Guide to Corticosteroids/Immunomodulator Use in COVID-19 Pneumonia

Assess the severity of the disease by assessing:

 Clinical
o Respiratory Rate/Drive
o Oxygen Saturation (SpO2)
o Oxygen Requirement: PaO2/FiO2 Ratio (PFR)*
o Presence of Fever
 Radiological
o Percentage of Ground Glass Opacity (GGO) Involvement on the chest
radiograph (CXR)
 Inflammatory markers
o C-Reactive Protein (CRP) level and trends (suggest to do daily CRP throughout
admission)

*Consider other causes of hypoxia such as bacterial pneumonia (serum procalcitonin (PCT) is
useful), acute decompensated heart failure, and pulmonary embolism.

REGIME 1/ STEP 1:

All COVID -19 patients who require any form of oxygen therapy should receive:

 IV Dexamethasone 6 -8 mg OD. Consider weight adjustment according to table below.

Actual Body Weight (kg) Dose of Dexamethasone (mg)

<60 6
61- 80 8
81- 100 10
101- 120 12

If there is lack of clinical improvement or clinical deterioration (clinically ill, rising CRPs,
increasing O2 requirements, worsening of GGOs on serial CXRs) WITHIN 48 HOURS,
consider intensification to STEP 2 or STEP 3.

REGIME 2/ STEP 2:

Any COVID-19 patient on oxygen therapy who fulfilled any of the following criteria:

 Initial CRP > 100 – 150 mg/L

 Initial/current PFR of 150-200 AND/OR requiring oxygen therapy of flow of > 5L/min
to maintain a SpO2 > 95% (e.g. Face Mask 5L/min, Venturri Mask 35% 8L/min)
 > 30% involvement of GGO on the initial/current CXR
 Patients who have failed STEP 1

Should consider:

 IV Methylprednisolone 2mg/kg STAT and followed by daily dose in 2 divided doses

(e.g. 1mg/kg/dose BD) or continuous infusion,

 for 3-5 days (duration to be determined by the clinical response e.g Oxygen
Requirement/PFR trends, CRP trends)

Strictly for Internal Use ONLY. Version 1.2. Last edited on 30 January 2021. Next review in 1
March 2021.
If there is a lack of clinical improvement or further clinical deterioration (clinically ill,
rising CRPs, declining PFRs, worsening GGOs on serial CXRs) IN 24 HOURS, consider to
step up to STEP 3.

REGIME 3/ STEP 3:

*verbal/written consent should be obtained after discussion with ID consultant

Any COVID-19 patient on oxygen therapy who have an initial/current PFR < 150 AND
fulfil any of the following criteria:
 Initial/current CRP > 100-150 mg/L
 Imminently requiring/requiring high flow nasal cannula (HFNC)/ non invasive
ventilation (NIV)/ Invasive Mechanical Ventilation
 Patients who have failed STEP 2 and/or STEP 3

Shall consider:

 IV Methylprednisolone 250-500mg STAT and daily (pulse)

 for up to 3 days at the clinician’s discretion based on clinical response e.g Oxygen
Requirement/PFR trends, CRP trends before dose de- escalation to 2mg/kg/day

If there is absence of clinical improvement/further clinical deterioration after 24-48 hours,

shall consider:

 IV Tocilizumab 8mg/kg STAT, infusion over 1 hour (maximum dose of 800mg,

round to nearest dose based on strength of formulation, 80mg & 400mg) after
discussion with ID consultant. Repeat dosing can be considered after 12 – 24 hours
later.

No. of 400mg No. of 80mg

Weight (kg) Dose (mg)
vial(s) vial(s)
< 40kg 8mg/kg - -
50 400 1 0
60 480 1 1
70 560 1 2
80 640 1 3
90 720 1 4
> 100 800 2 0

Contraindications of IV Tocilizumab: (adapted from the Exclusion Criteria of REMAP – CAP

trial)
 Known hypersensitivity to Tocilizumab
 Co-existing infection that might be worsened by Tocilizumab
 A baseline alanine transferase (ALT)/aspartate transferase (AST) more than 5 times the
upper limit of normal (ULN). Caution should be exercised if hepatic enzymes are more
than 1.5 times the ULN.
 A baseline platelet counts < 50 x 109/L
 A baseline absolute NEUTROPHIL count (ANC) of < 2 x 109/L
 Pregnancy
 Already receiving any other immune modulating drugs for treatment
Strictly for Internal Use ONLY. Version 1.2. Last edited on 30 January 2021. Next review in 2
March 2021.
 Figure 1: Suggested approach to steroids in COVID‐19 pneumonia in QEH

Strictly for Internal Use ONLY. Version 1.2. Last edited on 30 January 2021. Next review in March 2021. 3
Prepared by

Dr Ng Eng Kian,
Clinician
Hospital Queen Elizabeth

Reviewed by

Dr Lee Heng Gee

Infectious Disease Consultant,
Hospital Queen Elizabeth

Dr Giri Shan Rajahram

Infectious Disease Consultant,
Hospital Queen Elizabeth II

Ms. Law Bee Keng

Pharmacist
Hospital Queen Elizabeth

References:

1. Ministry of Health, Malaysia. Annex 2e: Clinical Management of Confirmed COVID-

19 Case in Adult (updated 3 November 2020). 2020; Available from: http://covid-
19.moh.gov.my/garis-panduan/garis-panduan-kkm
2. Horby P, Lim WS, Emberson JR, Mafham M, Bell JL, Linsell L, et al. Dexamethasone
in Hospitalized Patients with Covid-19 — Preliminary Report. N Engl J Med. 2020;
3. Meduri GU, Annane D, Confalonieri M, Chrousos GP, Rochwerg B, Busby A, et al.
Pharmacological principles guiding prolonged glucocorticoid treatment in ARDS.
Intensive Care Med [Internet]. 2020; Available from: https://doi.org/10.1007/s00134-
020-06289-8
4. Edalatifard M, Akhtari M, Salehi M, Naderi Z, Jamshidi A, Mostafaei S, et al.
Intravenous methylprednisolone pulse as a treatment for hospitalised severe COVID-
19 patients: results from a randomised controlled clinical trial. Eur Respir J.
2020;2002808.
5. Gordon AC, Mouncey PR, Al-Beidh F, Rowan KM, Nichol AD, et al. Interleukin-6
Receptor Antagonists in Critically Ill Patients with Covid-19 – Preliminary report.
medRxiv [Internet]. 2021 Jan 1;2021.01.07.21249390. Available from:
http://medrxiv.org/content/early/2021/01/07/2021.01.07.21249390.abstract
6. Department of Health and Social Care. Interim Position Statement: Tocilizumab for
patients admitted to ICU with COVID-19 pneumonia (Adults). 2020;1–5.
7. Tocilizumab Prescribing Information. Last revised May 2020. Last accessed on 21
January 2021. Available from:
https://www.gene.com/download/pdf/actemra_prescribing.pdf

Strictly for Internal Use ONLY. Version 1.2. Last edited on 30 January 2021. Next review in 4
March 2021.