Some of the enduring images of the Covid-19 era in the public domain are of doctors staking their lives to treat patients, and people banging thalis and clapping their hands in gratitude. At the same time, some of those who lost their kith and kin carry privately nightmarish memories of doctors, who seemed to be content to provide just minimal treatment and adopt a wait and watch approach till the fateful day.
This is happening even to the rarest of the rare patients who are able to make to intensive Care Unit (ICUs) of large corporate hospitals in Delhi-NCR (National Capital Region) in India. One dare not even guess what is happening in remote parts of India.
Covid-19 patients in India are not dying only for want of ICU beds or oxygen, but also probably because many hospitals are not even considering trying measures like Emergency Use Authorisation (EUA) of convalescent plasma therapy, or prescribing off-label injections like Remdesivir and Tocilizumab.
Such EUA and off-label use, which means employing a drug for a condition different from what it was originally created for based on limited available evidence and only in specific circumstances, are provided for in the latest ‘Clinical Guidance for Management of Adult Covid-19 Patients’ by the AIIMS/ ICMR-COVID-19 National Task Force/Joint Monitoring Group, Ministry of Health & Family Welfare, issued on 22nd April 2021.
Convalescent plasma therapy can be used within seven days of the appearance of symptoms in case of early to moderate disease and, of course, subject to availability of a suitable donor. After seven days elapse, it is no longer useful, notes the guidance.
Similarly, many doctors are shy of considering prescribing off-label injections like Remdesivir and Tocilizumab. It is another matter that these injections are not anyway available in the market. If available, these may be either fake or prohibitively priced in the black market or both. Recently the Central government has taken steps to increase the availability of Remdesivir in the country. The government has also submitted in the apex court that there are equivalent or better alternatives to Tociluzumab such as Itulizumab, Dexamethasone and Methylprednisolone.
EUA use of Remdesivir for moderately to severely infected patients on supplemental oxygen with no kidney or liver ailment within 10 days of appearance of symptoms, and off-label use of Tocilizumab for severely ill patients within 24 to 48 hours of admission in ICU, who don’t improve with steroids and have no known active bacterial, fungal or tubercular infection, are provided for in the government guidance.
The use of such therapies may be contested in the public domain, but so is the use of drugs like Hydroxychloroquine and Ivermectin. These drugs are frequently prescribed for mild cases by most doctors all over the country despite the guidance saying that these drugs are “may-do” therapies as their use is based on low certainty of evidence.
Of course, some of the government guidance is also at variance with the advisory of the World Health Organization (WHO). For example, WHO says that the positive impact of Hydroxychloroquine or chloroquine on Covid-19 patients varies from little to nil.
Similarly, the Indian guidance provides for prescribing micronutrients in mild cases, which has resulted in high spike in consumption of Vitamins D and C and zinc. WHO says that micronutrients are important for overall well-being, particularly immunity, but they have no direct role in the treatment of Covid-19.
While it is convenient to presume that the Indian authorities know what the best is in the Indian context in the current scenario, at the same time it is naive to believe that doctors all over the country are following this guidance.
It is an imperative that the authorities make an effort to successfully communicate their latest guidance to State governments and hospitals all over the country. It is also desirable to conduct awareness campaigns to reach the guidance directly to doctors. Some of them may not be themselves updating their knowledge for whatever reasons. Such communication would at least guide doctors to consider a recommended course of treatment of patients in the given circumstances.
A consistency in overall approach in Covid-19 treatment would be also comforting for ICU patients’ attendants, who are most of the time clueless about the treatment meted out to their patients inside ICUs. Anything that gives serious patients a chance for survival and reduces the trauma of attendants is worth a try in these pandemic times. Of course, revising the guidance in keeping with the latest developments is a dynamic process. So is the communication.
Source: The Times of India
Published on 10 May 2021