Month: March 2020

Medicines and COVID-19

This page was last updated: 28 March 2020 at 2:45PM

This site contains general information to assist health professionals in NZ respond to questions/concerns from the public about medicines and COVID-19. The information is compiled by a multidisciplinary team including pharmacists, pharmacologists and infectious diseases experts.

If you feel there are additional areas we need to cover, or for questions relating to specific patients, please contact us. If you cannot make contact by phone then please use email.

Summary

  • Patients should be advised to keep at least 1-2 weeks’ supply of their medicines.
  • Prescribers should only prescribe the usual maximum supplies of medicines (one month for controlled drugs, three months for non-controlled drugs). Pharmacy dispensing is limited to one month except for oral contraceptives.
  • The Ministry of Health has released criteria (see remote prescribing section) to allow remote prescribing of non-controlled medicines.
  • There are no clinical studies showing increased harm from any medicine use in relation to COVID-19. Patients should be advised not to stop any regular medicines unless there is a conventional indication to do so.
  • The treatment of COVID-19 is supportive. There are no medicines which should be prescribed for the direct treatment of COVID-19 outside of a clinical trial.
  • For symptomatic treatment of COVID-19 (pain and fever), paracetamol is preferred.
  • NSAIDs may still be used for refractory symptoms with the usual cautions and contraindications (e.g. elderly patients, renal impairment).

Medicine supply

The global effects of COVID-19 on manufacturing plants and transportation are likely to result in disruptions to the medicine supply chain. PHARMAC are working closely with the Ministry of Health (MoH) and suppliers to help maintain medicine supply chains. See PHARMAC: Information for coronavirus/COVID-19

Current supply

Patients should be advised to keep at least 1-2 weeks’ supply of their medicines.

However, to reduce hoarding dispensing of non-controlled medicines, other than oral contraceptives, is limited to one month. Prescribers should adhere to the usual prescribing restrictions (three month supply for non-controlled medicines and one month for controlled medicines).

See PHARMAC: Medicine and device supply issues

We currently have supply issues with paracetamol. Stocks of other medicines relevant to COVID-19 are unaffected at present. PHARMAC advice on dispensing paracetamol can be found at PHARMAC: Paracetamol supply issue

Patients may be anxious about medicine shortages and ask to stock-up on their regular medicines. This practice will lead to earlier and more problematic medicine shortages. Reassure patients that PHARMAC, the MoH, pharmacies and suppliers are working together to ensure equitable access to medicines. Prescribers should not issue multiple prescriptions for the same medicine. Pharmacies should not dispense more than one month’s supply of non-controlled medicines, with the exception of oral contraceptives for which a three month supply can be dispensed.

National advice, produced at CDHB, can be found here: COVID-19 Advice for prescribers and pharmacists about medicine supply. If this document is inaccessible due to password protection, use this link to access an older version. 

Remote prescribing

Remote prescribing by email or NZePS is possible for non-controlled drugs if Ministry of Health criteria are met (see below).

Remote prescribing has been facilitated by the Ministry of Health (MoH). Full details can be found here.

The New Zealand ePrescription Service (NZePS) is a secure prescribing system used in the community. The following GP Practice Management Systems (PMS) can produce electronic prescriptions via NZePS:

  • MedTech32, MedTech Evolution
  • MyPractice
  • Indici
  • Medimap.

These can be sent directly to pharmacies electronically, in which case a physical signature is not required. The prescription can also be printed and faxed to pharmacies. Contact the vendor for your PMS for guidance on accessing the PMS remotely to prescribe from home.

A physical signature is not required for under the following conditions:

  • The prescription is for non-controlled drugs only; and
  • The prescription is a NZePS barcoded prescription; and
  • The system that generates the prescription has been authorised by the Ministry of Health for Signature Exempt Prescriptions; and
  • The prescription is downloaded at the pharmacy from NZePS.

If you are not connected to NZePS you can email written prescriptions to pharmacies. These must be physically signed, and the original sent to the pharmacy by post or courier (within seven working days for non-controlled medicines and two working days for controlled medicines). The email must meet secure messaging criteria. For pharmacy email addresses see Healthpoint.

Medicines reported to worsen COVID-19

There are no clinical studies showing increased harm from any medicine use in relation to COVID-19. Patients should be advised not to stop any regular medicines unless there is a conventional indication to do so.

COVID-19 uses angiotension-coverting enzyme 2 (ACE2) to enter cells. There is pre-clinical data from in vitro and animal studies that some medicines may upregulate ACE2, raising concerns that these medicines could increase the severity of COVID-19 infection. However, there are no clinical data (including the publications from the large number of cases in China) to support this theory.

Immunosuppression theoretically increases the risk of coronavirus infection but there is no clinical evidence to support this.

Ibuprofen and other Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

Patients on long-term NSAIDs should continue to take them unless there is a conventional reason to stop (e.g. bleeding or acute kidney injury).

Paracetamol is preferred for symptomatic treatment of COVID-19, particularly in older patients or patients with comorbidities who are more vulnerable to adverse effects of NSAIDs. However, NSAIDs may still be used for refractory symptoms.

There has been longstanding concern over NSAIDs in viral infections. Randomised controlled trials and observational data comparing NSAIDs and paracetamol have produced mixed results that some showing no difference and others a small effect of NSAIDs. Overall, the data are too few to draw a convincing conclusion.

This existing concern has been compounded over the potential for COVID-19 to upregulate ACE2 in animal models. However, there are no clinical studies looking specifically at NSAIDs and COVID-19. Additionally, there are no data to support NSAIDs increasing the probability of becoming infected with COVID-19, or transmitting COVID-19. The European Medicines Agency (EMA) and World Health Organisation (WHO) have both acknowledged the theoretical concerns but still permit use of NSAIDs with COVID-19.

The usual contraindications and cautions still apply to NSAID use as they did prior to COVID-19, for example patients with renal impairment, heart failure or increased risk of gastrointestinal bleeding.

Angiotensin Converting Enzyme Inhibitors (ACEIs) and Angiotensin Receptor Blockers (ARBs)

Patients already taking ACEIs or ARBs should continue them unless there is a conventional reason not to (e.g. hyperkalaemia, acute kidney injury).

ACEIs and ARBs upregulate ACE2 in animal studies (see above). Observational studies of patients with COVID-19 have shown increased mortality for patients with underlying health conditions including diabetes and cardiovascular disease. Reports have suggested this could be due to ACEI and ARB use, however there are no data to substantiate this.

The usual contraindications and cautions still apply to ACEI and ARB use as they did prior to COVID-19, for example patients with hyperkalaemia or hypotension. Consensus from guidelines is that ACEIs and ARBs should be continued unless a conventional reason for cessation applies. See, for example, American College of Cardiology: Statement addressing concerns using RAAS antagonists COVID-19

Antidiabetic Medicines

Patients already taking thiazolidinediones (e.g. pioglitazone) should continue them unless there is a conventional reason not to (e.g. heart failure, history of bladder cancer).

Thiazolidinediones, such as pioglitazone, upregulate ACE2 in animal studies (see above). Observational studies of patients with COVID-19 have shown increased hospitalisation and mortality for patients with diabetes (7.3% vs 0.9%). Reports have suggested this could be due to ACEI and ARB use, however there are no data to substantiate this. Diabetes has separately been shown to upregulate ACE2 and increases the risk of other infections, both of which add to the confounding in the observational data.

The usual contraindications and cautions still apply to ACEI and ARB use as they did prior to COVID-19, for example patients with heart failure or a history of bladder cancer. We recommend clinicians continue usual practice around the use of pioglitazone during the COVID-19 pandemic.

Immunosuppressants

Patients should continue immunosuppressants while they remain well, even after potential COVID-19 exposure.

We refer to immunosuppressants as any medicine dampening immune response, including those described as “immunomodulatory” rather than immunosuppressive. These include drugs such as Disease Modifying Anti-Rheumatic Drugs (DMARDs) and monoclonal antibodies.

Immunosuppressants theoretically increase the chances of contracting coronavirus, or developing more severe infection. However, the extent of this effect is uncertain. Ceasing immunosuppressants could destabilise control of the underlying disease resulting in direct patient harm from disease, risk of hospitalisation (and COVID-19 exposure), and use of more immunosuppressing regimens (such as high-dose corticosteroids) to regain disease control. The long duration of effect of most immunosuppressants means omitting doses after COVID-19 exposure, for example, confers little or no short-term reduction of immunosuppression.

The management of immunosuppression for patients with an active infection is dependent on individual factors, such as the indication for immunosuppression and severity of the infection. It is therefore not possible to provide explicit guidance here, but clinicians are advised to use the same approach as applies to other significant viral infections, such as influenza. Discussion with the relevant specialist or Christchurch Medicines Information is recommended.

Medicines reported as treatment for COVID-19

The treatment of COVID-19 is supportive. There are no medicines which should be prescribed for the direct treatment of COVID-19 outside of a clinical trial.

Although there is pre-clinical data to support the efficacy of some medicines in vitro, there are no trials sufficient to justify using these medicines routinely for the treatment of COVID-19. Treatment remains supportive, although some medicines may be useful as part of supportive care, including paracetamol and oxygen.

CDHB memo: Specific medicines to treat COVID-19 infection

CDC: Interim clinical guidance for management of patients with confirmed coronavirus disease (COVID-19)

WHO: Clinical management of severe acute respiratory infection when novel coronavirus (nCoV) infection is suspected

Chloroquine and Hydroxychloroquine

Chloroquine and hydroxychloroquine currently have no role in the management of COVID-19.

There are pre-clinical data that these medicines may possess activity against COVID-19. However, there are no human trials and the reports from China of COVID-19 patients being treated with chloroquine do not contain sufficient details to conduct a retrospective observational study. There are no prospective randomised trials. Chloroquine or hydroxychloroquine exposes patients to adverse effects without good evidence of benefit.

Inappropriate prescribing for COVID-19 risks creating a shortage of these medicines for patients using them for established indications e.g. rheumatoid arthritis. Accordingly, PHARMAC has restricted funding of hydroxychloroquine to approved indications (rheumatoid arthritis, systemic or discoid lupus erythematosus, malaria).

Antivirals

Antivirals currently have no role in the management of COVID-19.

Remdesivir and lopinavir+ritonavir have potential activity in vitro against coronaviruses. There are no randomised controlled trials to support the use of these antiviral medicines to treat COVID-19 in humans with suspected or confirmed COVID-19 infection.

Observational studies from China reporting use have shown significant rates of adverse reactions. Inappropriate use of antivirals places patients at risk of harm without demonstrated evidence of benefit.

New Zealand may soon be taking part in clinical trials to assess the efficacy of antivirals for COVID-19.

Corticosteroids

Corticosteroids currently do not have a role in the treatment of COVID-19.

Patients should continue prescribed corticosteroids while they remain well, even after potential COVID-19 exposure.

Patients with asthma and/or COPD who use corticosteroid inhalers or oral corticosteroids as part of their asthma/COPD plan should continue to do so. 

Corticosteroids are not recommended for the treatment of pneumonia from COVID-19 except if there are other conventional indications e.g. exacerbation of chronic obstructive pulmonary disease (COPD). This recommendation is based on studies which found corticosteroid use was associated with delayed viral clearance and increased mortality in patients with influenza and Middle Eastern Respiratory Syndrome (MERS) coronavirus. During the Severe Acute Respiratory Syndrome (SARS) coronavirus pandemic, corticosteroids were widely used to manage SARS. However, there was no strong evidence of their effectiveness and some evidence of harm.

See CDC: Interim clinical guidance for management of patients with confirmed coronavirus disease (COVID-19)

Patients who are using long-term oral or inhaled corticosteroids may have an increased risk of contracting coronavirus or developing more severe COVID-19 symptoms. However, patients should not stop long-term corticosteroids abruptly solely because of the current pandemic, or if they are exposed to someone with COVID-19 or develop COVID-19. Abrupt cessation is unlikely to be of benefit and more likely to cause harm e.g. adrenal crisis, uncontrolled asthma.

There is minimal systemic exposure from topical corticosteroids. There is no evidence that topical corticosteroids for dermatological conditions e.g. eczema, psoriasis increase the chance of COVID-19 when used appropriately.

Patients with moderate to severe asthma and COPD are at higher risk of developing more severe symptoms of COVID-19. These patients may have ‘back-pocket’ prescriptions for self-administration of systemic corticosteroids. Patients using ‘back-pocket’ prescriptions should continue to do so during the pandemic. However, the symptoms of COVID-19 may be mistaken for an exacerbation of asthma and/or COPD so patients should be advised to seek medical attention urgently if self-administering corticosteroids. Note, prescriptions can be issued remotely (see remote prescribing section) and most pharmacies will have contactless delivery services prioritised for high risk patients.

Paracetamol

Paracetamol can treat symptoms of COVID-19 but does not improve clinical outcomes.

There are reports on social media that paracetamol can “cure” COVID-19. There is no scientific evidence to support this claim, or a plausible theory. Patients should be supported to use paracetamol in a supportive role, but warned that it does not protect them from serious harm from COVID-19 and is therefore not a substitute for established methods of infection control.

For information on dispensing paracetamol see PHARMAC: Paracetamol supply issue.