COVID-19 guidelines update on ACE-inhibitors, ARBs

Anastasia Tsirtsakis

18/05/2020 2:56:27 PM

newsGP talks to the Chair of the National COVID-19 Clinical Evidence Taskforce about the latest guidance for the care of coronavirus patients.

SARS-CoV-2 virus and ACE2 receptors
Clinicians have asked questions regarding ACE-inhibitors and ARBs in patients with COVID-19.

In its latest update, the National COVID-19 Clinical Evidence Taskforce (the taskforce) has included a guideline recommendation for the use of angiotensin-converting-enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) for patients with COVID-19.
Commonly used to treat chronic diseases such as heart disease and diabetes, clinicians have been questioning the safety of continuing such treatments given the limited understanding around COVID-19’s effects on different systems in the body.
‘The virus uses a receptor to enter cells as an ACE receptor, and so there’s this concern that ACE inhibitors would affect that and make people more vulnerable,’ Associate Professor Julian Elliott, Chair of the taskforce, told newsGP.
‘The recommendations from the taskforce provide reassurance that continuing treatment is the best course of action based on what we know now.’
Further monitoring of emerging research on antivirals such as hydroxychloroquine, lopinavir–ritonavir, remdesivir, and other disease-modifying treatments including tocilizimab and convalescent plasma, has seen the taskforce reinforce its recommendation that they should only be administered in the context of randomised trials with appropriate ethical approval.
Associate Professor Elliott expects more information to be available on remdesivir in the coming weeks.
Meanwhile, for adults with COVID-19 undergoing endotracheal intubation, the taskforce recommends that consideration be given to the use of videolaryngoscopy to visualise a patient’s airways over direct laryngoscopy.
The technology can help intubate patients safely while maintaining best practice precautions for healthcare professionals.
‘One thing to note [in] the recommendation around videolaryngoscopy is when the equipment is available and a practitioner is trained in its use,’ Associate Professor Elliott said.
‘The taskforce panels have been quite cognizant of the fact that there may be settings in which people may be required to intubate someone that don’t have access to that equipment, particularly in some remote areas.’
New recommendations have also been added for the use of higher versus lower positive end-expiratory pressure (PEEP) for mechanically ventilated patients.
While having access to ventilators is critically important for reducing the number of COVID-19 deaths, Associate Professor Elliott highlights that not all respiratory illnesses present in the same way.
‘So it’s also crucial that we’re equipping healthcare professionals with guidance on how to optimise ventilation strategies for this unique cohort of patients,’ he said.
GPs can access updated flowcharts on:

There is also updated guidance on the use of personal protective equipment (PPE) in non-inpatient healthcare settings.

‘The recommendations from the taskforce provide reassurance that continuing [ACE-inhibitors and ARB] treatment is the best course of action based on what we know now,’ taskforce Chair Associate Professor Julian Elliott said.

The taskforce has also responded to the need for guidance regarding the health of pregnant women and young people with two new expert panels.
Dr Wendy Burton, Chair of the RACGP Specific Interests Antenatal/Postnatal Care network, sits on the panel for pregnancy and perinatal care, and Dr James Best, Chair of the RACGP Specific Interests Child and Young Person’s Health network, is a part of paediatric and adolescent care.
‘There’s been a lot of anxiety and conflicting information about caring for pregnant women and their babies during the perinatal period, and so we hope to address that,’ Associate Professor Elliott said.
‘Also, pediatric and adolescent care, although they seem to be at much lower risk for severe disease, there’s of course been recent reports about Kawasaki-like syndrome.
‘People are understandably anxious about the health of their children and more than anything, there’s still a lot of questions that clinicians have.’
With Australia having managed to largely flatten the curve, Associate Professor Elliott says the health workforce is now in the mode of preparedness in case confirmed cases start to increase again. 
But one concern that has persisted since the pandemic began is the worsening of anxiety among people in the community, often exacerbated by the dissemination of misinformation.
‘GPs are very experienced at talking with people who’ve picked up pieces of information. Obviously, in the current context that’s ramped up because everyone is paying so much attention to this,’ Associate Professor Elliott said.
He advises that GPs continue to use their existing practices to reassure patients that, as soon as a safe and effective treatment is available, that they will be made aware if appropriate.
‘They can also reassure patients that Australia has established a system by which we can rigorously judge the potential benefits and harms of those treatments and make that information available immediately through the taskforce,’ he explained.
With all eyes on the pandemic, research is being conducted at a rapid rate, but Associate Professor Elliott reinforces the importance of being guided by strong evidence.
‘Some people sometimes feel, how can we deny people access to potentially useful medications? But the flip side of that is, should we really be exposing people to sometimes known or unknown harms when the benefits are not clear?’ he said.
‘The job of the taskforce is to encourage the best possible care for people with COVID-19. Getting the best possible care does not mean trying a medicine that is getting a lot of buzz on social media.
‘It means reviewing and analysing the latest research evidence to really understand the potential benefits and harms of a treatment, and then using this understanding to guide care for people in a consistent way. This allows doctors and nurses to have confidence there is evidence behind the treatments they are using.
‘Patients with COVID-19 – as well as their family and loved ones – should expect nothing less.’
The national clinical guidelines for COVID-19 will continue to be updated weekly throughout the pandemic.
The taskforce is currently developing guideline recommendations on issues regarding the retrieval of patients from rural and remote areas addressing timing of retrieval and the care patients receive in the interim.
Other clinical questions under review include:  
  • protocols for managing stroke and cardiac arrest
  • early rehabilitation
  • use of neuromuscular blocking agents
  • use of nitric oxide
  • use of corticosteroids
  • timing of mechanical ventilation.
GPs are encouraged to submit their clinical questions and provide feedback on the taskforce website.
The RACGP has more information on coronavirus available on its website.
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Dr Ian Mark Light   19/05/2020 9:02:36 AM

Allied to PPE in general practice clinics is the need for well ventilated waiting rooms with fresh air flowing through rather than a waiting room closed and with too many patients sitting in stale air environments.
The consulting rooms also ought to have part open windows but certainly one room needs good ventilation if the clinic takes in a patient with an acute respiratory tract infection with sneezing and coughing or acute attack of asthma or exacerbation of COPD that presents at the surgery door- these patients will have to be stabilised as a duty of care .
If this is not possible outside safe shelter triage and clinical stabilisation capacity ought be prepared .

Dr Frank Raphael Golik   19/05/2020 9:24:57 AM

Hyperbaric oxygen therapy in preventing mechanical ventilation in COVID-19 patients: a retrospective case series
Kerry Thibodeaux, MD; Marcus Speyrer, RN; Amer Raza, MD; Raphael Yaakov, MD; Thomas E. Serena, MD May 15, 2020
The early trials of this safe and very effective therapy compares with the quoted 40-80% mortality with intubation & ventilation in ICU in COVID-19. These were conducted in Lousiana USA this year. CRP and D-Dimer drop dramatically and oxygen levels rise.

Dr Shobha Balu   23/06/2020 8:12:43 PM

I have been fortunate not having any COVID 19 cases diagnosed in my solo practice up until now. My staff usually has standard questions they ask the patients when a patient telephones requesting an appointment. If the patient complains of having respiratory symptoms suggestive of possible COVID 19 , they are referred to a COVID clinic directly. By doing so, symptom free patients are protected.
Interesting reading about Hyperbaric oxygen therapy for COVID 19!