With input from Dr Monica Vasudev

1146: HCFI-CMAAO Round Table Expert Zoom Meeting on “Is my COVID serious?”

7^th November, 2020, 11am-12pm

Participants: Dr KK Aggarwal, Dr AK Agarwal, Dr Jayalal JA, Prof Mahesh Verma, Dr Ashok Gupta, Dr Jayakrishnan Alapet, Ms Upasana Arora, Dr KK Kalra, Dr Anil Kumar, Ms Ira Gupta, Dr S Sharma

Consensus Statement of HCFI Expert Round Table

• Most cases of COVID-19 are mild to moderate. But some become serious. We do not know who will become serious.
• All patients should be assessed on the basis of certain clinical and lab parameters which are indicative of disease progression to serious stage. A proactive approach is needed so that the required drugs can be given to the patient timely.
• We have been talking about preventing the disease, but now we must talk about preventing a cytokine crisis.
• World over, there is a single wave of infection with three peaks. In India too, there is a single wave overall; new cases and mortality follow the same pattern. Delhi is experiencing a third wave of the infection.
• In the US, there are three waves and the mortality is showing a reverse pattern, i.e., it is now reducing.
• Mouthwashes with antiviral ingredients can help decrease transmission of COVID-19 by reducing viral loads in the mouth of infected patients when they cough, sneeze or speak (Journal of Dental Research, online Oct. 22, 2020)
• COVID-19 is associated with a hypercoagulable state associated with inflammatory changes. The risk of venous thromboembolism is 25-43% in ICU patients, often despite prophylactic dose anticoagulation. The risk for arterial thrombotic events, such as stroke, MI and limb ischemia, also appears to be increased.
• If we can prevent clotting, we have won the game. All inpatients should receive thromboprophylaxis unless contraindicated.
• In patients with COVID-19, a relentless self-amplifying cycle of inflammation and clotting is seen in the body.
• Inflammation is inevitable in a patient with COVID-19. Inflammation is over by the fourth day. But, if the cycle of inflammation and clotting develops, this results in cytokine crisis.
• More than 50% of COVID-19 hospitalized patients have prothrombotic antiphospholipid autoantibodies in their blood, predisposing to venous and arterial thromboembolism (Science Translational Medicine, Online Nov. 2, 2020).
• Case series have detected antiphospholipid antibodies in COVID-19 patients. Moderate to high titers of antiphospholipid antibodies were found in roughly two-thirds of positive samples in a study.
• The hypercoagulable state can be prevented by dipyridamole (Science Translational Medicine, Online Nov. 2, 2020).
• Aspirin prophylaxis plus statin (LDL >70) will prevent formation of white (platelet) clot. Red clot is formed over the white clot, which requires anticoagulant.
• There are several lab parameters available. CRP is one parameter which is very useful as a prognostic factor. It reduces load of testing on a patient, reduces costs and avoids unnecessary tests.  Every practitioner is used to CRP.
• CRP starts rising within 4-6 hours and doubles every 8 hours.
• CRP should peak by the second day. CRP can remain elevated, if the underlying cause persists.
• CRP over 10 mg/L indicates clinically significant inflammation, while CRP between 3-10 mg/L indicates low grade inflammation (Ann Intern Med. 2015;163(4):326).
• Low grade inflammation or subclinical inflammation is also present in conditions such as obesity, insulin resistance.
• If CRP is more than 10 after Day 10, this is leading towards a cytokine reaction.
• If on Day 3, CRP is more than 10 or there is new onset of cough or fever more than 101, this means cytokine chain has started. To prevent this cascade of inflammation, start oral anticoagulant on Day 1 or aspirin before Day 1.
• Markedly high CRP levels are seen in infections, mostly bacterial infections.
• CRP may be elevated in viral infections, but not to the extent seen in cases of bacterial infections (Clin Infect Dis. 2004;39(2):206).
• Four CRP response patterns have been seen: Fast response pattern, slow response pattern, non-response pattern and biphasic response.
• Before the meeting ended, Mr Md Jawaid from DST gave a demonstration on hydroponics (domestic, commercial and aquaponics).

Dr KK Aggarwal

President CMAAO, HCFI and Past National President IMA