COVID-19 Outpatient Treatment Guidelines

COVID-19 Outpatient Treatment Guidelines - AAPS Protocol and More

By Dr Frank Yap, MD - February 10, 2021

The COVID-19 Outpatient treatment guidelines are based on the AAPS (American Association of Physicians and Surgeons). The aim of this article is to publish the guidelines in an electronic format that can be updated in step with the rapid pace and growing volume of related information regarding the outpatient treatment of COVID-19.

What's New

Feb 9, 2021 - Ivermectin plus Azithromycin plus Montelukast plus Aspirin totally crush Covid-19 in propective Mexican study (n=768). The TNR4 multidrug therapy (New Therapy for Recovery of COVID-19 infection, 4 medications; in Spanish: Terapia Nueva para la Recuperación en la infección por COVID19, 4 medicamentos).

Lima-Morales R, Mendez-Hernandez P, Flores YN, Osorno-Romero P, Cuecuecha-Rugerio E, Nava-Zamora A, Hernandez-Galdamez DR, Romo-Duenas DK, Salmeron J, Effectiveness of a multidrug therapy consisting of ivermectin, azithromycin, montelukast and acetylsalicylic acid to prevent hospitalization and death among ambulatory COVID-19 cases in Tlaxcala, Mexico, International Journal of Infectious Diseases (2021), doi: https://doi.org/10.1016/j.ijid.2021.02.014

Feb 8, 2021 - Successful UK randomized trial (STOIC - Steroids in COVID-19) of 146 outpatient inhaled budesonide, with 90% reduction in need for urgent care, ED or hospitalization. Median/avg clinical recovery 1/3 days quicker.

Ramakrishnan et al. Inhaled budesonide in the treatment of early COVID-19 illness: a randomised controlled trial.

Feb 4, 2021 - Povidone Iodine Mouthwash, Gargle, and Nasal Spray to Reduce Nasopharyngeal Viral Load in Patients With COVID-19: A Randomized Clinical Trial
RCT of PCR+ patients with Ct<=20 with 12 treatment and 12 control patients, concluding that nasopharyngeal decolonization may reduce the carriage of infectious SARS-CoV-2 in adults with mild to moderate COVID-19. All patients but 1 had negative viral titer by day 3 (group not specified). There was no significant difference in viral RNA quantification over time. The mean relative difference in viral titers between baseline and day 1 was 75% [43%-95%] in the intervention group and 32% [10%-65%] in the control group. Thyroid dysfunction occurred in 42% of treated patients, with spontaneous resolution after the end of treatment. Patients in the treatment group were younger.

Guenezan et al., JAMA Otolaryngol Head Neck Surg., doi:10.1001/jamaoto.2020.5490 (Peer Reviewed)

Related: Iodine and COVID-19

Jan 7, 2021 - Early ambulatory, multidrug therapy is associated with substantial reductions in hospitalization and death compared to available rates in the community. Prompt ambulatory treatment should be offered to high-risk patients with COVID-19 instead of watchful watching and late-stage hospitalization for salvage therapies. Their early ambulatory treatment regimen was associated with estimated 87.6% and 74.9% reductions in hospitalization and death respectively, p<0.0001.

Brian Procter, Casey Ross, Vanessa Pickard, et al. Early Ambulatory Multidrug Therapy Reduces Hospitalization and Death in High-Risk Patients with SARS-CoV-2 (COVID-19). Authorea. January 07, 2021.

Dec. 31, 2020 - A peer-reviewed updated summary of COVID-19 early-treatment best practices was published in Reviews in Cardiovascular Medicine, an interdisciplinary scientific, open access journal.

This international collaboration — comprised of physicians, like lead author Peter McCullough, MD, outlines the urgency of "prompt early initiation of sequenced multi-drug therapy (SMDT) … to stem the tide of hospitalizations and death."

The authors explain:

The early stage of viral replication provides a therapeutic window of tremendous opportunity to potentially reduce the risk of more severe sequelae in high risk patients. Precious time is squandered with a 'wait and see' approach … resulting in unnecessary hospitalization, morbidity, and death.… In newly diagnosed, high-risk, symptomatic patients with COVID-19, SMDT has a reasonable chance of therapeutic gain with an acceptable benefit-to-risk profile.

Included in the paper is a "sequential multidrug treatment algorithm" and summaries of the rationale and evidence for each component.

According to the AAPS’ Home-Based Treatment guide to treating COVID-19, hydroxychloroquine and ivermectin are antiviral agents that must be started quickly for those who are 50 years of age or more; or those with a single co-morbidity risk factor i.e. hypertension, diabetes mellitus, obesity, chronic respiratory disease, chronic heart disease, chronic kidney disease and cancer.

In an alert issued to members, the Association of American Physicians and Surgeons, urges physicians to "share this new article with your colleagues, any contacts you have in the media, and with leaders in your community." "To overcome the increasing censorship of lifesaving information, it is imperative that everyone pitch in to see that this manuscript is distributed as widely as possible," AAPS states.

The article also includes a list of the numerous countries around the world that are encouraging early treatment. The authors contrast the situation in countries including the U.S. where "the current failure of government support for randomized clinical trials evaluating widely available, generic, inexpensive therapeutics, and the lack of instructive outpatient treatment guidelines (U.S., Canada, U.K., Western EU, Australia, some South American Countries), clinicians must act according to clinical judgement and in shared decision making with fully informed patients."

"Until the pandemic closes with population-level herd immunity potentially augmented with vaccination, early ambulatory SMDT should be a standard practice in high risk and severely symptomatic acute COVID-19 patients beginning at the onset of illness," conclude the authors.