Preventive home therapy for symptomatic patients affected by COVID-19 and followed by teleconsultations.

In this paper we present our experience on the treatment at home of Covid+ symptomatic patients. One hundred and eighty-two subjects (111 men and 71 women) aged from 32 to 71 years have been consecutively followed at home in telemedicine from 1st September to 24th December 2020. We were informed almost twice daily in morning and evening about body temperature, symptoms (cough, shortness of breath or difficulty breathing, fatigue, muscle of body aches, headache, loss of taste or smell, sore throat, congestion or runny nose, nausea and vomiting, diarrhea), oxygen saturation measured by digital pulse oximetry and blood pressure. Our protocol of treatment was based on early use of prednisone (25 mg in the morning and 12.5 mg in the afternoon) and low molecular weight heparin (4000 UI one or two times daily) initiated just after the positivity of molecular nasopharyngeal test (about 3-4 days as mean time after initiation of symptomatology and not after 7-8 days as suggested by other protocols) and oxygen therapy when necessary. Antibiotics such as azithromycin for six days was added. It is always recommended to associate lansoprazole 30 mg to prevent gastric hemorrhages and potassium and magnesium supplements. This treatment scheme was able to reduce the risk of hospitalization as only 4 patients needed to be admitted to the Hospital, and only two in subintensive department. After negativeness of molecular nasopharyngeal test, patients were invited for a thoracic computerized tomography and laboratory evaluation of d-dimer and other data of inflammation to show eventual lung interstitial involvement characteristic of COVID-19. ©Copyright: the Author(s).

Introduction

COVID-19 has been declared a pandemic by the WHO [1]. Following the outbreak of the disease in China [2], Italy was the first European country to be heavily involved in the pandemic [3-5]. Initially, from March to June there was an exponential increase in cases prevalently in the Northern part of the country [3-5] reaching incidence and mortality rates among the highest in the world [3-6].

Many factors explain differences from other countries, including different application of detection tests, a larger elderly population, a different prevention policy but probably also for the role of atmospheric air pollution [7] and relative humidity rate. Deepening these correlations would be desirable to set forecasting models on the spread of the infection. Just after a reduction in July and August there has been a second increase of COVID-19 involving also the Southern part of Italy.

In Italy, the possibility of performing autopsies or post-mortem diagnostic studies on confirmed COVID-19 cases was intensively debated [2-5]; in autopsies the involvement of endotelial, prevalently of microvascular system has been identified for the recruitment of multiple cytokine-activated inflammatory cell lineages [8].

Other possibilities that deserve further experimental evidence include an exaggerated antibody-mediated response with complement activation and/or a hypothetical cytopathic effect of the virus [9]. The latter could explain the microvascular damage leading to disseminated intravascular coagulation (manifested as thrombosis, thrombocytopenia, and gangrene of extremities), anti-phospholipid syndrome, and mimicry of vasculitis. On the basis of these considerations we have proposed telemedicine [10-12] as treatment of COVID-19 patients (Table 1), the association of low molecular weight heparin (LMWE) (4000 uI or 6000 each day on the basis of weight and corticosteroid (prednisone 25 mg in the morning and 12,5 in the evening: dosage not immunodepressive but with antiinflammatory activity) to reduce the cytokine storm) [13,14]. Usually, we add azithromycin for its anti-inflammatory properties [15], one tablet daily for six days. With this approach we have treated from 1st September to 24th December 2020, consecutively followed at home in telemedicine, 182 subjects (111 men and 71 women), aged from 32 to 71 years, all in good health and only 15 men and 10 women with bronchial asthma in treatment with associations of bronchodilators and corticosteroids. We were informed almost two times daily in the morning and evening about body temperature, symptoms (cough, shortness of breath or difficulty breathing, fatigue, muscle of body aches, headache, loss of taste or smell, sore throat, congestion or runny nose, nausea and vomiting, diarrhea) and oxygen saturation measured by digital pulse oximetry. Our protocol of treatment was based on use of prednisone and low molecular weight heparin to reduce risks of thromboembolism induced by SARS-CoV-2 and initiated just after positivity of molecular test (about 3-4 days on the average after initiation of symptoms, not after 7-8 days as suggested by other protocols) and oxygen when necessary. We have used prednisone (25 mg in the morning and 12.5 in the evening) starting just in concomitance with the positivity of the molecular test and about 3-4 days after the start of symptoms. Antibiotics, such as azithromycin for six days were added [15]. Only 4 patients needed to go to hospital, and only two in intensive department. In diabetics we suggested to treat hyperglycemia by regulating the dosage of antidiabetic treatment and in case of hypertension to increase the dosage of anti-hypertensive drugs. This treatment was able to reduce the risk of hospitalization. After the negativeness of molecular nasopharyngeal test, patients were invited for a thoracic computerized tomography and laboratory evaluation of d-dimer (following cut-off for the continuous of treatment with LMWE) and other data of inflammation to show eventual pulmonary interstitial involvement.

Table 1.

Suggested protocol of preventive home therapy for symptomatic patients affected by COVID-19 and followed by teleconsultations.

182 subjects (111 men and 71 women) aged from 32 to 71 years have been consecutively followed at home in telemedicine from 1st September to 24th December 2020. We were informed two times daily in morning and evening about body temperature, symptoms (cough, shortness of breath or difficulty breathing, fatigue, muscle of body aches, headache, loss of taste or smell, sore throat, congestion or runny nose, nausea and vomiting, diarrhea) and oxygen saturation measured by digital pulse oximetry.

Therapy association of:

- Low molecular weight heparin (LMWE) (4000 UI or 6000 each day on the basis of weight).

- Corticosteroid, (prednisone 25 mg in the morning and 12,5 in the evening (dosage with anti-inflammatory activity, to reduce the cytokines storm, initiated about 3-4 days after initiation of symptomatology and not after 7-8 days as suggested by other protocols).

- Azithromycin 500 mg for its anti-inflammatory properties, one daily for six days.

- In case of fever and cough induced by COVID-19 but eventually also by bacterial sovrainfection, we suggest using as antibiotics levofloxacin and/or ceftriaxone.

- Lansoprazole 30 mg to prevent gastric hemorrhages.

- Potassium, magnesium and vitamin D supplements when needed.