Treatment Protocol for confirmed COVID-19 Infection

A. Version 9 recommendation changes:

1. Ritonavir + Lopinavir (Kaletra) was removed from treatment protocol as monotherapy but it was
kept as part of combination therapy for patients in ICU with pneumonia.
2. Convalescent plasma will be the treatment option for pregnant females with pneumonia
3. Reactive terminology was introduced for CT values > 30.
4. Cut off for CT value to be considered as non-infectious is > 30.
5. For patients with Reactive CT value > 30 upon diagnosis there is no need for repeat testing
unless symptoms suggestive of C0VID-19 infection developed.
6. Patients who are defined as cured and still needs hospitalization for various reasons, can be
transferred to non COVID facilities and they are considered noninfectious with no further
isolation precautions apart from standard precautions.
7. For asymptomatic patients with Reactive RT-PCR with CT value > 30 requiring
surgery/procedure:
 For emergency surgery/procedure then it can be done with full PPE( Gown, gloves,
N95 mask, face shield /goggles )
 For non-emergency (Elective) surgery/procedure postpone for at-least 1 week with
repeat testing then surgery/procedure can be performed unless CT value is ≤ 30.
8. All patients with symptoms suggestive of C0VID-19 infection should be evaluated to rule out
active disease regardless of the CT value and if emergency surgery/procedure is required then
full PPE (Gown, gloves, N95 mask, face shield /goggles) should be applied.
9. Alternatives to dexamethasone were added
10. Disposition of COVID 19 Positive Patient algorithm was added

Prepared by HMC CDC COVID-19 Scientific Committee (Doha-Qatar), version 9 (01/07/2020)

 B. Treatment Algorithm:

Asymptomatic patients
with or without risk No treatment is
factors including recommended
pregnant women

Symptomatic patients

Mild URTI infection for

all adult patients Non ICU pneumonia ICU pneumonia with
Non ICU pneumonia ICU pneumonia
including pregnant with pregnency pregnency
women

Antibiotics +Kaletra+Ribavirin +
Interferon +Dexamethasone
Antibiotics +Favipiravir ± Antibiotics + convalescent plasma
Antibiotics + convalescent plasma or +
Dexamethasone
Symptomatic ±
Antibiotics +Favipiravir +interferon Dexamethasone
treatment Dexamethasone + Dexamethasone
consider Tocilizumab and consider Tocilizumab if indicated
consider Tocilizumab if indicated
convalescent plasma if indicated
consider Tocilizumab and
convalescent plasma if indicated

C. General information:

1- The purpose of the protocol is to assist physicians and healthcare providers in management of patients
with confirmed COVID-19 infection.
2- Those recommendations are based on case series, registered and observational trials and recent
publications and available data on patients with MERS CoV, SARS and COVID-19 infections.
3- To date there is no approved vaccine against COVID-19 infection
4- Strict infection control measures should be maintained all the time.

D. Collection of swabs: (Table 1)

1- Strict infection control measures should be maintained all the time.
2- Samples should be collected in negative pressure room (if not available single room with HEPA FILTERS)
3- Staff should wear full personal protective equipment PPE (Gown, gloves, N95 mask, face shield (goggles))
4- Combined Nasopharyngeal/ Oropharyngeal swab is recommended.
5- Lower respiratory specimen is preferred when the patient is intubated.
6- Airborne / contact isolation is recommended
7- Confirmed cases can be cohorted in case of shortage of single isolation rooms
8- For further information contact your infection control practitioner.

Prepared by HMC CDC COVID-19 Scientific Committee (Doha-Qatar), version 9 (01/07/2020)

 E. Collection of other laboratory diagnostic tests: (Table 2)
1- Request CBC, CMP, CRP, Respiratory panel including COVID-19 PCR for all cases with confirmed
pneumonia, Chest X-ray as baseline investigations.
2- Request electrocardiogram (ECG) for all patients.
3- QuantiFERON test for patient whom will be started on Tocilizumab.
4- Repeat other blood tests if indicated and for patients in ICU.
5- CT Chest if clinically indicated
6- Appropriate PPE should be applied during laboratory investigation (specimen collection and transport)
performing ECG and radiological investigations.

F. Supportive therapy and monitoring:

1- No evidence linking NSAIDS to COVID-related clinical deterioration. This has not been proven clinically to
date, so we cannot make a recommendation for or against their use at this time.
2- American Heart Association, the Heart Failure Society of America and the American College of
Cardiology all recommend that ACE inhibitors or ARBs be continued in people who have an indication for
these medications We do not currently routinely recommend stopping these agents
3- Continue statins if already prescribed if no contraindications and can be prescribed if it is indicated ,
take precautions in patients with elevated Liver enzymes
4- Postexposure Prophylaxis for Healthcare Workers: There is currently no proven role for post exposure
prophylaxis for people with a known COVID-19 exposure. They should monitor themselves for appearance
of symptoms for another14-days.
5- Monitor for drug -drug interactions (consult with your clinical pharmacist)
6- Give supplemental oxygen therapy immediately to patients with COVID-19 and respiratory distress,
hypoxemia, or shock. Initiate oxygen therapy at 5 L/min and titrate flow rates to reach target SpO2 ≥90%
in non-pregnant adults and SpO2 ≥92-95 % in pregnant patients.
7- All areas where patients with COVID-19 are cared for should be equipped with pulse oximeters,
functioning oxygen systems and disposable, single-use, oxygen-delivering interfaces (nasal cannula,
simple face mask, and mask with reservoir bag). Use contact precautions when handling contaminated
oxygen interfaces of patients with COVID-19 infection.
8- Use conservative fluid management in patients with COVID-19 when there is no evidence of shock.
9- Give empiric antimicrobials to treat all likely pathogens causing secondary bacterial infection in COVID-
19 patients. Give antimicrobials within one hour of initial patient assessment for patients with sepsis.
According to HMC local protocol (CG 10015)
10- Systemic corticosteroids for treatment of COVID-19 pneumonia is recently found to decrease mortality in
patient with evidence of Cytokine Release Storm (CRS), patients’ needs oxygen and respiratory support.
(recovery trial)
11- Closely monitor patients with COVID-19 for signs of clinical deterioration, such as rapidly progressive
respiratory failure and sepsis, and apply supportive care interventions immediately.
12- Understand the patient’s co-morbid condition(s) to tailor the management of critical illness and
appreciate the prognosis. Communicate early with patient and family.
13- Home recovery advice for cured patients if required:
 Download Ehteraz application, activate it and check your status on regular basis
 Stay at home
 Don’t allow visitors into your house
 In the event of a medical emergency call 999.
 Your caregiver should wear a facemask and gloves every time he or she enters your room and
should dispose of the mask and gloves and wash their hands immediately after leaving the room.
 A distance of at least one-two meter shall always be maintained between you and others.

Prepared by HMC CDC COVID-19 Scientific Committee (Doha-Qatar), version 9 (01/07/2020)

 14- Home isolation advice for active COVID-19 cases in the community (if applicable):
 Download Ehteraz application, active it and check your status on regular basis
 Stay at home in a separate room to other family members, preferably one with an en-suite
bathroom, and ensure proper and regular ventilation
 Avoid any direct contact with other family members
 Don’t allow visitors into your house
 Use your phone if you need to contact anyone else in the house
 Ask others - a family member or friend - to run errands for you like buying food or medicine
 You must not leave your house. In the event of a medical emergency call 999.
 Only one member of the family should be allowed to provide care to you. Your caregiver should
wear a facemask and gloves every time he or she enters your room and should dispose of the
mask and gloves and wash their hands immediately after leaving the room.
 A distance of at least one-two meter shall always be maintained between you and your
caregiver.

15- patient can be discharge home If: Appendix 1

 For hospitalized patients:

1. Resolution of the fever for > 3 days without use of antipyretic medication.
Plus
2. Improve respiratory symptoms (supplementary oxygen not required for at least 48 hrs.)
Plus
3. Improving Pulmonary Imaging (if repeated)
Plus
4. One negative RT- PCR tests from Naso-oropharyngeal swab after 10 days of symptom
onset
Or
One Inconclusive RT- PCR tests from Naso-oropharyngeal swab after 10 days of symptom
onset.
Or
One Reactive result with CT Value > 30 after 10 days of symptom onset.

 If the swab is positive and CT value ≤ 30 repeat swab weekly till become Negative /Inconclusive
/Reactive.

 For asymptomatic/mild symptomatic patients in isolation facilities Patient can be discharged

home after:
1. After 14 days from diagnosis (first RT-PCR positive result) and minimum 5 days from
resolution of symptoms if present, whichever is longer
 Notes:
1. There will be no need for testing prior to discharge to confirm recovery unless the patient
had vulnerable population at home like household ≥ 60 years, immunocompromised
patients then swab will be repeated before discharge and he/she can be discharged
home if RT-PCR is negative or inconclusive or Reactive with CT value results > 30 , If the
swab is positive and CT value ≤ 30 patient will be kept in isolation facility to complete total
21 days from the first positive results, then can be discharge home without the need for
retesting.
2. For pneumonia patients transferred from hospitals and had previous positive RT-PCR with
CT value results ≤ 30 repeat another RT-PCR before discharge at day14.

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 3. For patients who are asymptomatic with Reactive CT value > 30 upon diagnosis can go
home with home recovery for 1 week from the first RT-PCR positive result.

4. For patients with Reactive CT value > 30 upon diagnosis there is no need for repeat testing
unless symptoms suggestive of C0VID-19 infection developed.

5. For patients who are defined as cured and still needs hospitalization for various reasons,
they can be transferred to non COVID facilities and they are considered noninfectious with
no further isolation precautions apart from standard precautions are needed.

6. For asymptomatic patients with Reactive RT-PCR with CT value > 30 requiring
surgery/procedure:
 For emergency surgery/procedure then it can be done with full PPE( Gown, gloves, N95
mask, face shield /goggles )
 For non-emergency (Elective) surgery/procedure postpone for at-least 1 week and
repeat testing, then surgery/procedure can be performed unless CT value is ≤ 30.

7. All patients with symptoms suggestive of C0VID-19 infection should be evaluated to rule
out active disease regardless of the CT value and if emergency surgery/procedure is
required then full PPE (Gown, gloves, N95 mask, face shield /goggles) should be applied.

 N.B: in all those conditions the patient should be asymptomatic or at least 5 days passed from
resolution of COVID-19 symptoms

16- For case definition please see Appendix 2

17- For Medication related consideration please see Appendix 3

18- For COVID-19 infection in special population please see Appendix 4

19- All patients admitted patients with COVID-19 should be evaluated for the risk of VTE and receive standard
prophylactic/therapeutic anticoagulation with LMWH/ Unfractionated heparin if no contraindications, D-
Dimer based protocol was established in some centers see Appendix 5

20- QTc Screening to Identify Patients at Increased Risk: Patients admitted with COVID-19 are likely to have
longer baseline QTc and have higher potential arrhythmic risks as a result of the metabolic and
physiologic sequelae of their illness, and a typically greater burden of comorbid disease. However, given
the risk of Covid-19 hospitalized and critically ill patients may also derive the most benefit from potentially
effective therapies. The goal of QTc screening in this setting is not to identify patients whom are not
candidates for therapy, but to identify those who are at increased risk for torsade de pointes (TdP) so
aggressive counter measures may be implemented for prediction of drug-associated QT prolongation
among hospitalized patients see Appendix 6

21- Favipiravir patient drug information Appendix 7

22- Dexamethasone alternatives see Appendix 8

23- Disposition of COVID 19 Positive Patient Appendix 9

Prepared by HMC CDC COVID-19 Scientific Committee (Doha-Qatar), version 9 (01/07/2020)

 With or without Risk factors for severe disease (Table 3)
 Admit the patient to isolation facility for observation
 No treatment is recommended
 Strict infection control measures should be maintained all the time.

With or without risk factors for severe disease (Table 3)

 For patients with no risk factors Admit the patient to isolation facility for observation
 No treatment is recommended
 Strict infection control measures should be maintained all the time.
 To be evaluated by obstetrician.

1. Positive COVID-19 PCR with Uncomplicated Upper Respiratory Tract Infection (URTI) (for definition see Table 4)

Admit the patient to Isolation Facility/ COVID Hospital upon physician decision
Strict infection control measures should be maintained all the time.
+
Symptomatic treatment

2. Treatment protocol for Pregnant females with Positive COVID-19 PCR with Uncomplicated Upper Respiratory
Tract Infection

Admit the patient to Isolation Facility/ COVID Hospital upon physician decision
Strict infection control measures should be maintained all the time.

+
Symptomatic treatment

Prepared by HMC CDC COVID-19 Scientific Committee (Doha-Qatar), version 9 (01/07/2020)

 3. Treatment protocol for COVID-19 Pneumonia (Documented pneumonia in CXR/CT scan) (for definition see Table 5)

Admit the patient to COVID Hospital

Strict infection control measures should be maintained all the time.

Start

Antibiotic * IV/PO As per local CAP guidelines for 7 days#

+
Favipiravir @ PO 1600 mg/dose twice a day on the first day; followed
by 600 mg/dose twice a day for 7 days
±
Dexamethasone $ PO/IV PO 6 mg Daily for 10 days
IV 8 mg Daily for 10 days
±
Tocilizumab For patients with evidence of cytokine release syndrome IV Initial dose of 4–8 mg/kg infused over more than 60
(Table 8) minutes. If initial dose not effective, may administer
second dose (in same dosage as initial dose) after 12
hours. No more than 2 doses should be given;
maximum single dose is 800 mg and not to be
infused in the same line with other medications
±
Consider Convalescent Plasma Infusion (Table 9) IV 2 units of CP. Each unit of plasma (200 -250 ml) will be
given over 2 h with an interval of 1 h between the
two units. Can be repeated if indicated.
Add Oseltamivir 75 mg po bid if co-infection with influenza virus is confirmed

*Antibiotic can be switched to PO if the patient is clinically stable

#Management of community acquired pneumonia (cap) in immuno-competent adults (CG 10015)

@ potential teratogenic and other side effects of the drug should be explained fully for the patients

$ Dexamethasone use for patients whom need Oxygen, respiratory support or evidence of Cytokine Release Storm

4. Treatment protocol for Pregnant females with COVID-19 Pneumonia

Admit the patient to COVID-19 Hospital

Strict infection control measures should be maintained all the time.

Start

Antibiotic * IV/PO As per local CAP guidelines for 7 days #

+
Convalescent Plasma Infusion (Table 9) IV 2 units of CP. Each unit of plasma (200 -250 ml)
will be given over 2 h with an interval of 1 h
between the two units. Can be repeated if
indicated
±
Dexamethasone $ PO/IV PO 6 mg Daily for 10 days
IV 8 mg Daily for 10 days
±
Tocilizumab For patients with evidence of cytokine IV IV infusion: initial dose of 4–8 mg/kg infused over
release syndrome (Table 8) more than 60 minutes. If initial dose not
effective, may administer second dose (in same
dosage as initial dose) after 12 hours. No more
than 2 doses should be given; maximum single
dose is 800 mg and not to be infused in the
same line with other medications
Add Oseltamivir 75 mg po bid if co-infection with influenza virus is confirmed

*Antibiotic can be switched to PO if the patient is clinically stable

# Management of community acquired pneumonia (cap) in immuno-competent adults (CG 10015)

$ Dexamethasone use for patients whom need Oxygen, respiratory support or evidence of Cytokine Release Storm

Prepared by HMC CDC COVID-19 Scientific Committee (Doha-Qatar), version 9 (01/07/2020)

 5. Treatment protocol for COVID-19 pneumonia requiring Intensive care (Septic shock/ARDS) for definition see
(Tables 6,7)

Admit the patient to ICU in COVID-19 Hospital, Strict infection control measures should be maintained all the time.
Start
Option 1 Option 2
Favipiravir* PO1600 mg/dose twice a day on the first day;
Ritonavir + Lopinavir (Kaletra) 500mg PO BID for 10 days followed by 600 mg/dose twice a day for 10 days

+
+ IFN-α2a (Pegasys®) Subcutaneously 180 μg weekly for 2
Ribavirin PO 2.4 g orally as a loading dose followed by 1.2 g BID to weeks
be started 24 hours after loading dose for 10 days. Or Or
Interferon beta-1b Subcutaneously 8 MIU on alternative
+ days for 3 doses
IFN-α2a (Pegasys®) Subcutaneously 180 μg weekly for 2 weeks
Or
Interferon beta-1b Subcutaneously 8 MIU on alternative days for 3
doses
+
Antibiotics @ IV As per local CAP guidelines #
+
Dexamethasone IV 8 mg Daily for 10 days
±
Tocilizumab For patients with evidence of cytokine release IV Initial dose of 4–8 mg/kg infused over more than 60 minutes.
syndrome (Table 8) If initial dose not effective, may administer second dose (in
same dosage as initial dose) after 12 hours. No more than 2
doses should be given; maximum single dose is 800 mg and
not to be infused in the same line with other medications
±
Consider Convalescent Plasma Infusion (Table 9) IV
2 units of CP. Each unit of plasma (200 -250 ml) will be given
over 2 h with an interval of 1 h between the two units. Can
be repeated if indicated
Oseltamivir 75 mg po bid can be added if co-infection with influenza virus is suspected /confirmed

* potential teratogenic and other side effects of the drug should be explained fully for the patients
@Antibiotic can be switched to PO if the patient is clinically stable
#Management of community acquired pneumonia (cap) in immuno-competent adults (CG 10015)

6. Treatment protocol for COVID-19 pneumonia requiring Intensive care (Septic shock/ARDS) in pregnant females

Admit the patient to ICU in COVID Hospital, Strict infection control measures should be maintained all the time.

Start
Antibiotics * IV As per HMC CAP guidelines#

+
Dexamethasone $ IV 8 mg Daily for 10 days
+
Convalescent Plasma Infusion (Table 9) IV 2 units of CP. Each unit of plasma (200 -250 ml) will be given over 2 h
with an interval of 1 h between the two units. Can be repeated if
indicated
±
Tocilizumab For patients with evidence of cytokine IV IV infusion: initial dose of 4–8 mg/kg infused over more than 60 minutes.
release syndrome (Table 8) If initial dose not effective, may administer second dose (in same
dosage as initial dose) after 12 hours. No more than 2 doses should be
given; maximum single dose is 800 mg and not to be infused in the
same line with other medications
Oseltamivir 75 mg po bid can be added if co-infection with influenza virus is suspected /confirmed

*Antibiotic can be switched to PO if the patient is clinically stable

# Management of community acquired pneumonia (cap) in immuno-competent adults (CG 10015)

Prepared by HMC CDC COVID-19 Scientific Committee (Doha-Qatar), version 9 (01/07/2020)

Table 1: SAMPLE COLLECTON AND INFECTION CONTROL MEASURES

1- Samples should be collected in negative pressure room (if not available room with HEPA FILTERS)
2- Staff should wear full personal protective equipment PPE (Gown, gloves, N95 mask, face shield (goggles)
3- Combined nasopharyngeal/ oropharyngeal swab is recommended
4- Lower respiratory specimen is preferred when the patient is intubated.
5- Airborne / contact isolation is recommended
6- Confirmed cases can be cohorted in case of shortage of single isolation rooms

Table 2: Laboratories recommended for hospitalized patients with confirmed or suspected COVID-19

Baseline investigation  CBC with diff (esp. total lymphocyte count)

 Complete metabolic panel
 CPK (creatine kinase)
 Ferritin/CRP
 D-Dimer
 LDH
 ECG
 HBV serologies (HepBsAb, HepBcAb, and HepBsAg)
 HCV antibody
 HIV 1/2 Ab/Ag
 In case of confirmed pneumonia full respiratory viral panel is recommended
Recommended follow up labs:  CBC with diff (esp. total lymphocyte count)
 Complete metabolic panel
 CPK (creatine kinase)
 Ferritin/CRP

 Routine blood cultures (2 sets)

If clinically indicated:  For acute kidney injury, send urinalysis and spot urine protein: creatinine
 Procalcitonin
 IL-6
 QuantiFERON test for patient who will be started on Tocilizumab.
 Anti X-a
Radiology  Chest X-ray
 CT chest if clinically indicated

Table 3: Risk factors for severe disease

Epidemiological Vital Signs Labs
1. Older adults Age > 55 1. Respiratory rate > 24 1. D-dimer > 1 mg/L
2. Patients of all ages with underlying medical breaths/min 2. CPK > twice upper limit of
2. Heart rate > 125 beats/min Normal
conditions, particularly if not well controlled,
3. SpO2 ≤ 94 % on ambient air 3. CRP > 100
including:
4. PaO2/FiO2 < 300 mmHg 4. LDH > 245 U/L
 Patients with chronic lung disease or moderate 5. Elevated troponin
to severe asthma
6. Admission absolute
 Patients who have serious heart conditions lymphocyte count < 0.8
 Diabetes with HbA1c > 7.6% 7. Ferritin > 500 ug/L
 History of hypertension
 Patients with chronic kidney disease undergoing
dialysis
 Patients with liver disease
3. immunocompromised patients, including cancer
treatment, smoking, bone marrow or organ
transplantation, immune deficiencies, poorly
controlled HIV or AIDS, and prolonged use of
corticosteroids and other immunosuppressants
4. Use of biologics
5. Obese patients (body mass index [BMI] ≥ 30

Prepared by HMC CDC COVID-19 Scientific Committee (Doha-Qatar), version 9 (01/07/2020)

Table 4: Definition of Uncomplicated upper respiratory tract viral infection:
Definition of Uncomplicated upper respiratory tract viral infection:

Patients with uncomplicated upper respiratory tract viral infection, may have non-specific symptoms such as fever, cough,
sore throat, nasal congestion, malaise, headache, muscle pain or malaise. The elderly and immunosuppressed may
present with atypical symptoms. These patients do not have any signs of dehydration, sepsis or shortness of breath.

Table 5: Definition of Pneumonia:

Definition of Pneumonia:

Mild pneumonia Patient with pneumonia and no signs of severe pneumonia.

Severe Adolescent or adult: fever or suspected respiratory infection, plus one of:
pneumonia - respiratory rate > 30 breaths/min
- severe respiratory distress, or SpO2 < 90% on room air

N.B: CURB65 and/or PSI can be used to assess pneumonia severity

Table 6: Definition of Sepsis &Septic shock

Definition of Sepsis &Septic shock

Sepsis Life-threatening organ dysfunction caused by a dysregulated host response to suspected or proven infection,
with organ dysfunction. Signs of organ dysfunction include altered mental status, difficult or fast breathing, low
oxygen saturation, reduced urine output, fast heart rate, weak pulse, cold extremities or low blood pressure,
skin mottling, or laboratory evidence of coagulopathy, thrombocytopenia, acidosis, high lactate or
hyperbilirubinemia.

Septic shock Persisting hypotension despite volume resuscitation, requiring vasopressors to maintain MAP ≥65 mmHg and
serum lactate level >2 mmol/L.

Table 7: Definition of ARDS

Definition of ARDS
Berlin Definition of ARDS requires that all the following criteria be present for diagnosis:

●Respiratory symptoms must have begun within one week of a known clinical insult, or the patient must have new or worsening
symptoms during the past week.

●Bilateral opacities must be present on a chest radiograph or computed tomographic (CT) scan. These opacities must not be
fully explained by pleural effusions, lobar collapse, lung collapse, or pulmonary nodules.

●The patient's respiratory failure must not be fully explained by cardiac failure or fluid overload. An objective assessment (eg,
echocardiography) to exclude hydrostatic pulmonary edema is required if no risk factors for ARDS are present.

●A moderate to severe impairment of oxygenation must be present, as defined by the ratio of arterial oxygen tension to fracti on
of inspired oxygen (PaO2/FiO2). The severity of the hypoxemia defines the severity of the ARDS:

•Mild ARDS – The PaO2/FiO2 is >200 mmHg, but ≤300 mmHg, on ventilator settings that include positive end-expiratory pressure
(PEEP) or continuous positive airway pressure (CPAP) ≥5 cm H2O.

•Moderate ARDS – The PaO2/FiO2 is >100 mmHg, but ≤200 mmHg, on ventilator settings that include PEEP ≥5 cm H2O.

•Severe ARDS – The PaO2/FiO2 is ≤100 mmHg on ventilator settings that include PEEP ≥5 cm H2O.

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Table 8: Guidance for Tocilizumab prescription:
 Studies indicate advanced stage disease responses to β-Coronaviruses including COVID-19 have a high IL-6 cytokine signature.
 Send serum IL-6 level prior to giving first dose of Tocilizumab
 Tocilizumab is currently under investigation for use in the treatment of coronavirus disease 2019 (COVID-19)-associated pulmonary
complications with elevated IL-6 levels at this time, safety and efficacy have not been established and information specific to
pregnancy has not been located. Risk and benefits should be discussed with the patients /family prior to medication administration

Establish clinical status to COVID-19 Determine treatment intervention

Grade 1 – mild reaction No treatment
Grade 2 – moderate reaction, Send for serum IL-6
fever, need for IVF (no
hypotension), mild oxygen
requirement
Grade 3 – severe, liver test Send for serum IL-6; consider Tocilizumab , if no effect can repeat x 2 more
dysfunction, kidney injury, IVF for doses 12 hours apart; if no response, consider low dose corticosteroids
resuscitation, low dose
vasopressor, supplemental oxygen
(high flow, BiPAP, CPAP)
Grade 4 – life threatening, Send for serum IL-6; consider Tocilizumab if no effect can repeat x 2 more
mechanical ventilation, high dose doses 12 hours apart; consider corticosteroid
vasopressor

(adopted and based on the Penn CRS criteria)

N.B: Use for confirmed COVID-19 cases guided by IL-6 level should be prescribed by infectious disease consultant, QuantiFERON test

Indication criteria for Use of Laboratory Parameters also Tocilizumab Exclusion Criteria of Patient:
Tocilizumab supportive of cytokine storm ( one
or more of the following):

 Extensive and bilateral lung
disease and severely ill patients
with elevated IL-6 level
 Alternatively, High levels of d-
dimer and / or CRP/ or ferritin
and / or fibrinogen progressively
increasing.
 Worsening of respiratory
exchanges such as to require non-
invasive or invasive support from
ventilation
 Serum IL-6 > 10 x upper normal
limit (Reference range ≤ 7
pg/mL)
 Ferritin >300 ug/L (or surrogate)
with doubling within 24 hours
 Ferritin >600 ug/L at
presentation
 LDH >250 U/L
 Elevated D-dimer (>1 mg/L)
 High CRP
 The inflammatory markers criteria should be in
context of IL-6 along with other markers
mentioned below :
 Active TB
 AST / ALT values higher than 5 times the normal
levels.
 Neutrophil value lower than 500 cells / mm3
 Platelets value lower than 50,000 cells /mm3
 Complicated diverticulitis or intestinal perforation
 Skin infection in progress (e.g.
dermohypodermatitis not controlled by antibiotic
therapy)
 Immunosuppressive anti-rejection therapy
 Confirmed systemic bacterial & or fungal infection
(i.e. Bacteremia with pathogenic bacteria,
fungemia)

Prepared by HMC CDC COVID-19 Scientific Committee (Doha-Qatar), version 9 (01/07/2020)

Table 9: Recommendations for Investigational COVID-19 Convalescent Plasma:
Patient inclusion Criteria
Patient exclusion Criteria
Donor inclusion criteria
Defined SARS-CoV-2 neutralizing
antibody titers
• COVID-19 Convalescent Plasma, Fresh Frozen, should be frozen within 8 hours after collection, stored at -18C◦ or colder and have an expiration date
one year from the date of collection
Prepared by HMC CDC COVID-19 Scientific Committee (Doha-Qatar), version 9 (01/07/2020)
 Laboratory confirmed COVID-19
 Patients with ARDS (any severity) with or without septic shock / multiple organ
dysfunction
 Age ≥to 18 years.
 Patient/family member to provide informed consent
 Negative RT-PCR from respiratory secretions or blood within 48 h prior to
assessment of eligibility.
 History of allergic reaction to blood or plasma products.
 Medical conditions in which receipt of 500 mL intravascular volume may be
detrimental to the patient (e.g. actively decompensated congestive heart failure).
 Severe multi-organ failure, hemodynamic instability.
 Other documented uncontrolled infection.
 Severe DIC needing factor replacement, FFP, cryoprecipitate.
 Expected survival for ≤ 48 hours
1- Prior diagnosis of COVID-19 documented by a laboratory test
2- Complete resolution of symptoms at least 28 days prior to donation
OR
3- Complete resolution of symptoms at least 14 days prior to donation AND Negative
results for COVID-19 either from one or more nasopharyngeal swab specimens or by
a molecular diagnostic test from blood
4- Male donors, female donors who have not been pregnant or female donors who
have been tested since their most recent pregnancy and results interpreted as
negative for HLA antibodies (if needed)
 Defined SARS-CoV2 neutralizing antibody titers, if testing can be conducted
(optimally greater than 1:80)
 NOTE: If neutralizing antibody titers cannot be obtained in advance, consider storing
a retention sample from the convalescent plasma donation for determining antibody
titers later.
Appendix 1: patient discharge criteria:
Hospitalized patients
Resolution of the fever for >3 days without use of antipyretic
medication.
Plus
Improve respiratory symptoms (not required oxygen x 4 8 hrs.)
Plus
Improving Pulmonary Imaging ( if repeated )
Plus
One negative RT- PCR tests from Naso-oropharyngeal swab after
10 days of symptom onset
Or
One Inconclusive RT- PCR tests from Naso-oropharyngeal swab
after 10 days of symptom onset.
Or
One Reactive result with CT > Value 30
Notes :If the swab is positive and CT value ≤ 30 repeat swab
weekly till Negative /Inconclusive /Reactive
Prepared by HMC CDC COVID-19 Scientific Committee (Doha-Qatar), version 9 (01/07/2020)
Patients in isolation facilities ( asymptomatic /mild
symptomatic )
After 14 days from diagnosis (first RT-PCR positive result) and
minimum 5 days from resolution of symptoms, whichever is longer.
Notes
1. There will be no need for testing prior to discharge to
confirm recovery unless the patient had vulnerable
population at home like household ≥ 60 years,
immunocompromised patients then swab will be repeated
before discharge and he/she can be discharged home if
RT-PCR is negative or inconclusive or Reactive with CT
value results > 30 , If the swab is positive and CT value ≤ 30
patient will be kept in isolation facility to complete total 21
days from the first positive results, then can be discharge
home without the need for retesting.
2. For pneumonia patients transferred from hospitals and
had previous positive RT-PCR with CT value results ≤ 30
repeat another RT-PCR before discharge at day 14.
3. For patients who are asymptomatic with Reactive CT value
> 30 upon diagnosis can go home with home recovery for
1 week from the first RT-PCR positive result.
4. In all those conditions the patient should be asymptomatic
or at least 5 days passed from resolution of COVID-19
symptoms.
Appendix 2: CASE DEFINITIO

Suspected case (requires diagnostic testing) Probable case Confirmed case

1. Acute respiratory tract infection (Sudden onset of the Suspected case + inconclusive Laboratory-confirmed infection,
following: fever ≥37.8C and/or cough and/or shortness of COVID-19 test regardless of signs and
breath) symptoms
+
No other etiology that fully explains the clinical presentation
particularly if he/she lives or works in area reporting recent local
transmission of COVID-19.
OR
Close contact with a confirmed or probable COVID-19 case
within ≤14 days prior to onset of symptoms
OR
Recent travel within the previous 14 days
OR
History of residence in country reporting local transmission of
COVID 19 Disease.

2. Severe acute respiratory infection (fever ≥37.8C and/or

at least one sign / symptoms of respiratory diseases (e.g: cough,
fever, shortness of breath)
+
Requiring hospitalization
+
No other etiology that fully explains the clinical presentation

3. Individuals present with any acute respiratory illness

including older adults (55 years or more) and individuals with
chronic medical conditions and/or an immunocompromised
state that may put them at higher risk for poor outcomes (e.g.,
diabetes, heart disease, receiving immunosuppressive
medications, chronic lung disease, chronic kidney disease,
cancer) regardless of travel history

4. Cluster case (2 or more cases with fever of 37.8 and/or

respiratory symptoms in a small area such as families, offices,
school room etc. within 2 weeks

Prepared by HMC CDC COVID-19 Scientific Committee (Doha-Qatar), version 9 (01/07/2020)

Appendix 3: COVID-19 Medications Information:
Lopinavir/Ritonavir (LPV/r) (Kaletra)
Baseline investigations
Monitoring recommendations
Most common side effects
Drug-Drug interaction
Oseltamivir
Common side
effects/contraindication
Drug-Drug interaction
Dose adjustment
Tocilizumab
Baseline investigations
Most common side effects
Drug-Drug interaction
Pregnancy Considerations
Breast-Feeding Considerations
Interferon
Baseline investigations
Monitoring recommendations
Most common side effects
Prepared by HMC CDC COVID-19 Scientific Committee (Doha-Qatar), version 9 (01/07/2020)
 ECG (Increase PR and QTc interval)
 LFT
 Follow up LFT
 Follow up ECG is recommended (Use with caution in these with cardiac conduction
abnormalities or when used with other medication that have similar effect).
 Monitor for bleeding especially if used concurrently with some anticoagulant and
anti-platelets.
 GI Symptoms (nausea, vomiting, diarrhea)
 Increase liver enzymes.
 Increase PR and QTc interval.
 Major Drug-Drug interaction (especially with anti-arrythmia, anticoagulant, anti-
platelets, Domperidone)
 GI side effects (Diarrhea, Nausea, vomiting),
 To reduce Nausea, administer with food.
 CNS symptoms (delirium and abnormal behavior)
 No major Drug-Drug interaction
 Needs dose adjustment based on renal function
 Consider QuantiFERON test
 CBC
 LFT
 Lipid profile
 Injection site reaction
 Infusion related reaction
 Increase Liver enzymes (AST, ALT, ALP and T-bilirubin)
 Neutropenia, thrombocytopenia, leukopenia
 Caution with other immune suppressive medication and live attenuated vaccines
 Post marketing data have not shown an increased rate of congenital malformations
or a pattern of specific malformations following in utero exposure to tocilizumab.
 At this time, safety and efficacy have not been established and information specific to
pregnancy has not been located.
 Informed consent is required
 Tocilizumab is present in breast milk and in the serum of one infant at birth following
in utero exposure, concentrations rapidly decreased and were not detectable by 4
weeks of age.
 Concentrations of tocilizumab are expected to be limited in breast milk due to large
molecular weight. Also, because tocilizumab is unlikely to be absorbed via the infant
gastrointestinal tract, use of tocilizumab may be considered in breastfeeding women
 CBC
 LFT
 CBC , Platelet count
 LFT
 Monitor for flu-like symptoms, allergic or anaphylactic reactions, injection-site
reactions,
 Cardiovascular: Peripheral edema
 Dermatologic: Skin rash
 Gastrointestinal: Abdominal pain
 Genitourinary: Urinary urgency
 Hematologic & oncologic: Leukopenia , lymphocytopenia , neutropenia
 Hepatic: Increased serum alanine aminotransferase (>5x baseline)
 Nervous system: Ataxia , chills , headache , hypertonia , insomnia , pain
 Neuromuscular & skeletal: Asthenia , myalgia

Drug-Drug interaction
Favipiravir
Baseline investigations
Monitoring recommendations
Most common side effects
Drug-Drug interaction
Ribavirin
Baseline investigations
Monitoring recommendations
Most common side effects
Prepared by HMC CDC COVID-19 Scientific Committee (Doha-Qatar), version 9 (01/07/2020)
 Respiratory: Flu-like symptoms
 Miscellaneous: Fever
 Cladribine: May enhance the adverse/toxic effect of Interferons (Beta). Specifically,
the risk for lymphopenia may be increased. Risk X: Avoid combination
 Zidovudine: Interferons may enhance the adverse/toxic effect of Zidovudine.
Interferons may decrease the metabolism of Zidovudine. Risk C: Monitor therapy
 CBC
 LFT
 Uric acid
 Pregnancy test for females in childbearing age
 Follow up CBC
 Follow up LFT
 Follow up Uric acid
 Anemia
 Increase Liver enzymes
 Testis toxicity
 Teratogenic ( contraindicated in pregnancy )
 For women of childbearing age (effective contraception is advised) and sexually
active men (use condoms and NO unprotected sexual intercourse with pregnant
women) for at least 7 days after the end of the treatment.
 Potential teratogenic and other side effects of the drug should be explained fully for
the patients and should be documented in the patient EMR.
 Pyrazinamide: Favipiravir may enhance the adverse/toxic effect of Pyrazinamide.
Specifically, the risk for increased uric acid concentrations may be increased. Risk C:
Monitor therapy
 Repaglinide: CYP2C8 Inhibitors (Weak) may increase the serum concentration of
Repaglinide. Risk C: Monitor therapy
 CBC
 Renal function test ( contraindicated if Crcl <50 ml/min stop the drug)
 Pregnancy test for females in childbearing age
 Monitor for any symptoms or signs of hemolysis. RBV may cause hemolysis especially
in patients with impaired renal function, older age, high dose per body weight and
female gender).
 Renal function test
 Dermatologic: Alopecia ,dermatitis, diaphoresis , pruritus , skin rash ,xeroderma
 Endocrine & metabolic: hyperuricemia,
 Gastrointestinal: Abdominal pain, decreased appetite, diarrhea , dyspepsia , nausea
,vomiting.
 Hematologic & oncologic: Anemia , hemolytic anemia , lymphocytopenia ,
neutropenia;
 Hepatic: Hyperbilirubinemia
 Nervous system: Anxiety ,depression, dizziness , emotional lability, fatigue, headache
insomnia, irritability ,nervousness
 Neuromuscular & skeletal: Arthralgia ,myalgia .
 Respiratory: Cough , dyspnea , flu-like symptoms , pharyngitis , sinusitis
 Miscellaneous: Fever , chills
 Drug-Drug interaction
Management of RBV induced
Hemolytic anemia
*check with your clinical pharmacist
Appendix 4: COVID-19 in special population:
Pregnancy
People living with HIV
If IgG <400
Heart/Liver/Kidney Transplant
Recipients
Lung transplant recipients
Prepared by HMC CDC COVID-19 Scientific Committee (Doha-Qatar), version 9 (01/07/2020)
 Azathioprine: Ribavirin (Systemic) may increase serum concentrations of the active
metabolite(s) of Azathioprine. Management: Consider using alternative agent(s)
when possible. When these drugs are used in combination, monitor patients closely
for signs/symptoms of myelosuppression. Risk D: Consider therapy modification
 Cladribine: Agents that Undergo Intracellular Phosphorylation may diminish the
therapeutic effect of Cladribine. Risk X: Avoid combination
 Didanosine: Ribavirin (Systemic) may enhance the adverse/toxic effect of Didanosine.
Risk X: Avoid combination
 Interferons (Alfa): May enhance the adverse/toxic effect of Ribavirin (Systemic).
Hemolytic anemia has been observed. Risk C: Monitor therapy
 Vitamin K Antagonists (eg, warfarin): Ribavirin (Systemic) may diminish the
anticoagulant effect of Vitamin K Antagonists. Risk C: Monitor therapy
 Zidovudine: May enhance the adverse/toxic effect of Ribavirin (Systemic). Specifically,
the risk/severity of anemia may be increased. Management: Due to significantly
increased risk of anemia, consider even closer monitoring for anemia than routinely
recommended for ribavirin. Alternative therapies should be considered when
clinically possible, particularly for patients with other risk factors. Risk D: Consider
therapy modification
 For patients with no cardiac disease, ribavirin can be held/stop if hemoglobin levels
<10 g/dL.
 Consult obstetrician
 The use of therapeutic agents should be guided by individual risk-benefit analysis
 Do not use statins
 Pregnant women with suspected or confirmed COVID-19 infection should be treated
with supportive therapies as described above, considering the physiologic adaptations
of pregnancy.
 Emergency delivery and pregnancy termination decisions are challenging and based
on many factors: gestational age, maternal condition, and fetal stability. Consultations
with obstetric, neonatal, and intensive care specialists (depending on the condition of
the mother) are essential.
 CXR and CT scan Chest can be performed if clinically indicated and after patient
consent with appropriate shield
 Tocilizumab is currently under investigation for use in the treatment of coronavirus
disease 2019 (COVID-19)-associated pulmonary complications with elevated IL-6 levels
at this time, safety and efficacy have not been established and information specific to
pregnancy has not been located. Risk and benefits should be discussed with the
patients /family prior to medication administration
 Avoid LPV/r monotherapy in people with HIV
 Consider IVIG at dose of 25 grams x 1 (unclear benefit)
 Consult transplant and transplant ID teams
 Consider decreasing Tacrolimus/Cyclosporine by 50%,
 Stop Mycophenolate and Azathioprine in kidney/liver transplant patients and reduce
dose by 50% in heart transplant patients.
 For Kidney transplant patients approximate target Tacrolimus level 3-5 ng/ml,
Cyclosporine level target 25-50 ng/ml.
 Critical illness – in liver and kidney – stop all immunosuppressants except for
Prednisone if they are on it at baseline
 Consult transplant and transplant ID teams
 No change to usual immunosuppression (avoids high levels, tailor to patient)
 For all those in ICU or with lower respiratory tract disease (most inpatients): pulse
Methylprednisolone 125mg IV q 12 hours
Appendix 5: Anti- coagulation use in COVID-1 positive patients:

- Adopted from HMGH local protocol for Management of Anticoagulation in COVID19 pneumonia patients admitted to Intensive Care
Unit May 2020

Prepared by HMC CDC COVID-19 Scientific Committee (Doha-Qatar), version 9 (01/07/2020)

Appendix 6: For prediction of drug-associated QT prolongation among hospitalized patients (Tisdale score)

Risk Factors Points

Age ≥68 y 1

Female sex 1

Loop diuretic 1

Serum K+ ≤3.5 mEq/L 2

Admission QTc ≥450 ms 2

Acute MI 2

≥2 QTc-prolonging drugs 6

sepsis 3

Heart failure 3

One QTc-prolonging drug 3

Calculated score

Maximum Risk Score 21

Low risk = ≤6 points

Moderate risk = 7-10 points

High-risk = ≥11 points

Prepared by HMC CDC COVID-19 Scientific Committee (Doha-Qatar), version 9 (01/07/2020)

Appendix 7: Favipiravir patient drug information:
Avigan© Favipiravir
IMPORTANT INFORMATION YOU NEED TO KNOW ABOUT YOUR MEDICATION
Medication Brand Name Avigan©
Medication Generic Name Favipiravir
Purpose This is an anti-viral medication which inhibits virus replication and it is used for COVID-19 in
many countries
How to take it Take 8 tablets at once, two times on day one, then take 3 tablets at once two times per day
from day 2 to day 7-10
For how long 7-10 days is the treatment duration
Important - This medication causes early embryonic death and teratogenicity, so it is not given to
women known or suspected to be pregnant
- Lactating women should stop lactation during treatment
- When given to sexually active men precautions should be used up to 7 days after
treatment is completed
Call your doctor If you noticed any of the following side effects:
- Skin rash
- Bruises
- Abdominal pain, nausea and vomiting
- Blood in urine
- Visual abnormalities
- Vertigo
- Anything that is abnormal

‫أفيغان © فافيبيرافير‬
‫معلومات هامة يجب عليك معرفتها عن هذا الدواء‬
©‫أفيغان‬ ‫االسم التجاري للدواء‬
‫فافيبيرافير‬ ‫االسم العلمي للدواء‬
‫هذا الدواء له خصائص مضادة للفيروسات ويعمل على منع تكاثر الفيروس ويستخدم‬ ‫الغرض من استخدام الدواء‬
‫ في العديد من البلدان‬19 ‫لكوفيد‬
3 ‫ ثم تناول‬،‫ مرتين في اليوم األول من العالج‬، ‫ أقراص في المرة الواحدة‬8 ‫تناول‬ ‫كيفية أخذ العالج‬
‫أقراص في المرة الواحدة مرتين في اليوم من اليوم الثاني إلى اليوم السابع إلى العاشر‬
‫ أيام‬10 -7 ‫مدة العالج‬
‫ لذلك ال يتم إعطاؤه‬، ‫ قد يتسبب هذا الدواء في اإلجهاض والتشوهات الخلقية للجنين‬- ‫ملحوظة هامة‬
‫للنساء في سن الحمل قبل الفحص وتأكيد عدم الحمل‬
‫ يجب على النساء المرضعات التوقف عن الرضاعة أثناء فترة العالج‬-
‫ عند إعطاء الرجال النشطين جنسيا يجب استخدام االحتياطات الالزمة لمنع الحمل‬-
‫ أيام بعد االنتهاء من مدة العالج‬7 ‫لمدة تصل إلى‬

:‫إذا الحظت أي من اآلثار الجانبية التالية‬ ‫يجب عليك إبالغ الطبيب‬

‫ الطفح الجلدي‬-
‫ كدمات‬-
‫ الغثيان والقيء‬,‫ آالم في البطن‬-
‫ وجود دم في البول‬-
‫ عدم وضوح في الرؤية‬-
‫ الشعور بالدوخة‬-
‫ أي عرض غير طبيعي وال يتعلق بالمرض‬-

Prepared by HMC CDC COVID-19 Scientific Committee (Doha-Qatar), version 9 (01/07/2020)

Appendix 8: Alternatives to dexamethasone include:

Drug Route Dose

Hydrocortisone IV 50 mg q8hrs (or q6h for refractory shock)
Methylprednisolone IV 30mg Once Daily
Prednisone PO 40mg Once Daily

Appendix 9: Disposition of COVID 19 Positive Patient

Prepared by HMC CDC COVID-19 Scientific Committee (Doha-Qatar), version 9 (01/07/2020)

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Prepared by HMC CDC COVID-19 Scientific Committee (Doha-Qatar), version 9 (01/07/2020)