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05/04/20 jm Antiviral Therapy for COVID-19 for ADULTS - Information for the Verifying Pharmacist
May 4, 2020

From: "Justin Muklewicz" <justin.muklewicz@hhsys.org>
To: "Pharmacists" <grp_allpharm@hhsys.org>
Cc: "Jonathan Edwards" <jonathan.edwards@hhsys.org>
Sent: Thursday, April 30, 2020 9:32:54 AM
Subject: Re: Antiviral Therapy for COVID-19 for ADULTS - Information for the Verifying Pharmacist

Good morning,

I would like to thank everyone for your support as we work together to ensure the best care for our patients during this pandemic. Below are key updates from the 4/28/20 P&T meeting that are now in effect for ADULT patients. Items in red are required steps (important updates) for pharmacists.

1. EKG monitoring with hydroxychloroquine: (link)
1. EKG monitoring protocol:
1. The verifying pharmacist will continue to place an intervention for follow-up in Cerner and order the two EKG's after the 2nd hydroxychloroquine loading dose and after the morning dose on day 3 of therapy. This is the absolute minimum level of monitoring. Pharmacists do not need to order EKGs if the prescriber orders EKGs on their own on the same day as our protocol, but should still place an intervention for follow-up. Prescribers are recommended to order a baseline and daily EKG
2. When should the pharmacist contact the prescriber?
1. Baseline QTc: ≥ 450 msec (males) or ≥ 470 msec (females)
2. Follow-up EKG: relative increase in QTc by ≥ 60 msec
3. Any point during therapy: QTc ≥ 500 msec 
3. What is the recommended course of action if any of the above QTc prolongation is observed?
1. Baseline: discuss the relative contraindication of therapy (risk vs benefit per prescriber). Our in-house data shows an average increase in QTc by ~30 msec from baseline after starting hydroxychloroquine. ISMP recommends avoiding the use of hydroxychloroquine in patients that exceed the above QTc values
2. Follow-up EKG or QTc > 500 msec: discuss discontinuation of azithromycin (if ordered) and/or recommend either discontinuing or reducing the dose of hydroxychloroquine as well as ordering a daily EKG
2. New COVID-19 Treatment Pathway (link)
1. Lopinavir/Ritonavir has been removed from the treatment pathway. If ordered, inform the ordering provider that this is not recommended by hospital-approved guideline based on lack of clinical benefit. 
2. Azithromycin has been deleted from the treatment pathway, however, there is insufficient evidence to either recommend for or against its use in COVID-19. Therefore the decision to use azithromycin is left to the ordering provider based on a risk vs benefit analysis. There are no restrictions for the use of azithromycin in COVID-19, however, caution should be taken to monitor for potential additive QT prolongation.
3. IL-6 inhibitors (e.g., tocilizumab) require AMT approval prior to verification and administration and must be ordered by an infectious diseases physician.

For any questions or situations that require urgent review by AMT, please do not hesitate to contact the AMT COVID-19 Hotline.