‫ثؼغ أُوزشؽبد ُزؾذ‪٣‬ش ثش‪ٝ‬ر‪ ًٍٞٞ‬ػالط ك‪٤‬ش‪ٝ‬ط ً‪ٞ‬س‪ٗٝ‬ب أُغزغذ‬

‫ٖٓ خالٍ ٓزبثؼز‪ُ ٠‬ؾبالد اٌُ‪ٞ‬س‪ٗٝ‬ب ػِ‪ٓ ٢‬ذاس ػبّ ًبَٓ ٓزبثؼ‪ُ ٚ‬ظ‪٤‬و‪ٓٝ ٚ‬جبشش‪ٓ ٙ‬غ أُشػ‪ٝ ٠‬ػالط ٓب ‪٣‬وشة ٖٓ اُل‪ ٖ٤‬ؽبُ‪ٓٝ ٚ‬زبثؼ‪ٗ ٚ‬زبئظ اُؼالط ‪ٝ‬اُؾبُ‪ٚ‬‬
‫اُظؾ‪ُِٔ ٚ٤‬شػ‪ٝ ٠‬اُؾ ٔذ هلل ٗغج‪ ٚ‬شلبء ػبُ‪ ٚ٤‬عذا رظَ اُ‪ٝ %89 ٠‬عذد اٗ‪ ٖٓ ٚ‬اُ‪ٞ‬اعت ٗوَ ‪ٛ‬ز‪ ٙ‬اُخجشاد ‪ٝ‬رغغ‪ َ٤‬ثؼغ أُالؽظبد ‪ٗٝ‬شش‪ٛ‬ب ُِ٘بط‬
‫‪ٝ‬االؽجبء ُؼِ‪ٜ‬ب رغبػذ ك‪ ٠‬اٗوبر اس‪ٝ‬اػ ٓشػبٗب‪.‬‬
‫ا‪ٝ‬ال اعجبة رذ‪ٞٛ‬س اُؾبُ‪ ٚ‬اُظؾ‪ُِٔ ٚ٤‬شػ‪:٠‬‬
‫ٓشع ً‪ٞ‬س‪ٗٝ‬ب ٓشع ك‪٤‬ش‪ٝ‬ع‪ٓ ٠‬ضَ االٗلِ‪ٗٞ‬ضا ‪ ٌُٚ٘ٝ‬عش‪٣‬غ االٗزشبس ٓٔب ‪٣‬غجت اسرلبع شذ‪٣‬ذ ك‪ ٠‬اػذاد أُظبث‪ٔٓ ٖ٤‬ب ‪٣‬غجت ص‪٣‬بد‪ ٙ‬ك‪ٗ ٠‬غج‪ ٚ‬اُؾبالد اُؾشع‪ٚ‬‬
‫اُز‪ ٠‬رؾزبط اُ‪ ٠‬سػب‪ ٚ٣‬طؾ‪ ٚ٤‬خبط‪ٛٝ ٚ‬زا هذ ‪٣‬ؤد‪ ٟ‬اُ‪ ٠‬اٗ‪٤ٜ‬بس أُ٘ظ‪ ٚٓٞ‬اُظؾ ‪ ٚ٤‬ثٔؼ٘‪ ٠‬إ اٗزشبس ً‪ٞ‬س‪ٗٝ‬ب اُغش‪٣‬غ ‪٣‬ؤد‪ ٟ‬اُ‪ ٢‬ص‪٣‬بد‪ ٙ‬االػذاد أُظبث‪ٝ ٚ‬ؽ‪٤‬ش إ‬
‫ٗغ ج‪ ٚ‬اُؾبالد اُؾشع‪ ٚ‬ال رٔضَ ؿ‪٤‬ش اهَ ٖٓ ‪ٗ ٖٓ % 5‬غج‪ ٚ‬االطبثبد ا‪ ُٞ ٟ‬ػ٘ذٗب ِٓ‪ٓ ٕٞ٤‬ظبة ع‪ٞ‬ف ‪ ٌٕٞ٣‬ػ٘ذٗب خٔغ‪ ٖ٤‬اُق ؽبُ‪ ٚ‬ؽشع‪ٓ ٚ‬ؾزبع‪ ٚ‬ػ٘ب‪ٚ٣‬‬
‫ٓشًض‪ٛٝ ٙ‬زا ‪٣‬ل‪ٞ‬م آٌبٗ‪٤‬بد اُذ‪ ٍٝ‬اٌُجش‪ٞ٣ٝ ٟ‬د‪ ٟ‬اُ‪ ٢‬اٗ‪٤ٜ‬بس ٓ٘ظ‪ ٚٓٞ‬اُظؾ‪ُٝ ٚ‬زا ا‪ ٍٝ‬خط‪ ٙٞ‬ك‪ ٠‬اُؼالط ‪ ٠ٛ‬اُ‪ٞ‬هب‪ٝ ٚ٣‬اُؾلبظ ػِ‪ ٢‬االعشاءاد االؽزشاص‪.ٚ٣‬‬
‫‪ ٖٓٝ‬اعجبة اٗزشبس ‪ٝ‬ص‪٣‬بد‪ ٙ‬ؽبالد ً‪ٞ‬س‪ٗٝ‬ب أُش‪٣‬غ ٗلغ‪ ٚ‬الٗ‪ ٚ‬ػ٘ذٓب ‪٣‬جذا ‪٣‬شؼش ثبػشاع اُ ٔشع ‪٣‬و٘غ ٗلغ‪ ٚ‬ثبٗ‪ٜ‬ب ؽبُ‪ ٚ‬ثشد ا‪ ٝ‬اٗلِ‪ٗٞ‬ضا ػبد‪٣ٝ ٚ٣‬غبػذ‪ ٙ‬ػِ‪٠‬‬
‫رُي ثؼغ اُضٓالء اُظ‪٤‬بدُ‪ ٚ‬ث‪ٞ‬طق ثؼغ أُغٌ٘بد اُز‪ ٠‬رغجت رخل‪٤‬ق ُالػشاع ث‪ٔ٘٤‬ب اُل‪٤‬ش‪ٝ‬ط ‪٣‬و‪ ّٞ‬ثزذٓ‪٤‬ش االع‪ٜ‬ض‪ ٙ‬اُؾ‪ ٚ٣ٞ٤‬ؽز‪٣ ٠‬ظَ أُش‪٣‬غ اُ‪٠‬‬
‫االػشاع اُشذ‪٣‬ذ‪٣ٝ ٙ‬زٌٖٔ اُل‪٤‬ش‪ٝ‬ط ٖٓ االٗغبٕ ‪ٝ‬رزذ‪ٞٛ‬س ؽبُز‪٘ٛٝ ٚ‬ب ‪٣‬غش‪ ٟ‬اُ‪ ٠‬ؽِت اُؼالط ‪ ٌُٖٝ‬ثؼذ ك‪ٞ‬اد اال‪ٝ‬إ‪.‬‬
‫‪ ٖٓٝ‬اخطش اعجبة اٗزشبس اُل‪٤‬ش‪ٝ‬ط ثؼغ اُضٓالء االؽجبء اُز‪ٌ٘٣ ٖ٣‬ش‪ ٕٝ‬اُل‪٤‬ش‪ٝ‬ط ا‪ ٝ‬ال ‪٣‬ؼشك‪ ٕٞ‬اُجش‪ٝ‬ر‪ًٞٞ‬الد أُ٘بع ج‪ُِٔ ٚ‬شػ‪٣ٝ ٠‬غزٔذ ًَ ٓؼِ‪ٓٞ‬بر‪ٖٓ ٚ‬‬
‫اُغ‪ٞ‬ش‪٤‬بٍ ٓ‪٤‬ذ‪٣‬ب ٓٔب ‪٣‬ؤد‪ ٟ‬اُ‪ ٠‬رذ‪ٞٛ‬س اُؾبُ‪ ٚ‬اُظؾ‪ُِٔ ٚ٤‬ش‪٣‬غ‪.‬‬
‫‪ ٖٓٝ‬اعجبة اٗزشبس اُل‪٤‬ش‪ٝ‬ط ثؼغ اُ ؼبداد االعزٔبػ‪ُ ٚ٤‬ذ‪ٓ ٟ‬غزٔؼ٘ب ٓضَ اُذفء االعش‪ٝ ٟ‬اُزغٔغ ثغ‪ٞ‬اس أُش‪٣‬غ ‪ٝ‬اٌُغ‪ٞ‬ف ٖٓ اُزؼبَٓ ٓؼ‪ ٚ‬ثؾشص ؽلبظب‬
‫ػِ‪ٓ ٠‬شبػش‪ٝ ٙ‬روج‪ٝ ِٚ٤‬االهزشاة ٓ٘‪ٗٝ ٚ‬ؼزجش ‪ٛ‬زا ‪ٝ‬اعت الثذ ٓ٘‪ٔٓ ٚ‬ب ‪ٞ٣‬د‪ ٟ‬اُ‪ ٠‬اٗزشبس أُشع داخَ اُؼبئِ‪ ٚ‬اُ‪ٞ‬اؽذ‪ٝ ٙ‬ص‪٣‬بد‪ٓ ٙ‬ب ‪٣‬غٔ‪ ٠‬ثبُؾَٔ اُل‪٤‬ش‪ٝ‬ع‪٠‬‬
‫‪ُ Viral Load‬ذ‪ ٟ‬اُ ٔش‪٣‬غ ٓٔب ‪٣‬ؤد‪ ٟ‬اُ‪ٓ ٠‬ض‪٣‬ذ ٖٓ اُزذ‪ٞٛ‬س ك‪ ٠‬اُؾبُ‪ ٚ‬اُظؾ‪ُِٔ ٚ٤‬شػ‪ُٝ ٠‬زا ٗؾٖ ك‪ ٠‬ؽبع‪ ٚ‬اُ‪ ٠‬رضو‪٤‬ق اػالٓ‪ٓٝ ٠‬غزٔؼ‪ٝ ٠‬ر‪ٞ‬ك‪٤‬ش ً‪ٞ‬ادس‬
‫طؾ‪ ٚ٤‬رز‪ٛ‬ت ُِٔ٘بصٍ ُزؼِ‪ ْ٤‬أُشاكو‪٤ً ٖ٤‬ل‪ ٚ٤‬رلبد‪ ٟ‬اُؼذ‪ٌٓٝ ٙٝ‬بكؾ‪ ٚ‬اُؼذ‪.ٙٝ‬‬
 ‫‪ ٖٓٝ‬صْ ر‪ٞ‬ط‪٤‬بر‪:٢ٛ ٠‬‬
‫اػبد‪ ٙ‬اُ٘ظش ك‪ ٠‬اُجش‪ٝ‬ر‪ًٞٞ‬الد اُؼالع‪ ٚ٤‬اُؾبُ‪ٝ ٚ٤‬ػَٔ ثش‪ٝ‬ر ‪٣ ًٍٞٞ‬ؾزشّ ػبَٓ اُ‪ٞ‬هذ ‪٣ٝ‬شاػ‪ ٠‬ك‪ ٚ٤‬إ ٗغجن اُل‪٤‬ش‪ٝ‬ط ثخط‪ ٙٞ‬الٕ ػبَٓ اُ‪ٞ‬هذ ٓ‪ ْٜ‬عذا ك‪ ٠‬اُوشاس ًٔب ع‪ٞ‬ف‬ ‫‪-1‬‬
‫ا‪ٝ‬ػؼ الؽوب‪.‬‬
‫اػبد روغ‪ ْ٤‬دسع‪ ٚ‬خط‪ٞ‬س‪ ٙ‬أُشع ثطش‪٣‬و‪ ٚ‬رؾزشّ ػبَٓ اُغٖ ‪ٝٝ‬ع‪ٞ‬د ٓخبؽش طؾ‪ ٚ٤‬اخش‪ٝ ٟ‬اُز‪٣ ٖ٣‬غٔ‪. High Risk Patients ٕٞ‬‬ ‫‪-2‬‬
‫ػَٔ ًز‪٤‬جبد طـ‪٤‬ش‪ُ ٙ‬الؽجبء ُزجغ‪٤‬ؾ االٓش ٓ ٖ اُ٘بؽ‪ ٚ٤‬اُزشخظ‪ٝ ٚ٤‬اُؼالع‪ٝٝ ٚ٤‬هذ اخز‪٤‬بس اُوشاس اُظؾ‪٤‬ؼ ك‪ ٠‬اُ‪ٞ‬هذ اُظؾ‪٤‬ؼ ‪ٓ ٞٛٝ‬ب ع‪ٞ‬ف اؽب‪ ٍٝ‬روذ‪ ٖٓ ٚٔ٣‬خالٍ ‪ٛ‬زا‬ ‫‪-3‬‬
‫اٌُز‪٤‬ت‪.‬‬
‫اُؾبع‪ ٚ‬اُ‪ ٠‬رضو‪٤‬ق اػالٓ‪ٓٝ ٠‬غزٔؼ‪ٝ ٠‬ر‪ٞ‬ك‪٤‬ش ً‪ٞ‬ادس طؾ‪ ٚ٤‬رز‪ٛ‬ت ُِٔ٘بصٍ ُزؼِ‪ ْ٤‬أُشاكو‪٤ً ٖ٤‬ل‪ ٚ٤‬رلبد‪ ٟ‬اُؼذ‪ٌٓٝ ٟٝ‬بكؾ‪ ٚ‬اُؼذ‪.ٟٝ‬‬ ‫‪-4‬‬
‫رذس‪٣‬ت ً‪ٞ‬ادس رٔش‪٣‬ؼ‪ٝ ٚ٤‬آذا د‪ٛ‬ب ثٌَ ‪ٝ‬عبئَ أُزبثؼ‪ٓ ٚ‬ضَ ع‪ٜ‬بص ه‪٤‬بط االًغغ‪ٝ ٖ٤‬اُزشٓ‪ٓٞ‬زش اُذ‪٣‬غ‪٤‬زبٍ ‪ٝ‬اد‪ٝ‬اد اُ‪ٞ‬هب‪ٝ ٚ٣‬اُز‪ٞ‬ػ‪.ٚ٤‬‬ ‫‪-5‬‬
‫رشغ‪٤‬غ أُجبدساد اال‪ٝ ٚ٤ِٛ‬دػٔ‪ٜ‬ب ك٘‪٤‬ب ‪ٓٝ‬غزٔؼ‪٤‬ب ‪ ٌٖٔ٣ٝ‬االعزلبد‪ٓ ٖٓ ٙ‬جبدسر٘ب اُؼظ‪ٓ( ٚٔ٤‬جبدس‪ ٙ‬أػضٍ ٗلغي ‪ٝ‬اؽ٘ب ٓؼبى) اُز‪ ٠‬ارٔ٘‪ ٖٓ ٠‬اُذ‪ ُٚٝ‬رو‪ٜٔ٤٤‬ب ‪ٝ‬دساعز‪ٜ‬ب ‪ٝ‬رؼٔ‪ٜٔ٤‬ب‪.‬‬ ‫‪-6‬‬

‫‪٣‬ؼ زٔذ اُجش‪ٝ‬ر‪ ًٍٞٞ‬أُوزشػ ػِ‪٠‬‬

‫‪ - 1‬روغ‪ ْ٤‬أُشػ‪ ٠‬اُ‪ ٠‬هغٔ‪ ٖ٤‬ؽجوب ُِغٖ اهَ ٖٓ ‪ 66‬ػبّ ‪ٝ‬اهَ ٖٓ ‪ 66‬ػبّ ‪٣ٝ‬زْ روغ‪ٓ ًَ ْ٤‬غٔ‪ٞ‬ػ‪ ٚ‬اُ‪ٓ ٠‬غٔ‪ٞ‬ػز‪ ٖ٤‬ؽجوب اُ‪ ٠‬رغَِ أُشع اُ‪ ٠‬اُشئ‪ٚ‬‬
‫ا‪ ٝ‬ػذّ رغِِ‪ ٚ‬اُ‪ ٠‬اُشئ‪ٝ ٚ‬روغ‪ ٚٔ٤‬ا‪٣‬ؼب اُ‪ٝ ٠‬ع‪ٞ‬د ٓب ‪٣‬غٔ‪ ٠‬ثؼ‪ٞ‬آَ خط‪ٞ‬س‪ ٙ‬اّ ال ‪ٓ Risk Factors‬ضَ ‪ٝ‬ع‪ٞ‬د عٌش ا‪ ٝ‬صساػ‪ ٚ‬اػؼبء ا‪ ٝ‬آشاع‬
‫ٓضٓ٘‪ ٚ‬ا‪ ٝ‬ر٘ب‪ ٍٝ‬اد‪٘ٓ ٚ٣ٝ‬بػ‪ ٚ‬ا‪ ٝ‬آشاع هِت ‪ٝ‬طذس ٓضٓ٘‪.ٚ‬‬
‫‪ - 2‬اؽزشاّ ػبَٓ اُ‪ٞ‬هذ ‪ٝ‬اُؼَٔ ٖٓ خالٍ ‪ٝTime Line‬إ ٗغجن اُل‪٤‬ش‪ٝ‬ط دائٔب ثخط‪ًٔ ٙٞ‬ب ع‪ٞ‬ف ا‪ٝ‬ػؾ‪ ٚ‬الؽوب‪.‬‬

‫‪> 60 Years‬‬ ‫‪< 60 Years‬‬

‫‪Without Lung‬‬ ‫‪With Lung‬‬ ‫‪Without Lung‬‬

‫‪With Lung‬‬
‫‪Infiltrate‬‬ ‫‪Infiltrate‬‬ ‫‪Infiltrate‬‬
‫‪Infiltrate‬‬

‫‪No Risk‬‬ ‫‪Risk‬‬ ‫‪No Risk‬‬ ‫‪Risk‬‬ ‫‪No Risk‬‬ ‫‪Risk‬‬ ‫‪No Risk‬‬
‫‪Risk‬‬
‫‪Factors‬‬ ‫‪Factors‬‬ ‫‪Factors‬‬ ‫‪Factors‬‬ ‫‪Factors‬‬ ‫‪Factors‬‬ ‫‪Factors‬‬
‫‪Factors‬‬
Definitions
1- Mild disease: Fever, cough, sore throat, malaise, headache, muscle pain without shortness of breath, dyspnea on
exertion, or abnormal imaging.
2- Moderate Pneumonia: Pneumonia with no clinical or laboratory indicators of clinical severity or respiratory
impairment. Evidence of lower respiratory disease by clinical assessment and/or imaging with SpO2 ≥93% on room air,
RR 24-30 breaths/min, X-ray infiltrates involve less than 50% of lung parenchyma
3- Severe pneumonia: SpO2 <93% on room air, RR >30, PaO2/FiO2 <300 mmHg, or lung infiltrates involving >50% of
lung parenchyma . All patients who require supplemental oxygen, mechanical ventilation, or extracorporeal mechanical
oxygenation (ECMO).
4- ARDS: Berlin Definition of ARDS requires that all the following criteria be present for diagnosis:
4..1 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.
4..2 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.
4..3 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.
4..4 A moderate to severe impairment of oxygenation must be present as defined by the ratio of arterial oxygen tension to
fraction of inspired oxygen (PaO2/FiO2).
The severity of the hypoxemia defines the severity of the ARDS:
4.4.1 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) ≥5cm H2O.
4.4.2 Moderate ARDS - The PaO2/FiO2 is > 100 mmHg, but ≤ 200 mmHg, on ventilator settings that include PEEP
≥5cm H2O.
4.4.3 Severe ARDS - The PaO2/FiO2 is ≤100 mmHg, on ventilator settings that include PEEP ≥5cm H2O.
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.
5-Septic Shock: Persisting hypotension despite volume resuscitation, requiring vasopressors to maintain MAP ≥65mmHg
and serum lactate level >2 mmol/L.
6- Cytokine Release Syndrome:
6.1. Serum IL-6> upper normal limit.
6.2. Ferretin > 300 ng/L with doubling within 24 hours.
6.3. Ferretin > 600 ng/L at presentation and LDH > 250.
6.4. Elevated D- dimer > 1 ng/ml.
6.5. High CRP > 100 mg/L.

What are the typical symptoms of COVID-19?

The three most symptoms of COVID-19 are:
 fever
 cough
 fatigue
Some of the other symptoms of COVID-19 can include:
 shortness of breath
 loss of smell or taste
 body aches and pains
 headache
 sore throat
 runny or stuffy nose
 digestive symptoms, including nausea, vomiting, or diarrhea
 Mild illness. A person has any of the symptoms of COVID-19 except for shortness of breath and difficulty
breathing.
 Moderate illness. A person may have lower respiratory illness, such as pneumonia. However, their blood
oxygen levels remain at 94 percent or higher.
 Severe illness. A person has blood oxygen levels that are less than 94 percent, a high breathing rate, and signs
of severe lung disease.
Laboratory parameters and associated pathophysiology in adult COVID-19 patients.
Lymphocytes:
Absolute count reduction, functional exhaustion of all populations (especially cytotoxic T-cells) Unknown exact
mechanisms Lower levels associated with: ↑Severity, ↑Mortality PMN/CD8+ ratio and PMN/Lymphocyte ratio may be
used as prognostic markers.
Total white blood cells/Neutrophils:
Increased due to inflammation Higher levels associated with: ↑Severity, ↑Mortality, Bacterial super-infections .
C-reactive protein (CRP):
Increased production due to inflammatory cytokines higher levels associated with: ↑Severity, Lack of improvement,
Bacterial super-infections.
Erythrocyte sedimentation rate:
Increased in inflammation Tendency for higher levels associated with: ↑Mortality. But post covid recovery associated
with unexplained very high ESR.
Ferritin:
Increased production due to inflammatory cytokines, released by activated macrophages Higher levels associated with:
↑Severity, ↑Mortality High levels are indicators of CSS development.
Procalcitonin:
Increased production due to inflammatory cytokines Higher levels associated with: ↑Severity, ↑Mortality, Bacterial super-
infections.
Lactate dehydrogenase (LDH):
Released by cell injury higher levels associated with: ↑Severity, ↑Mortality, Lack of improvement High levels on
admission may be used as prognostic marker for severity.
Cardiac biomarkers Hs-troponin I:
Released by myocardial injury Higher levels associated with: ↑higher levels associate, lack of improvement High levels
on admission or gradual increase may be used as prognostic marker for severity and mortality.
Renal function indices Creatinine:
Decreased discharge due to renal injury higher levels associated with: ↑Severity, ↑Mortality.
BUN Decreased discharge due to renal injury higher levels associated with: Higher levels associated with: ↑Severity,
↑Mortality Urinary protein Possibly positive due to renal dysfunction Proteinuria may associated with: ↑proteinuria.
Urinary erythrocyte:
Possibly positive due to renal dysfunction Hematuria may associate with: ↑Severity, ↑Mortality.
Liver function indices:
ALT Possibly liver injury, unknown exact mechanism Higher levels associated with: ↑high severity, (↑Mortality,
indeterminate data).
AST Possibly myocardial or liver injury, unknown exact mechanism Higher levels associated with: ↑higher level
(↑Mortality, indeterminate data).
TBIL Unknown exact mechanism Higher levels associated with↑Severity, ↑Mortality.
GGT Unknown exact mechanism Higher levels associated with: ↑Severity, ↑Mortality.
ALP Increased levels in some patients, unknown exact mechanism No clear association with disease severity and
outcomes.
Coagulation profile:
D-dimer: Elevated levels possibly due to hypercoagulability and secondary fibrinolysis higher levels associated with:
↑Severity, ↑Mortality. D-dimer>1 ng/ml on admission or gradual increase may be used as prognostic marker for severity
and mortality.
PT: Prolonged PT possibly due hypercoagulability and secondary fibrinolysis higher levels associated with: ↑Severity,
↑Mortality.
INR: Elevated levels possibly due hypercoagulability and secondary fibrinolysis higher levels associated with: ↑Severity,
↑Mortality
APTT: Unknown exact mechanism indeterminate association with disease severity and outcomes.
Fibrinogen: Elevated as an acute phase protein and may decrease due to hypercoagulability higher levels associated with:
↑Severity, ↑Mortality.
Cytokines and chemokines
IL-6: Increased production/Associated with CSS/sHLH Higher levels associated with: ↑Severity, ↑Mortality IL-6 levels
may monitor disease progression Higher of IL-6 to IFN-γ ratio may distinguish severe from moderate cases.
Bicarbonates:
Decreased due to respiratory alkalosis and metabolic acidosis Not enough data – possibly lower among non-survivors.
PaO2:
Decreased due to alveolar and microvasculature injury (direct and indirect) Frequency of type I respiratory failure is
significantly higher among non survivors markedly low PaO2.
 ‫‪One year Experience in Management of COVID-19‬‬
‫ٖٓ خالٍ ٓزبثؼز‪ُ ٠‬ؾبالد اٌُ‪ٞ‬س‪ٗٝ‬ب ػِ‪ٓ ٢‬ذاس ػبّ ًبَٓ ٓزبثؼ‪ُ ٚ‬ظ‪٤‬و‪ٓٝ ٚ‬جبشش‪ٓ ٙ‬غ أُشػ‪ٝ ٠‬ػالط ٓب ‪٣‬وشة ٖٓ اُل‪ ٖ٤‬ؽبُ‪ٓٝ ٚ‬زبثؼ‪ٗ ٚ‬زبئظ اُؼالط ‪ٝ‬اُؾبُ‪ٚ‬‬
‫اُظؾ‪ُِٔ ٚ٤‬شػ‪ٝ ٠‬اُؾ ٔذ هلل ٗغج‪ ٚ‬شلبء ػبُ‪ ٚ٤‬عذا رظَ اُ‪ٝ %89 ٠‬عذد اٗ‪ ٖٓ ٚ‬اُ‪ٞ‬اعت ٗوَ ‪ٛ‬ز‪ ٙ‬اُخجشاد ‪ٝ‬رغغ‪ َ٤‬ثؼغ أُالؽظبد ‪ٗٝ‬شش‪ٛ‬ب ُِ٘بط‬
‫‪ٝ‬االؽجبء ُؼِ‪ٜ‬ب رغبػذ ك‪ ٠‬اٗوبر اس‪ٝ‬اػ ٓشػبٗب‪.‬‬
‫‪ٛٝ‬ز‪ ٙ‬أُالؽظبد هبثِ‪ُِ٘ٔ ٚ‬بهش‪ٝ ٚ‬اُ٘وذ ا‪ ٝ‬اُزب‪٤٣‬ذ ؽ‪٤‬ش اٗ٘ب ٗزؼبَٓ ٓغ ٓشع عذ‪٣‬ذ ال ر‪ٞ‬عذ ك‪ٓ ٚ٤‬شاعغ ػِٔ‪ٗٝ ٚ٤‬ؼزٔذ ك‪ ٚ٤‬ػِ‪٠‬‬
‫(‪)Evidence based medicine Level V‬‬
‫‪ٝ‬الٗ٘ب ٖٓ ا‪ٝ‬ائَ االؽجبء اُز‪ ٖ٣‬رؼبِٓ‪ٞ‬ا ٓغ أُشػ‪ ٠‬ثشٌَ ٓجبشش ‪ٓٝ‬زبثؼ‪ُ ٚ‬ظ‪٤‬و‪ ٖٓ ٚ‬خالٍ ٓجبدس‪ٓ ٙ‬غزٔؼ‪ُٔ ٚ٤‬غبػذ‪ٓ ٙ‬شػ‪ ٠‬اٌُ‪ٞ‬س‪ٗٝ‬ب ٖٓ خالٍ كش‪٣‬ن ٓزٌبَٓ‬
‫ٖٓ اؽجبء ‪ٝ‬ط‪٤‬بدُ‪ٝ ٚ‬رٔش‪٣‬غ ‪ٝ‬ك٘‪ٝ ٖ٤٤‬اداس‪٘ٗ ُْٝ ٖ٤٣‬غ‪ٞٓ ٠‬ر‪ًٞ ٠‬س‪ٗٝ‬ب كٌبٕ ٓؼ٘ب كش‪٣‬ن ُزـغ‪ٝ َ٤‬رٌل‪ٝ ٖ٤٤‬دكٖ أُ‪ٞ‬ر‪ٝ ٠‬ث٘بء ػِ‪ٛ ٠‬ز‪ ٙ‬اُخجشاد ‪ٝ‬اُ٘زبئظ‬
‫أُج‪ٜ‬ش‪ُ ٙ‬جش‪ٝ‬ر‪ ًٍٞٞ‬اُؼالط اُز‪ ٟ‬رْ اعزؼٔبُ‪ ٚ‬ك‪ ٠‬أُجبدس‪ ٙ‬هشسد رِخ‪٤‬ض اُخجشاد ‪ٝ‬ا‪ٛ‬ذاء‪ٛ‬ب اُ‪ ٠‬عٔ‪ٞ‬ع االؽجبء ُؼِ‪ٜ‬ب رٌ‪ ٕٞ‬عجت ك‪ ٠‬شلبء ٓشػ‪ٝ ٠‬اٗوبر‬
‫اس‪ٝ‬اػ‪.‬‬
‫ر‪ٞ‬ط‪٤‬بد ٓ‪٣ ْٜ‬غت رذاسً‪ٜ‬ب اص٘بء ػالط اٌُ‪ٞ‬س‪ٗٝ‬ب‪:‬‬
‫ًٔب عجن ‪ٝ‬رًشٗب إ اٌُ‪ٞ‬س‪ٗٝ‬ب ٓشع ٓضَ االٗلِ‪ٗٞ‬ضا ‪ ٌُٖٝ‬اُخط‪ٞ‬س‪ ٙ‬ػِ‪ ٠‬اُؾبالد اطؾبة االٓشاع أُضٓ٘‪ٝ ٚ‬خبط‪ٓ ٚ‬شػ‪ ٠‬اُغٌش الٗ‪ٔ٣ ْٜ‬ضِ‪ٗ ٕٞ‬غج‪ً ٚ‬ج‪٤‬ش‪ٙ‬‬
‫ٖٓ أُغزٔغ رظَ اُ‪ ٖٓ %9 ٠‬أُغزٔغ ا‪ ٟ‬ك‪ ٠‬ؽذ‪ٝ‬د ‪ٓ ٕٞ٤ِٓ 9‬ش‪٣‬غ ‪ٓٝ‬ؼظْ اُ‪ٞ‬ك‪٤‬بد رؾذس ُ‪ٜٞ‬الء أُشػ‪ٝ ٠‬اُز‪٣ ٖ٣‬غت رطؼ‪ ْٜٔ٤‬اعجبس‪٣‬ب‪.‬‬
‫‪٣‬غت اؽزشاّ ػبَٓ اُ‪ٞ‬هذ اص٘بء ػالط اٌُ‪ٞ‬س‪ٗٝ‬ب الٕ ػبَٓ اُ‪ٞ‬هذ ٓ‪ٝ ْٜ‬ؿبُجب ٓب ‪٣‬بر‪ ٠‬أُش‪٣‬غ ٓزبخشا الٗ‪ ٚ‬ا‪ٝ‬ال ‪٣‬و٘غ ٗلغ‪ ٚ‬اٗ‪ٜ‬ب ٗضُ‪ ٚ‬ثشد ‪٣ٝ‬ؼزٔذ ػِ‪ ٠‬اُ‪ٞ‬طلبد‬
‫اُزوِ‪٤‬ذ‪ٝ ٚ٣‬ػ٘ذٓب ‪٣‬ضداد أُشع ‪٣‬ز‪ٞ‬خ‪ ٚ‬اُ‪ ٠‬اُظ‪٤‬ذُ‪ ٠‬اُز‪٣ ٟ‬ظق االد‪ ٚ٣ٝ‬ؽزظ رغ‪ٞ‬ء االٓ‪ٞ‬س اًضش ك‪٤‬ززًش إ ‪٣‬ز‪ٛ‬ت اُ‪ ٠‬اُطج‪٤‬ت ‪ٝ‬ؿبُجب ‪ ٌٕٞ٣‬أُش‪٣‬غ ‪ٝ‬طَ‬
‫ُٔشؽِ‪ ٚ‬اٍ (‪ ) Cytokine storm‬شب‪ٛ‬ذ اُظ‪ٞ‬س أُشكو‪ ٚ‬اُز‪ ٠‬ر‪ٞ‬ػؼ ا‪ ٚ٤ٔٛ‬ػبَٓ اُ‪ٞ‬هذ ك‪ ٠‬ػالط اٌُ‪ٞ‬س‪ٗٝ‬ب‪.‬‬
‫اؽزشاّ ػبَٓ اُ‪ٞ‬هذ ‪٣ٝ‬غت إ ٗغجن اُل‪٤‬ش‪ٝ‬ط ث خط‪ ٙٞ‬اص٘بء ػالط اُؾبالد راد اُخط‪ٞ‬س‪ ٙ‬اُؼبُ‪( ٚ٤‬آشاع اُغٌش ‪ٝ‬اٌُِ‪ٝ ٠‬اال‪ُٝ‬شا ّ ‪ٝ‬ؿ‪٤‬ش‪ ٖٓ ْٛ‬اطؾبة‬
‫آشاع أُ٘بػ‪ٝ ٚ‬آشاع اُوِت) الٕ اُل‪٤‬ش‪ٝ‬ط ُ‪ ٚ‬عذ‪ ٍٝ‬صٓ٘‪ً ٠‬بالر‪:٠‬‬

‫‪ - 1‬ا‪ 7 ٍٝ‬ا‪٣‬بّ ٓشؽِ‪ ٚ‬اٍ (‪ٛٝ ) Viral Replication‬ز‪ ٙ‬أُشؽِ‪ ٚ‬ا‪ ٚ٣ُٞٝ‬اُؼالط ُالد‪.)Antiviral( ٚ٣ٝ‬‬
‫ٓغ‬ ‫‪ - 2‬اُ‪ ّٞ٤‬اُغبثغ اُ‪ ٠‬اُ‪ ّٞ٤‬اُؼبشش ( ‪ٛٝ )Host inflammatory phase‬ز‪ ٙ‬أُشؽِ‪ ٚ‬ا‪ ٚ٣ُٞٝ‬اُؼالط ُالد‪)Antiviral( ٚ٣ٝ‬‬
‫(‪.)Antinflammatory, Anti-IL, JACJ inhibitors‬‬
‫‪ - 3‬ثؼذ اُ‪ ّٞ٤‬اُؼبششٓشؽِ‪ ٚ‬اٗ‪٤ٜ‬بس أُ٘بػ‪ٝ ٚ‬ع‪٤‬طش‪ ٙ‬اُل‪٤‬ش‪ٝ‬ط ػِ‪ ٠‬اُغ‪ٜ‬بص اُز٘لغ‪ ٝ ٠‬االػؼبء اُؾ‪ٝ )Systemic complications( ٚ٣ٞ٤‬ك‪ٛ ٠‬ز‪ ٙ‬اُؾبُ‪ٚ‬‬
‫رظجؼ اُؼ٘ب‪ ٚ٣‬أُشًض‪ٌٓ ٠ٛ ٙ‬بٕ اُؼالط‪.‬‬
Predictive criteria for COVID-19 cytokine storm Entry criteria (must be all met)
+Signs/symptoms of COVID-19
±RT-PCR positive for COVID-19
+GGO by HRCT (or chest X-ray)
Ferritin >250 ng/mL
C reactive protein >4.6mg/dL
AND (one variable from each cluster)
Cluster I
Albumin 11.4K/mm3
Lymphocytes (%) <10.2
Neutrophil Abs >11.4K/mm3
Cluster II
ALT >60U/L
AST >87U/L
D-dimers >4,930 ng/mL
LDH >416U/L
Troponin I >1.09 ng/mL
Cluster III
Anion gap 106mmol/L
Chloride >106mmol/L
Potassium >4.9mmol/L
BUN: creatinine ratio >29 ratio
Criteria are met when patients fulfill all the entry criteria and at least one criterion per each cluster.
Cut-off values were calculated using a genetic algorithm. Abs, absolute numbers; ALT, alanine aminotransferase;
AST, aspartate aminotransferase; BUN, blood urea nitrogen; GGO, ground-glass opacity; HTCT, high-resolution
CT; LDH, lactate dehydrogenase; RT-PCR, reverse transcriptase PCR
 ‫اُجش‪ٝ‬ر‪ ًٍٞٞ‬أُغزخذّ ك‪ ٠‬اُؼالط‬
‫‪٣‬ؼزٔذ ثش‪ٝ‬ر‪ ًٍٞٞ‬اُؼالط ػِ‪ ٠‬اػطبء أُش‪٣‬غ ‪:‬‬
‫‪1- Antiviral (Ivermectin – Favipiravir- Remdesivir).‬‬
‫‪2- Antibiotics ( Azithromycin – Levofloxacin – Ceftriaxon).‬‬
‫‪3- Anti – inflammatory( Dexametgasone – Methylpredinisolon).‬‬
‫‪4- Anti-fibrotic ( Colchecin 500 mg).‬‬
‫‪5- Analgesic ( Paracetamol – Celicoxib).‬‬
‫‪6- JAC inhibitor Baricitinib) e.g. Alumianet 4 mg.‬‬
‫‪7- Anti-interleukin e.g. Tocilizumab (Actimra).‬‬
‫رْ روغ‪ ْ٤‬أُشػ‪ ٠‬اُ‪ٓ ٠‬غٔ‪ٞ‬ػبد ؽجوب ُالػشاع ‪ٝ‬االشؼبد ‪ٝ‬اُزؾبُ‪ٝ َ٤‬اُلئ‪ ٚ‬اُؼٔش‪ٝٝ ٚ٣‬ع‪ٞ‬د آشاع ٓضٓ٘‪ً ٚ‬بالر‪:٠‬‬
‫ٓغٔ‪ٞ‬ػ‪ ٚ‬هِ‪ ِٚ٤‬أُخبؽش ‪ ٠ٛٝ‬طـ‪٤‬ش‪ ٙ‬اُغٖ ‪٤ُٝ‬ظ ُذ‪ٜ٣‬ب آشاع ٓضٓ٘‪ ٚ‬ا‪ ٝ‬ربص‪٤‬ش ػِ‪ ٠‬اُشئ‪ٚ‬‬
‫ْزِ انًجًٕعّ يتى عالجٓا بعقاس ‪ Ivermectin‬أ ‪ Iverzin‬بجشعّ ثالثّ اقشاص جشعّ ٔاحذِ عهٗ يعذِ فاسغّ نًذِ ‪ 6‬اياو يتظهّ باالػافّ انٗ‬
‫‪ Azithromycin 500 mg‬كًؼاد نهفيشٔس ٔفٗ حانّ ٔجٕد تكسييش بانجسى يتى اعطاء انًشيغ ‪ Celecoxib 200 mg‬الَّ عالج يسكٍ نالنى ٔنّ دٔس فٗ‬
‫عالج انكٕسَٔا ٔسٕف اجًع فٗ َٓايّ انتقشيش االبحاث انًذعًّ نكاليٗ ْٔزا انبشٔتٕكٕل اقتظادٖ ٔسخيض بانُسبّ نهحاالت انغيش قادسِ ياديا ايا انحاالت‬
‫انقادسِ ياديا يًكٍ استبذال ‪ Iverzin‬بعقاس ‪ ْٕٔ (Avipiravir 200mg) Favipiravir‬عقاس يؼاد نهكٕسَٔا بجشعّ ‪ 8‬اقشاص كم ‪ 23‬ساعّ انيٕو االٔل ثى‬
‫‪ 4‬اقشاص كم ‪ 23‬ساعّ نًذِ يٍ ‪ 25- 7‬يٕو حسب انحانّ ٔاالعشاع ‪ٗ ٞٛٝ‬لظ اُجش‪ٝ‬ر‪ ًٍٞٞ‬اُز‪٣ ٟ‬غت اعزؼٔبُ‪ ٚ‬ك‪ ٠‬ؽبالد اُلئ‪ ٚ‬اُؼٔش‪ ٚ٣‬اٌُج‪٤‬ش‪ٝٝ ٙ‬ع‪ٞ‬د‬
‫آشاع ٓضٓ٘‪( ٚ‬ػـؾ ا‪ ٝ‬عٌش ا‪ ٝ‬آشاع هِت ا‪ ٝ‬ا‪ٝ‬ساّ ا‪ ٝ‬آشاع ًِ‪ٝ )٠‬ػذّ ‪ٝ‬ع‪ٞ‬د ربص‪٤‬ش سئ‪ٔ ٟٞ‬سٕف اسفق تقشيشٖ بجذٔل ادٔيّ انكٕسَٔا فٗ انحاالت‬
‫انخاطّ يثم قظٕس انكهيتيٍ ٔانحًم ٔانشػاعّ ٔصساعّ االعؼاء‪.‬‬
‫ٓغٔ‪ٞ‬ػ‪ ٚ‬هِ‪ ِٚ٤‬أُخبؽش ‪ ٠ٛٝ‬طـ‪٤‬ش‪ ٙ‬اُغٖ ‪٤ُٝ‬ظ ُذ‪ٜ٣‬ب آشاع ٓضٓ٘‪ُٝ ٚ‬ذ‪ٜ٣‬ب ربص‪٤‬ش ػِ‪ ٠‬اُشئ‪ ٖٓ ٚ‬خالٍ االشؼ‪ ٚ‬أُوطؼ‪Presence of Ground ( ٚ٤‬‬
‫‪:) Glass‬‬
‫ْزِ انًجًٕعّ يتى عالجٓا بعقاس ‪ Ivermectin‬أ ‪ Iverzin‬بجشعّ ثالثّ اقشاص جشعّ ٔاحذِ عهٗ يعذِ فاسغّ نًذِ ‪ 6‬اياو يتظهّ باالػافّ انٗ‬
‫‪ Azithromycin 500 mg‬كًؼاد نهفيشٔس ٔفٗ حانّ ٔجٕد تكسييش بانجسى يتى اعطاء انًشيغ ‪ Celecoxib 200 mg‬الَّ عالج يسكٍ نالنى ٔنّ دٔس فٗ‬
‫عالج انكٕسَٔا بانُسبّ نهحاالت انغيش ق ادسِ ياديا ايا انحاالت انقادسِ ياديا يًكٍ استبذال ‪ Iverzin‬بعقاس ‪ ْٕٔ (Avipiravir 200mg) Favipiravir‬عقاس‬
‫يؼاد نهكٕسَٔا بجشعّ ‪ 8‬اقشاص كم ‪ 23‬ساعّ انيٕو االٔل ثى ‪ 4‬اقشاص كم ‪ 23‬ساعّ نًذِ يٍ ‪ 25- 7‬يٕو حسب انحانّ ٔاالعشاع بانؼافّ انٗ‬
‫‪ )Tavanic 500( Levofloxacin 500 mg‬قشص يٕييا يٍ ‪ 6‬انٗ ‪ 21‬اياو ٔ ( ‪ )Ceftriaxon 1gm IM‬ايبٕل عؼم يٕييا نًذِ ‪ 7- 6‬اياو باالػافّ انٗ‬
‫)‪2.6 ) Dexamethasone 8mg‬سى عؼم يٕييا نًذِ ‪ 9‬اياو (‪ (Recovery Study‬باالػافّ انٗ (‪ ) Clexan‬تحت انجهذ حسب انٕصٌ طباحا ٔيساءا‬
‫حتٗ نٕ كاٌ تحهيم ال ‪ D Dimer‬ؽبيعٗ الٌ ٔجٕد ال ‪ Presence of Ground Glass‬يعتبش دنيم عهٗ ٔجٕد تجهطات طغيشِ ٔيتى اعطاء ادٔيّ انسيٕنّ‬
‫اسبٕع ‪ٔ .‬بعذ رنك يتى اعطاءْى عالج يتى بعذ انكٕسٌٔ ٔسٕف يزكش الحقا‪.‬‬
‫ٓغٔ‪ٞ‬ػ‪ ٚ‬هِ‪ ِٚ٤‬أُخبؽش ‪ً ٠ٛٝ‬ج‪٤‬ش‪ ٙ‬اُغٖ ‪٤ُٝ‬ظ ُذ‪ٜ٣‬ب آشاع ٓضٓ٘‪ُٝ ٚ‬ذ‪ٜ٣‬ب ربص‪٤‬ش ػِ‪ ٠‬اُشئ‪ ٖٓ ٚ‬خالٍ االشؼ‪ ٚ‬أُوطؼ‪Presence of Ground ( ٚ٤‬‬
‫‪:) Glass‬‬
‫ْزِ انًجًٕعّ يتى عالجٓا بعقاس ‪ ْٕٔ (Avipiravir 200mg) Favipiravir‬عقاس يؼاد نهكٕسَٔا بجشعّ ‪ 8‬اقشاص كم ‪ 23‬ساعّ انيٕو االٔل ثى ‪ 4‬اقشاص‬
‫كم ‪ 23‬ساعّ نًذِ يٍ ‪ 25- 7‬يٕو حسب انحانّ باالػافّ انٗ ‪ Azithromycin 500 mg‬كًؼاد نهفيشٔس ٔفٗ حانّ ٔجٕد تكسييش بانجسى يتى اعطاء انًشيغ‬
‫‪ Celecoxib 200 mg‬الَّ عالج يسكٍ نالنى ٔنّ دٔس فٗ عالج انكٕسَٔا باالػافّ انٗ ‪ )Tavanic 500( Levofloxacin 500 mg‬قشص يٕييا يٍ ‪6‬‬
‫انٗ ‪ 21‬اياو ٔ ( ‪ )Ceftriaxon 1gm IM‬ايبٕل عؼم يٕييا نًذِ ‪ 7- 6‬اياو باالػافّ انٗ )‪2.6 ) Dexamethasone 8mg‬سى عؼم يٕييا نًذِ ‪ 9‬اياو‬
‫(‪ (Recovery Study‬باالػافّ انٗ (‪ ) Clexan‬تحت انجهذ حسب انٕصٌ طباحا ٔيساءا حتٗ نٕ كاٌ تحهيم ال ‪ D Dimer‬ؽبيعٗ الٌ ٔجٕد ال‬
‫‪ Presence of Ground Glass‬يعتبش دنيم عهٗ ٔجٕد تجهطات طغيشِ ٔيتى اعطاء ادٔيّ انسيٕنّ اسبٕع ‪ٔ .‬بعذ رنك يتى اعطاءْى عالج يا بعذ انكٕسٌٔ‬
‫ٔسٕف يزكش الحقا‪.‬‬
‫ٓغٔ‪ٞ‬ػ‪ً ٚ‬ج‪٤‬ش‪ ٙ‬أُخبؽش ‪ً ٠ٛٝ‬ج‪٤‬ش‪ ٙ‬اُغٖ ‪ُ ٝ‬ذ‪ٜ٣‬ب آشاع ٓضٓ٘‪ُٝ ٚ‬ذ‪ٜ٣‬ب ربص‪٤‬ش ػِ‪ ٠‬اُشئ‪ ٖٓ ٚ‬خالٍ االشؼ‪ ٚ‬أُوطؼ‪Presence of Ground Glass( ٚ٤‬‬
‫)‪:‬‬
‫ْزِ انًجًٕعّ يتى عالجٓا بعقاس ‪ ْٕٔ (Avipiravir 200mg) Favipiravir‬عقاس يؼاد نهكٕسَٔا بجشعّ ‪ 8‬اقشاص كم ‪ 23‬ساعّ انيٕو االٔل ثى ‪ 4‬اقشاص‬
‫كم ‪ 23‬ساعّ نًذِ يٍ ‪ 25- 7‬يٕو حسب انحانّ أ غقاس (‪ ) Remedisvir‬بجشعّ ‪ 3‬ايبٕل بانٕسيذ أل يٕو ثى ايبٕل بانٕسيذ يٕييا نًذِ ‪ 21- 6‬اياو حسب‬
‫االستجابّ يع يشاعاِ يتابعّ ٔظائف انكبذ باالػافّ انٗ ‪ Azithromycin 500 mg‬كًؼاد نهفيشٔس ٔفٗ حانّ ٔجٕد تكسييش بانجسى يتى اعطاء انًشيغ‬
‫‪ Celecoxib 200 mg‬الَّ عالج يسكٍ نالنى ٔنّ دٔس فٗ عالج انكٕسَٔا باالػافّ انٗ ‪ )Tavanic 500( Levofloxacin 500 mg‬قشص يٕييا يٍ ‪6‬‬
‫انٗ ‪ 21‬اياو ٔ ( ‪ )Ceftriaxon 1gm IM‬ايبٕل عؼم يٕييا نًذِ ‪ 7- 6‬اياو باالػافّ انٗ )‪2.6 ) Dexamethasone 8mg‬سى عؼم يٕييا نًذِ ‪ 9‬اياو‬
‫(‪ (Recovery Study‬باالػافّ انٗ (‪ ) Clexan‬تحت انجهذ حسب انٕصٌ طباحا ٔيساءا حتٗ نٕ كاٌ تحهيم ال ‪ D Dimer‬ؽبيعٗ الٌ ٔجٕد ال‬
‫‪ Presence of Ground Glass‬يعتبش دنيم عهٗ ٔجٕد تجهطات طغيشِ ٔيتى اعطاء ادٔيّ انسيٕنّ اسبٕع ٔيًكٍ استعًال ادٔيّ ( ‪JACK inhibitors‬‬
‫‪ٔ .)orally‬بعذ رنك يتى اعطاءْى عالج يتى بعذ انكٕسٌٔ ٔسٕف يزكش الحقا‪.‬‬
 :‫ٗب‬ٝ‫س‬ٌُٞ‫ػالط ٓب ثؼذ ا‬
:‫ شٕٓس‬4 ٗ‫نًُع حذٔث تهيف بانشئّ أ تقهيم َسبّ انتهيف كُا َعطٗ انًشػٗ انعالج انتانٗ نًذِ يٍ شٓش ان‬
1- Colchecin 500 mg tab (1 tablet daily).
2- Predisolon 5 mg tab. (2 Tablets daily single morning dose).
3- Lanzoprazol 40 mg tab.( Tablets daily single morning dose).
4- Rivaroxipan 10 mg once daily or Abixipan 2.5 mg twice daily.
:ٚ٣ٝ‫ اعزؼٔبٍ ثؼغ االد‬٠ِ‫ثؼغ أُالؽظبد ػ‬
:٠‫ االر‬ٚ‫ٗب رْ ٓالؽظ‬ٝ‫س‬ًٞ ٠‫اص٘بء ػالط ٓشػ‬
‫) كًا سبق ٔركشَا ايا انحاالت رات يستٕٖ اكسجيٍ بانذو تحت‬Dexamethasone( ‫ أ اعهٗ تستجيب جيذا اليبٕالت ال‬% 95 ‫اٌ انحاالت رات يستٕٖ اكسجيٍ بانذو‬ -2
.‫ اياو‬21- 6 ِ‫ يجى ٔسيذ طباحا ٔيساءا نًذ‬61 ّ‫) بجشع‬Methylprednsiolon( ‫ فتستجيب افؼم اليبٕالت‬%95
‫اٌ يشػٗ انسكش يشتفع يستٕٖ انسكش بشكم كبيش يًا يجعم انًشيغ اكثش عشػّ نهًؼاعفات ٔنزا اَظح بُقم انًشيغ انٗ االَسٕنيٍ نحيٍ استقاس انحانّ ٔخاطّ ٔجٕد‬ -3
.‫) باالػافّ انٗ انتٕتش انُفسٗ انزٖ يحذثّ انًشع‬Dexamethasone( ‫ادٔيّ يثم‬
‫) الٌ انًشيغ يبذٔ يعاف ٔاالكسجيٍ ؽبيعٗ ٔنكٍ عُذ ٔػع انسًاعّ عهٗ ظٓش انًشيغ تجذ ال‬Silent Killer( )‫انًٕجّ انثانثّ يًكٍ اٌ َطهق عهيٓا (انقاتم انظايت‬ -4
.‫) نزا ال َتشدد فٗ ؽهب االشعّ انًقطعيّ ْٔزا نيس يشتبؾ بسٍ يعيٍ نتحذيذ انبشٔتٕكٕل انًُاسب‬Crepitation(
.ِ‫انفيشٔس اطبح شذيذ االَتشاس ٔخاطّ داخم االسشِ انٕاحذ‬ -5
Some notes about commonly used drugs:
Vitamin D:

There are insufficient data to recommend either for or against the use of vitamin D for the prevention or treatment of
COVID-19. General Information Vitamin D is critical for bone and mineral metabolism. Because the vitamin D receptor
is expressed on immune cells such as B cells, T cells, and antigen-presenting cells, and because these cells can synthesize
the active vitamin D metabolite, vitamin D also has the potential to modulate innate and adaptive immune responses. In
observational studies, low vitamin D levels have been associated with an increased risk of community-acquired
pneumonia in older adults and children. Vitamin D supplements may increase the levels of T regulatory cells in healthy
individuals and patients with autoimmune diseases; vitamin D supplements may also increase T regulatory cell activity.
The rationale for using vitamin D is based largely on immunomodulatory effects that could potentially protect against
COVID-19 infection or decrease the severity of illness.
Zinc
Rationale Increased intracellular zinc concentrations efficiently impair replication in a number of RNA viruses. Zinc has
been shown to enhance cytotoxicity and induce apoptosis when used in vitro with a zinc ionophore (e.g., chloroquine).
Chloroquine has also been shown to enhance intracellular zinc uptake in vitro. The relationship between zinc and COVID-
19, including how zinc deficiency affects the severity of COVID-19 and whether zinc supplements can improve clinical
outcomes, is currently under investigation. The doses used in registered clinical trials for patients with COVID-19 vary
between studies, with a maximum dose of zinc sulfate 220 mg (50 mg of elemental zinc) twice daily. However, there are
currently insufficient data to recommend either for or against the use of zinc for the treatment of COVID-19. Long-term
zinc supplementation can cause copper deficiency with subsequent reversible hematologic defects (i.e., anemia,
leukopenia) and potentially irreversible neurologic manifestations (i.e., myelopathy, paresthesia, ataxia, spasticit y).6,7
The use of zinc supplementation for durations as short as 10 months has been associated with copper deficiency. In
addition, oral zinc can decrease the absorption of medications that bind with polyvalent cations. Because zinc has not been
shown to have a clinical benefit and may be harmful, the Panel recommends against using zinc supplementation above the
recommended dietary allowance for the prevention of COVID-19
Nonsteroidal Anti-Inflammatory Drugs
Cyclooxygen-ase-2 (COX2) inhibition (Celebrex 200) :
Excessive prostaglandin E2 (PGE2) produced by cyclooxygenase-2 was a key pathological event of COVID-19. The
clinical study indicates that Celebrex adjuvant treatment promotes the recovery of all types of COVID-19 and further
reduces the mortality rate of elderly and those with comorbidities. The patients in experimental group were treated with
Celebrex (celecoxib, Pfizer, Dalian, China) in combination with routine treatments suggested by the guideline. The usage
and dose of Celebrex was once or twice a day (0.2 g/time) for 7–14 days by oral. The dosage or duration of medication
was subject to change based on each individual case.
Risk factors for severe disease
Epidemiological
Age > 55 years
- Patients of any age with underlying medical conditions, particularly if not well controlled, including:

ase
- Immunocompromised patients, including cancer treatment, smoking, bone marrow or organ transplantation, immune deficiencies,
poorly controlled HIV infection , and prolonged use of corticosteroids and other immunosuppressants
- Use of biologics
Vital Signs
- Body mass index ≥ 30 kg/m2.
-Respiratory rate > 24 breaths/min
- Heart rate > 125 beats/min
- SpO2 ≤ 93% on ambient air
- PaO2/FiO2 < 300 mmHg
Labs:
- D-dimer > 1ng/L
- CPK > 2 times upper limit of normal
- CRP > 100 mg/L
- LDH > 245 U/L
- Elevated troponin
- Absolute lymphocyte count < 0.8x109 cells/L
- Ferritin > 600n g/L
 ‫اُز‪ٞ‬ط‪٤‬بد ٓذح اُؼضٍ ‪ٝ‬االؽز‪٤‬بؽبد‬
‫ثبُ٘غجخ ُٔؼظْ اُجبُـ‪ ٖ٤‬أُظبث‪ ٖ٤‬ثٔشع ‪ ٌٖٔ٣ ، COVID-19‬إ‪٣‬وبف اُؼضٍ ‪ٝ‬االؽز‪٤‬بؽبد ثؼذ ‪ 16‬أ‪٣‬بّ ٖٓ ظ‪ٜٞ‬س األػشاع * ‪ٝ‬ثؼذ ص‪ٝ‬اٍ اُؾٔ‪ُٔ ٠‬ذح ‪ 24‬عبػخ ػِ‪ ٠‬األهَ ‪ ،‬د‪ ٕٝ‬اعزخذاّ‬
‫األد‪٣ٝ‬خ اُخبكؼخ ُِؾٔ‪ٓٝ ، ٠‬غ رؾغٖ األػشاع األخش‪.ٟ‬‬
‫هذ ‪٘٣‬زظ ػٖ ثؼغ اُ جبُـ‪ ٖ٤‬أُظبث‪ ٖ٤‬ثٔشع خط‪٤‬ش ك‪٤‬ش‪ٝ‬ط هبدس ػِ‪ ٠‬اُزٌبصش ألًضش ٖٓ ‪ 16‬أ‪٣‬بّ ٓٔب هذ ‪٣‬زطِت رٔذ‪٣‬ذ كزشح اُؼضٍ ‪ٝ‬االؽز‪٤‬بؽبد ُٔذح رظَ إُ‪ًٓ ٞ٣ 26 ٠‬ب ثؼذ ظ‪ٜٞ‬س األػشاع ؛‬
‫ً‬
‫ٓؤ‪ٛ‬ال ُِزٌبصش ألًضش ٖٓ ‪ًٓ ٞ٣ 26‬ب ‪٣ٝ‬زطِج‪ ٕٞ‬اخ زجبساد إػبك‪٤‬خ ‪ٝ‬اعزشبسح ٓغ ٓزخظظ‪ ٢‬األٓشاع أُؼذ‪٣‬خ ‪ٝ‬خجشاء ٌٓبكؾخ‬ ‫عب‬
‫أُشػ‪ ٠‬اُز‪٣ ٖ٣‬ؼبٗ‪ٗ ٖٓ ٕٞ‬وض أُ٘بػخ اُشذ‪٣‬ذ ** هذ ‪٘٣‬زغ‪ ٕٞ‬ك‪٤‬ش‪ً ٝ‬‬
‫اُؼذ‪.ٟٝ‬‬
‫ثبُ٘غجخ ُِجبُـ‪ ٖ٤‬اُز‪ ٖ٣‬ال رظ‪ٜ‬ش ػِ‪ ْٜ٤‬األػشاع ٓطِوًب ‪ ٌٖٔ٣ ،‬إ‪٣‬وبف اُؼضٍ ‪ٝ‬االؽز‪٤‬بؽبد األخش‪ ٟ‬ثؼذ ‪ 16‬أ‪٣‬بّ ٖٓ ربس‪٣‬خ أ‪ٗ ٍٝ‬ز‪٤‬غخ إ‪٣‬غبث‪٤‬خ الخزجبس ‪ُ RT-PCR‬ـ ‪.SARS-CoV-2 RNA‬‬
‫د‪ٝ‬س اخزجبس اُزشخ‪٤‬ض اُل‪٤‬ش‪ٝ‬ع‪ RT-PCR( ٢‬أ‪ ٝ‬أُغزؼذ) *** ُ‪ٞ‬هق اُؼضٍ أ‪ ٝ‬االؽز‪٤‬بؽبد‬
‫ثبُ٘غجخ ُِجبُـ‪ ٖ٤‬اُز‪٣ ٖ٣‬ؼبٗ‪ٗ ٖٓ ٕٞ‬وض أُ٘بػخ اُشذ‪٣‬ذ ‪ ٌٖٔ٣ ،‬اُزلٌ‪٤‬ش ك‪ ٢‬اعزشار‪٤‬غ‪٤‬خ هبئٔخ ػِ‪ ٠‬االخزجبس ثبُزشب‪ٝ‬س ٓغ خجشاء األٓشاع أُؼذ‪٣‬خ‪.‬‬
‫ثبُ٘غجخ ُغٔ‪٤‬غ ا‪٥‬خش‪٣ ُْ ، ٖ٣‬ؼذ ُ‪٘٣‬ظؼ ثبعزشار‪٤‬غ‪٤‬خ هبئٔخ ػِ‪ ٠‬االخزجب س ثبعزض٘بء اُز‪ٞ‬هق ػٖ اُؼضٍ أ‪ ٝ‬االؽز‪٤‬بؽبد ك‪ٝ ٢‬هذ أثٌش ٓٔب هذ ‪٣‬ؾذس ك‪ ٢‬ظَ االعزشار‪٤‬غ‪٤‬خ أُ‪ٞ‬ػؾخ ك‪ ٢‬اُغضء ‪ 1‬أػال‪.ٙ‬‬
‫اخزجبس اُزشخ‪٤‬ض اُل‪٤‬ش‪ٝ‬ع‪ RT-PCR( ٢‬أ‪ ٝ‬أُغزؼذ) *** ‪ٝ‬اُؾغش اُظؾ‪ ٢‬ثؼذ اُز‪ٞ‬هق ػٖ اُؼضٍ أ‪ ٝ‬االؽز‪٤‬بؽبد‬
‫ثبُ٘غجخ ُِجبُـ‪ ٖ٤‬اُز‪ ٖ٣‬رْ رشخ‪٤‬ظ‪ ْٜ‬عبث ًوب ثأػشاع ‪ COVID-19‬أُؤًذح ٓخزجش‪ً٣‬ب ‪ٝ‬اُز‪٣ ٖ٣‬ظِ‪ ٕٞ‬ثذ‪ ٕٝ‬أػشاع ثؼذ اُشلبء ‪ ،‬ال ‪ٞ٣‬ط‪ ٠‬ثئػبدح االخزجبس أ‪ ٝ‬اُؾغش اُظؾ‪ ٢‬ك‪ ٢‬ؽبُخ ؽذ‪ٝ‬س‬
‫رؼشع آخش أ‪ ٝ‬سثٔب ؽذس ك‪ ٢‬ؿؼ‪ًٓ ٞ٣ 86 ٕٞ‬ب ثؼذ ربس‪٣‬خ ظ‪ٜٞ‬س األػشاع ٖٓ اإلطبثخ األ‪٤ُٝ‬خ ثـ ‪. SARS-CoV-2‬‬
‫ثبُ٘غجخ ُِجبُـ‪ ٖ٤‬اُز‪ ٖ٣‬رظ‪ٜ‬ش ػِ‪ ْٜ٤‬أػشاع عذ‪٣‬ذح رزلن ٓغ ‪ COVID-19‬خالٍ ‪ًٓ ٞ٣ 86‬ب ثؼذ ربس‪٣‬خ ظ‪ٜٞ‬س األػشاع األ‪ ، ٢ُٝ‬إرا رؼزس ػِ‪ٓ ٠‬وذّ اُشػب‪٣‬خ اُظؾ‪٤‬خ رؾذ‪٣‬ذ أُغججبد اُجذ‪ِ٣‬خ‬
‫ثغ‪ُٜٞ‬خ ‪ ،‬كٖٔ أُؾزَٔ إٔ ‪٣‬غزذػ‪ ٢‬اُجبُؾ إػبدح االخزجبس‪ٞ٣ .‬ط‪ ٠‬ثبُزشب‪ٝ‬س ٓغ خجشاء األٓشاع أُؼذ‪ ٣‬خ أ‪ٌٓ ٝ‬بكؾخ اُؼذ‪ ، ٟٝ‬خبطخ ك‪ ٢‬ؽبُخ ظ‪ٜٞ‬س األػشاع ك‪ ٢‬ؿؼ‪ًٓ ٞ٣ 14 ٕٞ‬ب ثؼذ االرظبٍ‬
‫اُ‪ٞ‬ص‪٤‬ن ثشخض ٓظبة ثل‪٤‬ش‪ٝ‬ط ‪٣ . SARS-CoV-2‬غت ػضٍ اُجبُـ‪ ٖ٤‬اُز‪٣ ٖ٣‬زْ رو‪ ْٜٔ٤٤‬إلػبدح اُؼذ‪ ٟٝ‬ثل‪٤‬ش‪ٝ‬ط ‪ SARS-CoV-2‬أ‪ ٝ‬أ‪ ١‬ػذ‪ ٟٝ‬ر٘لغ‪٤‬خ ٓؾزِٔخ اُؼذ‪ ٟٝ‬ثٔ‪ٞ‬عت االؽز‪٤‬بؽبد‬
‫أُ‪ٞ‬ط‪ ٠‬ث‪ٜ‬ب هجَ اُزو‪ٝ ْ٤٤‬أص٘بء‪ .ٙ‬إرا رْ رأً‪٤‬ذ اإلطبثخ ٓشح أخش‪ ٟ‬أ‪ ٝ‬ظَ ٓشزج ً‪ٜ‬ب ث‪ٜ‬ب ‪ ،‬ك‪٤‬غت إٔ ‪٣‬ظِ‪ٞ‬ا رؾذ كزشح ػضٍ ‪ SARS-CoV-2‬أُ‪ٞ‬ط‪ ٠‬ث‪ٜ‬ب ؽز‪٣ ٠‬غز‪ٞ‬ك‪ٞ‬ا ٓؼب‪٤٣‬ش اُز‪ٞ‬هق ػٖ االؽز‪٤‬بؽبد‬
‫‪ -‬ثبُ٘غجخ ُٔؼظْ اُجبُـ‪ ، ٖ٤‬ع‪ٛ ٌٕٞ٤‬زا ثؼذ ‪ 16‬أ‪٣‬بّ ٖٓ ظ‪ٜٞ‬س األػشاع ‪ٝ‬ثؼذ ص‪ٝ‬اٍ اُؾٔ‪ ٠‬ك‪ 24 ٢‬عبػخ ػِ‪ ٠‬األهَ ‪ ،‬د‪ ٕٝ‬اعزخذ اّ األد‪٣ٝ‬خ اُخبكؼخ ُِؾٔ‪ٓٝ ، ٠‬غ رؾغٖ األػشاع األخش‪.ٟ‬‬
‫ثبُ٘غجخ ُِجبُـ‪ ٖ٤‬أُظبث‪ ٖ٤‬ثل‪٤‬ش‪ٝ‬ط ‪ SARS-CoV-2‬أُؤًذ ٓخزجش‪ً٣‬ب ‪ٝ‬اُز‪ ُْ ٖ٣‬رظ‪ٜ‬ش ػِ‪ ْٜ٤‬أػشاع ٓطِوًب ‪ٝ‬رؼشػ‪ٞ‬ا الؽوًب أ‪ ٝ‬رؼشػ‪ٞ‬ا الؽوًب ‪٣ ،‬غت إٔ ‪ ٌٕٞ٣‬ربس‪٣‬خ أ‪ٗ ٍٝ‬ز‪٤‬غخ اخزجبس رشخ‪٤‬ض‬
‫ك‪٤‬ش‪ٝ‬ع‪ ٢‬إ‪٣‬غبث‪ RT-PCR( ٢‬أ‪ٓ ٝ‬غزؼذ) ُـ ‪ SARS-CoV-2‬رغزخذّ ثذالً ٖٓ ربس‪٣‬خ ظ‪ٜٞ‬س األػشاع ُزؾذ‪٣‬ذ اُلزشح اُلبطِخ ث‪ ٖ٤‬اإلطبثخ اُغبثوخ ‪ٝ‬اُزؼشع األخ‪٤‬ش‪ ٌٖٔ٣ .‬ثؼذ رُي اعزخذاّ ‪ٛ‬زا‬
‫اُلبطَ اُضٓ٘‪ ٢‬إلثالؽ اُوشاساد ؽ‪ ٍٞ‬اخزجبس اُزؼشع األخ‪٤‬ش‪.‬‬
‫‪٣‬غت اخزجبس اُجبُـ‪ ٖ٤‬اُز‪ُ ٖ٣‬ذ‪ ْٜ٣‬ربس‪٣‬خ عبثن ٖٓ األػشاع أُز‪ٞ‬اكوخ ٓغ ‪ُ ٌٖ٣ ُْ ٌُٖٝ COVID-19‬ذ‪ ْٜ٣‬رأً‪٤‬ذ ٓخزجش‪ُ ١‬ـ ‪ COVID-19‬ثبخزجبس رشخ‪٤‬ض ك‪٤‬ش‪ٝ‬ع‪ RT-PCR( ٢‬أ‪ٓ ٝ‬غزؼذ)‬
‫‪ٝ‬اُز‪ ٖ٣‬رظ‪ٜ‬ش ػِ‪ ْٜ٤‬أػشاع عذ‪٣‬ذح رز‪ٞ‬اكن ٓغ ‪٣ٝ COVID-19‬خؼغ ُِؾغش اُظؾ‪.٢‬‬
‫ثبُ٘غجخ ُألؽلبٍ ‪ٝ‬اُشػغ ‪ ،‬كئٕ اُج‪٤‬بٗبد أُزؼِوخ ثخطش اإلطبثخ ٓشح أخش‪ ٟ‬ك‪ ٢‬ؿؼ‪ًٓ ٞ٣ 86 ٕٞ‬ب ثؼذ اُزشخ‪٤‬ض أُؤًذ ٓخزجش‪ً٣‬ب ٓؾذ‪ٝ‬دح ُِـب‪٣‬خ‪ٓٝ .‬غ رُي ‪ ،‬ك‪ ٢‬ع‪٤‬بم اُ‪ٞ‬ثبء ‪٘٣ ،‬جـ‪ ٢‬اُزؼبَٓ ٓغ‬
‫األؽلبٍ ‪ٝ‬اُشػغ ػِ‪ ٠‬اُ٘ؾ‪ ٞ‬أُ‪ٞ‬ط‪ ٠‬ث‪ُِ ٚ‬جبُـ‪ ٖ٤‬أػال‪ .ٙ‬ع‪ٞ٤‬اطَ ٓشًض اُغ‪٤‬طشح ػِ‪ ٠‬األٓشاع (‪ٓ ) CDC‬شاهجخ رط‪ٞ‬س اُؼِْ ػٖ ًضت ُِؾظ‪ ٍٞ‬ػِ‪ٓ ٠‬ؼِ‪ٓٞ‬بد ٖٓ شأٗ‪ٜ‬ب إٔ رجشس إػبدح اُ٘ظش ك‪٢‬‬
‫‪ٛ‬ز‪ ٙ‬اُز‪ٞ‬ط‪٤‬بد ُ‪ٜ‬ز‪ ٙ‬اُلئخ ٖٓ اُغٌبٕ‪.‬‬
 Drug Dosing Guideline for COVID-19 Patients with Pregnancy
Drug Dose
Clexan(Enoxaparin) T: 1mg/kg SUBQ Q12H
P: 40 mg once per day* SQ
Unfractionated heparin 10.000-15.000 U once per day
Nitazoxanide 600 mg bid PO for 5 days
Azithromycin 500 mg once per day PO for 5 days No adjustment
Hydroxychloroquine 200 mg q12h for 10 days
Chloroquine Day 1: 450 mg bid PO Days 2 to 5: 450 mg once per day PO
Lopinavir/ritonavir 400 mg/100 mg once per day PO for 10-14 days
Remdesivir Day 1: 200 mg once per day IV Remdesivir can be given in pregnancy if the benefits outweigh the potential
Days 2 to 5 or 10: 100 mg once risks. Discussion with UKTIS is recommended to discuss the clinical
circumstances around each individual case.
Colchicine 1 tablet 3 time daily
Tocilizumab 8 mg/kg (maximum of 800 mg) IV single dose, Tocilizumab is currently offered for COVID-19
can be repeated 1-2 times if there is no clinical treatment as part of the RECOVERY trial,[8] which
improvement within 24 hours No adjustment pregnant women are eligible to enter. Whilst there are
currently no major concerns about the use of tocilizumab
in pregnancy, discussion with UKTIS is recommended.
Dexamethasone Contraindication dexamethasone crosses the placenta.
hydrocortisone 80mg intravenously twice daily
prednisolone 40mg orally once daily
Zinc 50 mg of zinc
Vitamin C 1 gm. twice daily
Rivaroxaban Contraindication
Apixaban Contraindication
Ivermectin Contraindication
Paracetamol 1 tablet every 6 hours
Alessandro Favillia , Marta Mattei Gentilib, Francesca Raspab, Irene Giardinab, Fabio Parazzinic , Amerigo Vitaglianod, Anna V.
Borisovae and Sandro Gerlib: Effectiveness and safety of available treatments for COVID-19 during pregnancy: a critical review:
The Journa of Maternal –Fetal & Neonatal Medicine.
 Drug Dosing Guideline for Adult COVID-19 Lactating Patients
Rivaroxaban 15mg - 20mg/24h
Apixaban Contraindication
Clexan(Enoxaparin) 40 mg once per day* SQ
Unfractionated heparin 10.000-15.000 U once per day No adjustment Not dialyzable
Nitazoxanide 600 mg bid PO for 5 days
Azithromycin 500 mg once per day PO for 5 days No adjustment
Hydroxychloroquine 200 mg q12h
Chloroquine Day 1: 450 mg bid PO Days 2 to 5: 450 mg once per day PO
Lopinavir/ritonavir 400 mg/100 mg once per day PO for 10-14 days
Remdesivir Day 1: 200 mg once per day IV Days 2 to 5 or 10: 100 mg once
Favipiravir contraindicated
Tocilizumab 8 mg/kg (maximum of 800 mg) IV single dose, can be repeated 1-2
Dexamethasone Contraindication.
Hydrocortisone Contraindication.
Methylprednisolone 1-2 mg/kg once per day for 5-7 days
Ivermectin 1 Tablet for every 30 kg body weight single dose, can be repeated on day 7 (Prophylaxis)
2 tablets before each meal (6 tablets) day 0, 3,6 (Treatment)
Zinc 50 mg of zinc
Vitamin C 1 twice daily
‫ب‬٤ُ٘ٔ‫ ا‬ٚ‫ عبٓؼ‬٠ٌُِ‫ا‬ٝ ٚ٘‫ اعزبر اُجبؽ‬ٟٝ‫س ٓؾٔذ أؽٔذ شؼشا‬ٞ‫ االعزبر اُذًز‬ٚ‫اعط‬ٞ‫ٓبد ث‬ِٞ‫غ أُؼ‬٤ٔ‫رْ رغ‬
Treatments considered for COVID-19. Med Lett Drugs Ther 2020. Available at https://secure.medicalletter.org/downloads/ 1595e_table.pdf (accessed
September 2, 2020).
Wiesen MH, Blaich C, Muller C, et al. The direct factor Xa inhibitor rivaroxaban passes into human breast milk. Chest. 2016;150:e1–4.
Suggested proposal for immunosuppressive medications modulations in COVID-19 infected kidney transplant recipients.
No Lung Infiltrate
<60 years >60 years
– Maintain, do not change the immunosuppressive treatment. Suspend MMF and maintain with tacrolimus1 (levels 4–6 ng/mL) and
– If you start treatment with hydroxychloroquine, decrease the dose of prednisone (usual dose, do not go up to 20 mg)
tacrolimus and iMTOR by 20% of entry (due to the interactions between
tacrolimus and iMTOR and chloroquine) and then always monitor levels
every 48 h and maintain tacrolimus levels: 4–6 ng/mL
With Lung Infiltrate
without hypoxemia and fever without hypoxemia and fever with hypoxemia and fever <60 with hypoxemia and fever >60
<60 years >60 years years years
Discontinue MMF only. Maintain Discontinue MMF, reduce 1. – Discontinue tacrolimus and 1. – Discontinue tacrolimus and
with tacrolimus1 (levels 4–6 tacrolimus1 to levels of 3–5 ng/mL MMF (or iMTOR) and maintain MMF (or iMTOR) and maintain
ng/mL) and prednisone 20 mg daily and maintain prednisone (usual only with prednisone 20 mg a day only with prednisone 20 mg a day
dose, do not go up to 20 mg) for the first 4 days. for the first 4 days.
2. – After the 5th day of admission, 2. – After the 5th dayof admission,
if there is clinical improvement if the patient improves (does not
(he/she does not have a fever and have a fever and does not need
does not need oxygen): resume tacrolimus1 to
Oxygen): resume tacrolimus1 to maintain levels of 3–5 ng/mL
maintain levels of 4–6 ng/mL associated with prednisone of 20
associated with prednisone of 20 mg.
mg. 3. – After the 5th day, if the clinical
3. – After the 5th day of admission, situation does not improve (persists
if the clinical situation is not fever or requires oxygen), maintain
improved (persists fever or requires only with prednisone 20 mg/day.
oxygen), maintain only with Tacrolimus will be started again as
prednisone 20 mg/day. Tacrolimus in point 2 when the patient
will be started again as in point 2 improves.
when 1 – If you start or are already on
the patient improves. hydroxychloroquine, decrease the
dose of tacrolimus and iMTOR by
20% of entry (due to the
interactions between Tacrolimus
and iMTOR with chloroquine)
Patients who have been in contact with Start with hydroxychloroquine 200 mg every 12 h for 5 days. Reduce tacrolimus or iMTOR doses by 20% during
a case of coronavirus no symptoms these days and then return to the usual dose. Maintain unchanged the rest of immunosuppression
 Management of Covid-19 in renal Transplanted Patients
Azathioprine Cyclosporine Mycophenolate Tacrolimus Sirolimus
Lopinavir/ritonavir ↔ ↑ ↓↑ ↑ ↑
Remdesivir ↔ ↔ ↔ ↔ ↔
Favipavir ↔ ↔ ↔ ↔ ↔
Nitazoxanide ↔ ↔ ↔ ↔ ↔
Hydroxychloroquine ↔ ↑ ↔ ↑ ↑
Ribavirin ↑ ↔ ↔ ↔ ↔
Rivaroxaban
Apixaban
Clexan(Enoxaparin)
Unfractionated heparin
Baricitimib
Azithromycin
Tocilizumab
Dexamethasone
Methylprednisolone
Ivermectin
Zinc
Vitamin C
↑= potential increased exposure ↓ = potential increased exposure ↔ = No significant effect
No drug interaction Potential drug interaction need dose adjustment These drugs shouldn’t administrated together
 1- Tacrolimus doses could be maintained on the same doses if the patient is not severely ill. Decreased or halved in critically ill patients.
2- Precautions must be taken regarding tacrolimus, cyclosporine, and sirolimus trough levels when administering hydroxychloroquine
or RTV. Antiproliferative medications are supposed to be suspended during illness
3- Sanchez and colleagues suggest cyclosporine A as a treatment of COVID-19 and to be tested in randomized clinical trials owing to
its protective effect against COVID-19-induced cytokine storm in patients with COVID-19.
4- Belatacept causes blockade of massive cytokine/ chemokine production. So, infected patients receiving belatacept showed mild
symptoms.
5- To decrease nosocomial infection during outbreaks, some suggest giving belatacept monthly.
6- belatacept was replaced with cyclosporine A during outbreaks.
7- Sirolimus should be suspended during COVID-19 outbreaks, as it may cause pneumonitis, which could be misdiagnosis as
suspicious for COVID-19.
8- All immunosuppressive medications should be suspended in critical ill patients.

General recommendations for kidney transplant patients

1. Maintain adequate hygiene. Wash your hands frequently with soap and water for at least 20 s, or with an
alcohol based hand sanitizer (at least 60% alcohol), especially: after using the bathroom, before eating, after
blowing, coughing or sneezing and after direct contact with sick people or their surroundings. Avoid
touching your eyes, nose and mouth before washing your hands.
2. Cleaning of house surfaces should be done regularly. Clean and disinfect frequently touched objects and
surfaces.
3. Avoid contact or maintain a distance of at the least two meters with people with respiratory infection
symptoms (fever, cough, generalized sore muscle, sore throat or respiratory difficulty) and do not share
personal belongings.
4. During the state of alarm, you must remain at home except for the stipulated exceptions, according to the
rules established by the political and health authorities. Phone the kidney transplant clinic at your referral
center or the phone numbers authorized by the health authorities.
5. Try to follow a correct diet. Avoid smoking and alcohol. In addition to being harmful to health, these
substances weaken the immune system, making the body more vulnerable to infectious diseases.
6. Avoid sharing food and utensils (cutlery, glasses, napkins, handkerchiefs, etc.) and other objects without
cleaning them properly.
7. The Centers for Disease Control and Prevention and (CDC): does not recommend to the general
population that people who are well to wear a face mask to protect himself from respiratory diseases,
including COVID-19. Today, the kidney transplant population must comply with the recommended
measures of protection in the general population, especially if they are asymptomatic at home. However, the
responsible physicians will recommend the use of a mask on an individual basis, mainly in cases where the
patient goes to a health center or other place with agglomeration. People who show symptoms of being
infected with SARS-CoV-2 should wear masks to prevent the spread of the disease to others.
8. It would advisable to authorize a sick leave in patients whose profession entails a high risk for infection.
References

1- Ahmed Y. Elmowafy, Ahmed A.-F. Denewar, Mohamed E. Mashaly,Mohamed Osama, Ahmed F. Donia, Ayman F.
Refaie, Hussein A. Sheashaa: COVID-19 and kidney transplantation: how to face the disaster? Journal of The
Egyptian Society of Nephrology and Transplantation, Vol. 20 No. 4, October-December 2020.

2- Verónica Lópeza, Teresa Vázqueza, Juana Alonso-Titos a, Mercedes Cabelloa, Angel Alonsob, Isabel Beneytoc,
Marta Crespod, Carmen Díaz-Corted, Antonio Francoe, Francisco González-Roncerof, Elena Gutiérreza, Luis
Guiradog, Carlos Jiménezh, Cristina Jirondaa, Ricardo Lauzuricai, Santiago Llorentej, Auxiliadora Mazuecosk,
Javier Paull, Alberto Rodríguez-Benotm, Juan Carlos Ruizn, Ana Sánchez-Fructuosoo,Eugenia Solaa, Vicente
Torregrosap, Sofía Zárragaq, Domingo Hernández: Recommendations on management of the SARS-CoV-2
coronavirus pandemic (Covid-19) in kidney transplant patients; n e f r o l o g i a. 2 0 2 0;4 0(3):265–271.
Prepared by prof. Dr. Mohamed Ahmed Sharawy Prof. of int. Med. and Nephrology Minia University.