races, underlying conditions, and more.
● Results that stand up to scientific peer review and can be duplicated in different settings.
● Trial methods that keep bias out of findings and conclusions.
● Studies that can determine which drug is having what effect, if multiple treatments are happening at the same time.

Not all studies meet these same standards of quality. Oftentimes, findings in low-quality research look very different when higher-quality research practices are applied. 

When adequate evidence doesn’t exist, Intermountain experts support clinical trials that let patients try unproven treatments in a carefully monitored way to ensure safety while also advancing knowledge. 

What’s the best way to sift the good from the bad if you don’t want to examine the methodology behind every single COVID-19 treatment study? People should ask their personal doctors and clinic teams, not Dr. Google. They have the expertise to evaluate treatments and research, and their top priority is your health and safety.

In the first week or so of illness, patients may have symptoms like body aches, fever, or cough. During this week, virus levels are highest and begin to trigger a chain reaction of symptoms. The goal of treatment during this early time is to block the virus and prevent more serious infection.

  • Antiviral treatments
    • Monoclonal antibodies. These treatments are created from people who have recovered from COVID-19. Researchers analyzed their blood to identify antibodies that are most effective in blocking or slowing the virus. These antibodies are reproduced in a lab and given as intravenous infusions. When given to high-risk patients, monoclonal antibodies have been shown to reduce the chance of hospitalization and death. They are most effective when used as early as possible. In the United States, there are three anti-SARS-CoV-2 monoclonal antibody treatments with FDA Emergency Use Authorization (EUA) for the treatment of COVID-19: bamlanivimab plus etesevimab, casirivimab plus imdevimab, and sotrovimab. These are used at Intermountain.
    • Other promising antivirals. Remdesivir is an intravenous medicine that prevents the virus from making copies of itself. It is approved by the Food and Drug Administration (FDA) to fight COVID-19 in hospital patients. And new clinical trial data suggests that if given earlier it is effective at preventing hospitalization. It isn’t yet being used widely outside of the hospital until insurance companies provide coverage for that setting. Molnupiravir is another exciting new antiviral drug that blocks the virus from replicating. It is a pill, taken twice a day for five days. In clinical trials in high-risk patients, it prevented hospitalization by more than 50%. This drug will likely be a game-changer in the fight against COVID and may be available for very-high risk patients in late 2021. An antidepressant drug called fluvoxamine has also recently shown promising results in a clinical trial, suggesting that it may be helpful in preventing hospitalization.
  • Not helpful: Treatments in this early phase that impair the immune system’s ability to fight the virus, such as steroids like dexamethasone or prednisone, may actually be harmful rather than helpful. Clinical trials have also shown that other drugs like hydroxychloroquine or ivermectin are not effective treatments in early COVID-19.
  • Blood thinners. Clinical trials have shown that blood clots are not common enough in this early phase to justify the risk of bleeding that comes with taking blood thinners like aspirin, warfarin, or other similar drugs. These drugs are helpful in later stages of COVID-19.
  • At-home remedies for mild cases
    • Over-the-counter medications (ex: acetaminophen, ibuprofen, decongestants) to reduce fever and congestion.
    • Lots of fluids and plenty of rest.
    • Vitamins C, D, and zinc may have a possible benefit of preventing infection. Although several clinical trials have studied these vitamins, they did not prove that these help patients who already have COVID-19 get better any faster. However, they’re not believed to cause harm when taken in reasonable doses.
  • Oxygen levels. Patients with COVID-19 should check the oxygen level in their blood. This is important, because it may be dangerously low before an individual starts feeling short of breath. Fingertip oxygen monitors are available at many pharmacies and retailers.

For patients in middle COVID stages, the goal is to limit problems

In some patients, between day 7 and day 14 after symptoms start, the infection progresses. Patients often develop COVID-19 pneumonia during this stage. During this time, the virus can often trigger the immune system to respond in ways that may become dangerous. Patients may need to be cared for in the emergency department or in the hospital at this point. Treatments at this stage are used to prevent or treat lung injury and control inflammation.

  • Antivirals. In this middle phase of treatment, the virus levels may be declining. Remdesivir is used in hospitalized patients to stop the virus from triggering further damage. Research shows that this treatment helps patients in the hospital recover more quickly.
  • Anti-inflammatory medicines. Inflammation is a normal response to infection, but for some patients, inflammation goes into overdrive and can lead to respiratory failure, organ failure, and death. Steroids such as dexamethasone can be lifesaving in some patients who have developed an out-of-control immune response. In some patients who are sick but not hospitalized, steroid inhalers used to treat asthma may be helpful. And for patients in the emergency department or hospital, doctors and care teams use specific laboratory tests and vital signs to track each patient’s inflammation levels and oxygen levels to determine who will benefit from oral or intravenous steroid treatment.
  • Blood thinners. Because COVID-19 may cause clots to form in blood vessels, blood thinners are often carefully used in hospitalized patients during this phase of illness to prevent damage to organs. Clinical trials have shown that carefully tailoring the use of these drugs at this stage can prevent the need for ventilation and save lives.
  • Oxygen. Oxygen levels are monitored very closely in this stage. Some patients may receive oxygen at home with close monitoring if their oxygen levels are only low when they are moving or sleeping. But if oxygen levels are too low, patients may need to be hospitalized so they can have a high-flow nasal tube or face mask for a more intensive level of treatment.
  • Remote patient monitoring. Some patients may have TeleHealth care at home by hospital staff. This program uses technology to monitor patients remotely for signs that the infection is getting worse, including changes in heart rate and blood oxygen levels, and provides the same treatments that patients receive in the hospital.

For patients with advanced COVID, the goal is to address dangerous complications 

Some patients unfortunately progress to the most serious stage of the disease. At this point, inflammation levels are extremely high, causing damage to many different organs. Many patients in this stage develop severe lung damage, known as acute respiratory distress syndrome, or “ARDS.” Treatments in this phase are used to “cool off” the inflammation, stop the progression of ARDS, and increase chances of survival.

  • Steroids. These potent anti-inflammatory medicines are one of the most important treatments in this phase. They reduce inflammation, and many clinical trials have confirmed that these drugs can be lifesaving when given early enough.
  • Other powerful anti-inflammatory drugs. Sometimes, steroids aren’t powerful enough by themselves to calm the out-of-control immune response. Cytokines are chemicals that are produced by immune cells in the body to fight off infection. Sometimes the body overreacts, causing a “cytokine storm” that can cause fatal levels of inflammation. Anti-inflammatory drugs that block cytokines from causing damage to organs include specialized drugs such as tocilizumab, tofacitinib, and baricitinib. Clinical trials have shown that when used in addition to steroids in very inflamed patients, these drugs can also be lifesaving.
  • Ventilator support. A breathing tube is inserted through the mouth into the lungs to provide the highest level of oxygen. Intermountain doctors have been leaders in studying and treating ARDS for decades, and helped develop ventilator strategies that are now the gold standard for treating ARDS around the world.
  • Prone positioning. Turning patients face down in their hospital bed relieves pressure on the lungs and allows more oxygen into the body.

Not recommended

There’s not enough evidence from high-quality research to support the use of some drugs. In fact, using drugs without evidence could harm a patient’s health or interfere with proven treatments. Treatments in this group include ivermectin and hydroxychloroquine (HCQ). Both drugs have received a lot of attention, but it’s important to remember that researchers using the best methods available to assess effectiveness have not found reliable evidence that they work against COVID to prevent serious illness, hospitalization, or death. The FDA, CDC, World Health Organization, Merck, the European Medicines Agency, Infectious Disease Society of America, the American Medical Association (AMA), American Pharmacists Association, the American Society of Health-System Pharmacists and the National Institutes of Health all recommend against using ivermectin for COVID-19 outside of a clinical trial.

Evidence-based treatments, world-class outcomes

“We feel very confident that the way we treat COVID using evidence-based therapies is improving the survival of our patients,” said Brandon Webb, MD, an infectious disease specialist. Intermountain Healthcare is committed to offering the best possible treatments to patients receiving care at our facilities. We participate in a national scorecard program where hundreds of the top U.S. hospitals compare their results. In a recent comparison with other top research institutions around in the country, patients with COVID-19 receiving evidence-based treatment at Intermountain hospitals have among the highest survival anywhere in the country.