Making sense of the COVID-19 pandemic has been confusing for the lay person and it hasn’t been any simpler for those developing treatment strategies.
“It was very fluid; changing on a weekly basis, if not faster than that,” John Kappes, a critical care clinical pharmacist at Monument Health in Rapid City and a professor in pharmacy practice, said in reference to treatment protocols that were being developed in summer 2020.
“The biggest challenge was we didn’t really know what to do. Case by case, we were making decisions … taking your best guess. It made it very stressful for us not being confident in what we were doing,” he said.
Across the state at Avera McKennan, the situation was no different, although Rapid City didn’t experience COVID-19 patients until about a month after Sioux Falls.
‘Drinking from fire hose’
Brad Laible, professor of pharmacy practice and lead pharmacist with Avera’s inpatient antimicrobial stewardship program, said, “The biggest challenge
was evaluating literature that was collected so quickly that it often had flaws. We had to evaluate study flaws and consider if it was better to use (the treatment) or not to use it. There was wide-ranging quality in the studies and so much of it.
“It was like drinking directly from the fire hose. We had to make a good determination of how usable the information was, particularly information that wasn’t peer-reviewed.
“People were so desperate for positive information and providers were wanting to be able to provide an option for people, so I think we used some medications we wouldn’t have thought had enough information to use them. However, we tried to keep our protocols within the guidelines of the NIH (National Institutes of Health.”
Laible was referencing hydroxychloroquine, which garnered significant media attention due to non-peer reviewed reports of benefit early in the pandemic. It was used for about a month at Avera, but “it just didn’t appear that it was useful for treatment or prevention,” he said.
Another area without strong evidence to back its usage is vitamin supplements. However, because the perceived risk is low, a small number of Avera providers ordered vitamin C, D, zinc, quercetin, thiamine and ivermectin, a cheap and widely available drug that treats tropical diseases caused by parasites, Laible said.
Anti-inflammatories found effective
One of the most effective treatments has been dexamethasone, a corticosteroid, according to Joe Strain, a professor of pharmacy practice and clinical faculty member at Monument.
It works to decrease the inflammatory response by the body. Strain explained COVID-19 causes an overreaction of the immune system, which produces flareups of the inflammatory system. Like other medications, timing is critical with dexamethasone. When given early in the illness, there is no apparent benefit, Strain said.
“However, once the patient was sick enough to be hospitalized and require oxygen, there was a benefit,” he said.
Protocols ‘changing very rapidly’
Kari Taggart, a critical care clinical pharmacist at Avera and an assistant professor in pharmacy practice, said, “When COVID first hit and our ICU began to experience surge capacity, things were changing very rapidly, sometimes daily but also sometimes hourly. We (the multidisciplinary team) were just trying to keep up with all of the new information that was coming out as well as taking care of the very ill patient in front of us.
“This was unlike anything anyone had ever experienced before and so our treatment approach was to do the things we had solid evidence to support, continue to care for patients as close to the same way as we always have, and to incorporate new ‘unproven’ therapies as safely as possible.
“We took a ‘do no harm’ approach and really took the time to evaluate the information that was available in order to make the best decisions we could.”
Clinical pharmacists were joined on protocol advisory committees by the stewardship pharmacist, ICU physicians, pulmonologists, infectious disease physicians and nurses.
Trial and error in treatments
Strain, a 2002 Pharm.D. graduate, said because of COVID-19’s delay in arriving in Rapid City, he, Kappes and their Monument colleagues “spent a lot of time reviewing literature” and had initial protocols well in place. Nonetheless, there was a “fair amount” of trial and error in treating patients, he said.
Kappes, a 2007 Pharm.D. graduate, added, “That’s not the best way to practice either. Results you find with treating a patient or two may not be replicated in a larger study. Practicing based on what is seen with a small group of patients is not a good way of doing things.”
Laible, a 2001 Pharm.D. graduate, said, “There certainly was a level of (trial-and-error treatment) with this disease; more of that than we would be comfortable with normally. However, now we’ve been dealing with this disease for nearly a year and we know better what works and what doesn’t.”
Taggart, a 2005 Pharm.D. graduate, explained, “Because COVID was nothing like anything we had experienced in the past, our usual pre-COVID standard acceptance of certain vital signs, lab values or thresholds for escalation of care all had to change.” Generally, the new protocols were developed through multidisciplinary teams.
However, “for some of the more urgent decisions that needed to be made at the bedside, the provider, nurse, pharmacist and respiratory therapist would collaborate and come up with the best possible option to support the patient in the moment. We would then take those experiences and develop the necessary protocols and order sets in order to streamline the process for future patients,” Taggart said.
The takeaway lesson
The takeaway lesson for developing protocols in the midst of a pandemic?
“A coordinated response is key,” Laible said. “We need to be very careful about making treatment protocols that are based on unpublished reports and press releases in the media.”
Strain added, “You have to be patient and wait for the data to support what you’re doing. If you’re going to do experimental treatment, do it in the midst of a clinical trial rather than a case-by-case basis.”