Experimental therapies used to treat COVID-19 in India’s first two waves should not be used this time, warn doctors
India is currently battling the third wave of the novel coronavirus disease (COVID-19), triggered by the high infectious omicron variant. Medical experts have warned that past mistakes, especially regarding treatment, must not be repeated.
Hydroxychloroquine, convalescent plasma therapy, ivermectin, favipiravir, doxycycline and antibiotics were widely used in the first two COVID-19 waves in India.
Their efficacy was questioned at the time. But it is now known for sure that none of these have any role in the treatment for patients infected by the SARS-CoV-2 virus.
“In the first two waves, it was correct to use certain therapies as experimentation because we wanted to save lives. The key thing to remember is that we are better informed about COVID-19 treatment protocols today than ever before,” Chandrakant Lahariya, a public health analyst and epidemiologist, told Down To Earth (DTE).
Last month, the World Health Organization (WHO) officially recommended against the use of convalescent plasma therapy, citing high uncertainty of outcome and logistical concerns.
“Despite its initial promise, current evidence shows that it does not improve survival nor reduce the need for mechanical ventilation and it is costly and time-consuming to administer,” WHO noted.
The All India Institute of Medical Sciences-Indian Council of Medical Research (ICMR) COVID-19 National Task Force and the Union health ministry had dropped the treatment in early 2021.
“Much of the treatment, especially during the second wave, was influenced by the demand of patients. There was a significant rise in convalescent plasma therapy, ivermectin and other such treatments being used. Our approach should be guided by clinical protocol and perceived benefit, not a patient’s demand,” Lahariya said.
COVID-19 treatment has become very simplistic over the past two years. A majority of current patients can be treated in home isolation, given a history of past infection, vaccination and the fact that omicron likely causes milder infection than its predecessor.
Pradeep Rangappa, an intensive case physician and member of Karnataka’s Critical Care Support System Team (CCST) for COVID-19, detailed a four-step approach for treatment, depending on the severity of disease.
Antivirals such as Remdesivir, Molnupiravir and Paxlovid — which is not yet available in India — are recommended in the early phase of a viral infection. This is primarily done to prevent further progression of the disease.
“Both Remdesivir and Molnupiravir have a similar mechanism where they create viral errors to block replication of the virus to prevent the viral load from increasing,” Rangappa said.
However, experts have cautioned against the use of Molnupiravir. While it has been approved for use by the Drugs Controller General of India, the ICMR has refrained from including it in its national COVID-19 treatment protocol, citing safety concerns.
“Molnupiravir’s clinical trials were done in an unvaccinated population, the majority of which had no past infection. This is no longer accurate for the current Indian population where its benefits are unknown and side-effects are very high. Excessive use based on demand and prescription is a real risk in India and should be avoided,” Lahariya said.
Reports have revealed that despite ICMR’s warning about the side effects of Molnupiravir such as mutagenicity, muscle, bone damage and the need for three months of contraceptive for women because it may affect the child, its demand has increased.
Doctors have begun pre-ordering the medication in bulk, with millions of pills being delivered within a week of its launch, media outlet ThePrint reported.
Ravi Mehta, a pulmonologist at Apollo Hospitals, said the medication should be given within three days of illness for comorbid people to prevent hospitalisation and death.
“It is a new drug and needs to be given carefully. Extrapolating the results of a study done on unvaccinated population to a vaccinated one is a huge leap of faith,” he told DTE.
Rangappa has already begun witnessing a rise in the demand for Molnupiravir from patients. However, following ICMR’s warning, some have become wary of it.
The second pillar of treatment is when a patient needs oxygen or hospitalisation. Here, steroids are used to reduce inflammation.
“There has been heavy debate on steroids’ usage. They should only be administered once a patient is on oxygen support,” Rangappa said.
Mehta said steroids should be used in the second week of illness and should be administered under clinical supervision. “They were used indiscriminately in the second wave, leading to mucormycosis,” he said.
The third pillar is treatment to prevent blood clots, since SARS-CoV-2 patients are vulnerable to an increase in thrombotic complications in the arteries and vessels. Anticoagulation doses are needed, but only in a hospital setting.
The fourth and final pillar comes into the picture when oxygen devices are needed depending on the patient’s requirement. Antibody cocktails are also used now, a step which can be considered early on for high-risk patients.
“However, if a person is infected with omicron, we are not very sure how effective this will be since the new variant escapes antibodies,” Rangappa said.
It should be assumed that the current wave is because of omicron, based on epidemiological and scientific evidence and also considering that every single case cannot be sequenced.
Therefore, an antibody cocktail is unlikely to be effective. Mehta has seen an increase in its demand from patients — a trend reported nationally — and hopes that once RT-PCR tests which can indicate omicron’s presence are made available, distinguishing treatment would become easier.
Till now, cases have been milder than they were in the second wave. Most patients are referred to home quarantine and over the counter medication. Symptomatic management, the first pillar, remains the medical fraternity’s focus.
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