COVID-19: Guidelines of drugs for home therapy situations

An annotated guide to the Guidelines for Home Treatment of SARS-CoV-2 infections - by Dr Carla Bruschelli

A summary to the Guidelines for Home Treatment of SARS-CoV-2 infections - by Dr Carla Bruschelli

This article is a translation from the original post COVID-19: i farmaci per la terapia domiciliare, done by our partners from esanum.it. You can also visit the German translation of this article by our partners at esanum.de.

Dr. Carla Bruschelli, a General Practitioner specialising in Internal Medicine and Pharmacology, has summarised the main guidelines on COVID-19 home therapy issued until late November by the World Health Organization (WHO), the US' National Institutes of Health (NIH) and the UK’s National Institute for Health and Care Excellence (NICE). The tables below are intended as an aid to colleagues involved in patient care but are also an invitation to continually update their knowledge and clinical practice using appropriate tools to improve the quality of the patient care we provide.

Medicine is an evolving practice based on the scientific method

At the end of 2019, an unknown and highly contagious virus appeared in China, causing severe pneumonia in patients that required intensive treatment. Within a few weeks, the whole world, and primarily the scientific community, was confronted with a novel virus and disease, which in its severe forms was difficult to treat and for which there was no effective therapy.

On 31 December 2019, Chinese authorities announced an outbreak in Wuhan, China, of a pneumonia from an unknown agent that was eventually isolated by Chinese scientists by 9 January 2020. On 12 February 2020, the International Committee on Taxonomy of Viruses (ICTV) assigned the virus the name SARS-CoV-2.

Almost two years later, knowledge about the virus and the disease has increased. Diagnostic and therapeutic protocols have been developed. Above all, effective vaccines have been developed that can reduce, and in many cases eliminate, the effects of infection. Considerable progress has been made, but there is certainly still a long way to go.

The first months of the pandemic, at the beginning of 2020, were characterised by uncertainties, and the first therapeutic interventions were based on empirical knowledge. From the therapeutic point of view, the recommendations of the international monitoring institutions followed a cautious evolution, pending the results of the various studies that had been activated. At that time, there was an attempt from several corners of the world to shatter the cardinal principles of the scientific method, especially the experimental verification of the hypotheses formulated, all following the belief that “if it worked with my patient, it´ll work on others”. One thinks, for example, of the cases of chloroquine and hydroxychloroquine, or that of hyperimmune plasma. If this was understandable, though not justifiable, in the early 2020s, this is totally unacceptable today.

International and national guidelines for the treatment of SARS-CoV-2 infection are now based on solid studies and increasingly robust evidence. While still in flux, they represent a valuable tool for the management of COVID-19 patients. And at present, the only scientifically valid one.

In the Italian context (as in many other parts of the world), especially regarding home-based care, the phenomenon of administering therapy that does not comply with the guidelines and recommendations for COVID-19 patients is still alive. So much so that, in a quasi-organised way, committees have been set up to support home care for COVID-19 patients that all too often may have no scientific basis, and may also disregard basic principles of drug administration, including in-depth knowledge of the patient or the importance of a caring relationship between physicians and their patients.

In order to contribute to patient care during the ongoing pandemic, and to allow our colleagues to stay up-to-date on latest COVID-19 care and clinial practice developments, the tables below hope to create an easy-to-access format on the available scientific information.

Medications used at home for SARS-CoV-2 infection

DRUG / ACTIVE COMPONENT WHO NIH NICE Min/AIFA*
NSAIDS yes yes yes yes
Coxibs  n.e. n.e. n.e. n.e.
Systemic corticosteroids only with ↓PO2 no only with ↓PO2 no
Inhaled corticosteroids yes yes n.e. yes
Antithrombotic drugs (heparin) only high risk only high risk only high risk only high risk
Antibiotics no no only if bacterial risk no
Immunosuppressants (hydroxychloroquine) no no no no
Immunomodulators (colchicine) no no no no
Antiparasitics (ivermectin) no no no no

n.e.: not evaluated

Supplements used at home for SARS-CoV-2 infection

SUPPL. WHO NIH NICE Min/AIFA
Vitamin C n.e. no n.e. no
Vitamin D no no no no
Zinc n.e. no n.e. no
Lactoferrin n.e. n.e. n.e. no
Quercetin n.e. n.e. n.e. n.e.
Resveratrol n.e. n.e. n.e. n.e.

n.e.: not evaluated

The person comes before the disease

It is crucial to remember that in the treatment of any health problem that may require pharmacological intervention, the administration of any drug or active ingredient requires an assessment of the individual and not just of a phenomenon such as a pathology/problem. Each administration must consider age, body weight and adipose tissue, sex, pre-existing pathologies and therapies, patient compliance, and general risk factors.

A complex issue such as the novel coronavirus therefore requires a correct and individual management, while considering the options available in the choice of validated drugs and those included in the recommendations. This to optimise results by reducing the possible occurrence of unwanted effects or ADRs and obtaining control of the inflammatory condition underlying the etiopathogenetic mechanism of the COVID-19 disease. The use of antibiotics, inhaled steroids, systemic steroids, and antithrombotic drugs should only be justified by the suspected or established presence of specific complications during infection.

In this respect, the family physician is certainly the person who, by making use of his or her individual, longitudinal and family knowledge of a patient, can guarantee observation and a capacity for targeted intervention with faster resolution of the condition associated with the viral infection. In this sense, a more in-depth knowledge of the characteristics of individual active ingredients can be a winning factor in achieving treatment objectives; reducing doses according to gender, age, weight, or choosing to avoid interactions with other drugs already taken by the patient, considering the metabolism of the drug to choose mode of intake and time, evaluating possible occurrence of allergic reactions or adverse effects, is what we hope will guide the physician in the appropriate choice of individual treatment.

 

Data sheets of treatments included and excluded in the main guidelines for Sars-CoV-2 infection management

Treatments used off label and in the absence of literature data in the home treatment of SARS-CoV-2 infection

 

Personalised Medicine

After considering all the aspects of home treatment, to conclude and confirm what has been examined, the recent Vademecum (in Italian language only) for the care of the person with SARS-CoV-2 infection of the SIMIT (Italian Society of Infectious and Tropical Diseases) reiterates in a concise manner that pharmacological treatments aimed at attacking the disease induced by SARS-CoV-2 infection are and remain hospital-based, consisting of antiviral drugs (Remdesivir), monoclonal antibodies (Casirivimab/imdevimab, Bamlanivimab/etesevimab and Sotrovimab) and biotechnological drugs (Tocilizumab, Anakinra, Baricitinib).

An additional observation is the recommendation to treat patients with COVID-19 with gastric protectants, if indicated by previous history or clinical conditions predisposing to gastroduodenal bleeding during disease.

In the light of all this, could we at least acknowledge that the pandemic has led physicians to the most complex of clinical practice, that of personalised medicine and tailor-made treatments? We hope that it can be an expression of rebirth, resilience, and even cultural and methodological growth, especially for local-scale medicine.

 
PARACETAMOL
Indications Treatment of pain and fever
Spectrum of activity CNS
Adult dosage 500 mg, 1 g
Posology Minimum intervals of 8 hours at a dose of 1gr, 6 hours at lower doses
In pregnancy: doses of 500 mg
Pharmacodynamics Action on CNS opioid system and inhibition of prostaglandins (PGs)
Pharmacokinetics Hepatic metabolism 98%, renal metabolism 2%
Rapid absorption
Interactions Rifampicin
Phenobarbital
Carbamazepine
CAF regime
Anticoagulants
Undesirable side effects or adverse drug reactions Overdose: renal tubular necrosis, acute liver failure
Contraindications Creatinine Clearance <10ml/min
Gilbert's disease
G6PHD deficiency
Alcohol use disorder (AUD)

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IBUPROFEN
Indications Treatment of pain and fever
Spectrum of activity Prostaglandins (PGs)
Adult dosage 200 mg, 400 mg, 600 mg
Posology Minimum intervals of 8 hours at maximum dose
Pharmacodynamics NSAID PG inhibitor with antalgic, anti-edematous, anti-inflammatory, anti-aggregant (antiplatelet) action
Pharmacokinetics Hepatic metabolism, mainly renal excretion, half-life 1.8/3.5 hours, plasma peak 1-2 hours
Interactions NSAID Acetylsalicylic
Steroids
Anticoagulants
Serotonin reuptake inhibitors (SRI)
Diuretics
Beta-blockers
Angiotensin-converting enzyme (ACE) inhibitors
Digoxin
Methotrexate
Cyclosporine
Undesirable side effects or adverse drug reactions Gastrointestinal bleeding (GI bleed)
Bronchospasm
Anaphylaxis
Kidney failure
Acute liver failure
Pancreatitis
Drowsiness
Skin ulcers
Contraindications Alcohol consumption
Empty stomach
Urticaria
Chronic kidney failure
Severe heart failure (NYHA Class IV)
Ischemic heart disease
Stroke
Ulcerative colitis (UC) (also ulcerative proctitis)
Porphyria
3rd trimester pregnancy

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KETOPROFENE
Indications Treatment of inflammatory states associated with pain
In paediatrics, also treatment of fever
Spectrum of activity Central Nervous System (CNS)
Prostaglandins (PGs)
Quinine
Adult dosage 40 mg, 80 mg
Posology Minimum intervals of 8 hours
Pharmacodynamics NSAID derivative of propionic acid, PG inhibitor and interaction with quinines, analgesic action, including central analgesic, anti-inflammatory, antipyretic
Pharmacokinetics Renal metabolism, half-life of 6 hours, plasma peak at 2 hours
Interactions NSAIDS
Anticoagulants
Lithium
SSRIs
ACE inhibitors
Steroids
Diuretics
Beta-blockers
Sulphonamides
Antiplatelet drug (antiaggregant)
Methotrexate (MTX)
Undesirable side effects or adverse drug reactions Gastrointestinal bleeding (GI bleed)
Arterial thrombosis
Severe skin reactions
Hypertransaminasemia
Bronchospasm
Acute hepatitis
Kidney failure
Fertility impairment
Diarrhoea
Drowsiness
Vertigo
Contraindications NSAID allergy
Third trimester pregnancy
Peptic ulcers (gastric or duodenal)
Ulcerative colitis (UC) (also ulcerative proctitis)
Asthma
Heart failure
Kidney failure
Liver failure
Thrombocytopenia
Leukopenia
Smoking

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DOXICYCLINE
Indications Respiratory, urinary, ENT, gynaecological, dermatological, surgical, or gastrointestinal acute infections
Spectrum of activity Gram+ and Gram- bacteria
Mycoplasmas
Chlamydia
Rickettsia
Adult dosage 100 mg, always taken with plenty of water
Posology 100 mg/24 hours/7-10 days
100 mg/12 hours
200 mg single dose 1st day, followed by 100 mg/24 hours
Pharmacodynamics Systemic antibacterial, 2nd generation synthetic lipophilic tetracycline, bacteriostatic, inhibits protein synthesis in susceptible bacteria through specific and reversible binding to the 30S ribosomal subunit
Pharmacokinetics Renal absorption, plasma peak in 2-4 hours, half-life 16-22 hours, 40% renal excretion and 60% faecal excretion
Interactions Barbiturates
Anticoagulants
Lithium
Methotrexate
Cyclosporine
Digoxin
Penicillins
Magnesium-based antacids
Undesirable side effects or adverse drug reactions Esophageal ulcer
Liver failure
Kidney failure
Urticaria
Pericarditis
Neutropenia
C. difficile–associated diarrhoea (CDAD)
Candidiasis
Headache
Tooth discolouration
Photosensitivity
Contraindications Consumption on an empty stomach
Pregnancy
Breastfeeding
Oesophagitis
Gastro-Esophageal Reflux Disease (GERD)
Kidney failure
Milk and dairy products

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AZITHROMYCIN
Indications ENT, dental, cutaneous, bronchial, and pulmonary infections; urethritis caused by Chlamydia
Spectrum of activity Gram+ aerobes
Gram- facultative aerobe
Anaerobes
Adult dosage 500 mg
Posology 500mg/24 hours for 3 days
Pharmacodynamics Azalide macrolide, inhibits assembly of 50S ribosomal subunits
Pharmacokinetics Plasma peak 2-4 hours, half-life 2-4 days, biliary excretion
Interactions Ergotamine
Procainamide
Amiodarone
Sotalol
Pimozide
Citalopram
Quinolones
Chloroquine
Cyclosporine
Undesirable side effects or adverse drug reactions QT prolongation
C. difficile–associated diarrhoea (CDAD)
Heart failure
Bradycardia
Vomiting
Lymphocytopenia
Hyperglycaemia
Elevated creatinine
Hyperpotassemia
Contraindications Insufficient studies in pregnancy
Multi-morbid elderly patients

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CEFIXIME
Indications Acute ENT, urinary, pulmonary and bronchial infections
Spectrum of activity Clinically significant Gram+ and Gram-
Adult dosage 400 mg
Posology 400mg/24 hours for 7-14 days
Pharmacodynamics Cephalosporin, inhibits bacterial cell wall synthesis
Pharmacokinetics Plasma peak 3-4 hours, half-life 4 hours, biliary and renal excretion
Interactions Warfarin
Nifedipine
Contraceptives
Undesirable side effects or adverse drug reactions Severe skin reactions
Pseudomembranous colitis
Acute kidney failure
Contraindications Penicillin allergy
First trimester pregnancy

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LEVOFLOXACIN
Indications

Acute pyelonephritis
Complicated urinary tract infections (UTIs)
Chronic prostatitis

Next, to be used ONLY when other recommended antibacterials are inadequate: 
COPD exacerbation, including bronchitis 
Acute bacterial rhinosinusitis (ABRS)
Community-acquired pneumonia (CAP)
Complicated skin and soft tissue infections
Acute cystitis

Spectrum of activity Gram+ Aerobes - including resistant ones
Gram- Aerobes and Anaerobes, including resistant ones
Mycoplasma
Chlamydia
Adult dosage 500 mg, 750 mg
Posology 500 mg/24 hours for 7-14 days
750 mg/24 hours as an induction dose 1-3 days followed by 500 mg/24 hours
Pharmacodynamics Synthetic fluoroquinolone, acts on the DNA gyrase and Topoisomerase IV complexes. It penetrates the bronchial mucosa, the fluids of the lining epithelia, alveolar macrophages, lung tissue, skin, prostate, and urine.
Pharmacokinetics Plasma peak 1-2 hours, half-life 8-14 hours, renal excretion
Interactions Glibenclamide
Insulin
Tricyclics
Macrolides
Antipsychotics
Antiarrhythmics
Warfarin
Cyclosporine
Undesirable side effects or adverse drug reactions Tendon rupture, especially in the elderly
C. difficile–associated diarrhoea
Hypoglycaemia
Photosensitivity
Psychotic reactions
QT prolongation
Peripheral neuropathy
Acute hepatitis
Confusion
Aortic dissection
Hypertransaminasemia
Depression
Vertigo
Skin reactions
Contraindications G6PHD deficiency
Pregnancy
Breastfeeding
Acute kidney failure
Epilepsy
Cardiac arrhythmias
Paediatric age
Tendinopathies

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AMOXICILLIN - CLAVULANIC ACID
Indications Acute ENT and skin infections, pyelonephritis, Community-acquired pneumonia (CAP), COPD flare-ups
Spectrum of activity Gram+ and Gram- sensitive
Adult dosage 875 mg amoxicillin + 125 mg clavulanic acid
Posology 875 mg + 125 mg every 8 hours for 8-10 days
Pharmacodynamics Amoxicillin: beta lactam, inhibits enzymes for structuring the bacterial cell wall
Clavulanic acid is a beta lactamase structurally related to penicillin and prevents inactivation of amoxicillin
Pharmacokinetics Plasma peak 1 hour; half-life 1-2 hours; amoxicillin excreted via renal route; clavulanic acid mainly via renal route
Interactions Allopurinol
Anticoagulants
Probenecid
Mycophenolate (Mycophenolic acid)
Undesirable side effects or adverse drug reactions Colitis
Nausea
Acute Kidney Failure (overdose)
Urticaria
Candidiasis
Contraindications Allergy to penicillins and cephalosporins
Liver failure
Mononucleosis (severe rashes)

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BUDESONIDE - Nasal Spray
Indications Seasonal allergic rhinitis (hay fever), perennial allergic and non-allergic rhinitis. Treatment of nasal polyps (NP). Prophylaxis of recurrences of nasal polyposis after polypectomy
Spectrum of activity Nasal mucosal inflammation
Adult dosage 100 mcg
Posology 100 mcg every 12 hours
Pharmacodynamics Glucocorticosteroid, inhibits synthesis and release of inflammatory mediators and cytokines, and inhibits immediate allergic response
Pharmacokinetics Absorption in 1-3 min, plasma peak within 1 hour, half-life 4 hours, hepatic metabolism, urinary excretion
Interactions Tricyclics
Levothyroxine
Hypoglycemic drugs
Undesirable side effects or adverse drug reactions Hyperglycaemia
ENT infections
Respiratory infections
Glaucoma
Adrenal crisis
Candidiasis
Headache
Insomnia
Contraindications Coronary heart disease (CHD)
Arterial hypertension
Thyrotoxicosis
Diabetes
Glaucoma
Breastfeeding

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DEXAMETHASONE
Indications Inflammatory lung diseases including interstitial diseases (ILDs). Allergies, rheumatic diseases, dermatological diseases, inflammatory eye diseases, gastrointestinal diseases, lymphoma, leukaemia, cerebral oedema, thrombocytopenia, autoimmune hemolytic anemia (AIHA)
Spectrum of activity Tissues with inflammatory states
Adult dosage 0,5-0,75 mg
Posology 0.5-3 mg per day, 1 to 4 intakes per 24 hours
Pharmacodynamics Steroid, four to six times more potent than methylprednisolone, six to eight times more potent than prednisone and prednisolone, approximately 35 times more potent than cortisone
Pharmacokinetics Blood peak 30 min, half-life 3.5 h, liver metabolism
Interactions NSAIDS
Furosemide
Thiazide
Cyclosporine
Diltiazem
Ketoconazole
Anticoagulants
Macrolides
Ritonavir
Lopinavir
Undesirable side effects or adverse drug reactions Aside from effects such as in Budesonide (spray):
Depression
Psychosis
Hypocalcaemia
Hypertensive crises
Hyperparathyroidism (increased PTH)
Tachycardia
Epigastric pain (epigastralgia)
Abdominal pain
Peptic ulcer
Pancreatitis
Contraindications Aside from the indications for Budesonide spray:
Heart failure
Acute liver failure
Osteoporosis
Systemic infections
Pregnancy

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ENOXAPARIN
Indications Treatment of Deep Venous Thrombosis (DVT) and Pulmonary Embolism (PE). Acute coronary syndrome (ACS). Venous thromboembolism (VTE) in surgical patients at moderate and high risk, particularly those undergoing orthopaedic, general or oncological surgery. VTE prophylaxis in non-surgical patients with acute pathology such as heart failure. Respiratory failure, severe infections, rheumatic diseases and reduced mobility.
Spectrum of activity Coagulation system
Adult dosage From 2000 a 10000 IU s.c. daily
Posology Prophylaxis: 2000/4000 IU as a single dose per day

Treatment: 100 IU/kg, one or two administrations per day for at least 10 days.
Pharmacodynamics Anti-Xa/IIa activity
Antithrombin III (ATIII)-dependent inhibition of other factors
Pharmacokinetics Plasma peak 3-5 hours, half-life 7 hours, hepatic metabolism
Interactions NSAIDS
Thrombolytics
Antiplatelets
Glucocorticoids
Undesirable side effects or adverse drug reactions Thrombocytopenia
Haemorrhages
Vasculitis
Hyperkalemia
Headache
Elevated transaminase levels
Urticaria
Contraindications Liver failure
Chronic Kidney Failure
Bleeding and bleeding risk conditions
Mechanical / prosthetic valves
Low BMI

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ASCORBIC ACID
Indications Vitamin c deficiency
Spectrum of activity All tissues
Adult dosage 500 mg, 1000 mg
Posology 500 mg to 2 g per day (the daily requirement for adults is normally 60 mg/day)
Pharmacodynamics Water-soluble vitamin, reduces cellular oxidation
Pharmacokinetics Rapid absorption, renal excretion
Interactions
Undesirable side effects or adverse drug reactions Headache
Diarrhoea
Nausea
Contraindications Urinary calculi
G6PDH deficiency
Haemochromatosis
Sideroblastic anaemia

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CHOLECALCIFEROL
Indications Prevention and treatment of proven vitamin D deficiency (e.g. in patients with dietary abnormalities, malabsorption, chronic steroid therapy or anticonvulsants)
Spectrum of activity All tissues
Adult dosage 750-1000 IU /day
Posology Prevention: 750-1000 IU/day
Treatment: 1000 IU/day
Pharmacodynamics Fat-soluble vitamin. Increases intestinal absorption of calcium
Pharmacokinetics Hepatic and subsequent renal hydroxylation, accumulation in muscle and adipose tissue, renal and faecal excretion
Interactions Thiazide diuretics
Digitoxin
Magnesium
Anticoagulants
Undesirable side effects or adverse drug reactions Arrhythmia
Asthenia
Confusion
Headache
Abdominal pain
Vomiting
Diarrhoea
Urinary calculus
Skin rash
Acute kidney failure
Hypercalcaemia
Contraindications Hypercalcaemia
Hypercalciuria
Urinary calculi
Kidney failure
Sarcoidosis

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HYDROXYCHLOROQUINE
Indications Treatment of active and chronic Rheumatoid Arthritis (RA) and Systemic Lupus Erythematosus (SLE)
Spectrum of activity Both the anti-rheumatic and antimalarial effects can be explained in relation to the concentration achieved in acid intracellular vesicles and through the increase in their pH
Adult dosage 200 mg
Posology 400 to 600mg /day initial dose and after 4-12 weeks 200-400 mg
Pharmacodynamics Antimalarial belonging to the 4-aminoquinoline family. Interaction with sulphydryl groups, modulation of enzyme activity, DNA fixation; stabilisation of lysosomal membranes; inhibition of prostaglandin synthesis, chemotaxis of polymorphonucleates and phagocytosis; possible interference with IL-1 production
Pharmacokinetics Peak in 3-4 hours, hepatic metabolism, terminal half-life 30-50 DAYS, renal excretion
Interactions Antiarrhythmics
Tricyclics
Quinolones
Macrolides
Fluconazole
Mefloquine
Hypoglycaemic drugs
Aminoglycosides
Clopidogrel
Digoxin
Dabigatran
Metoprolol
Undesirable side effects or adverse drug reactions Retinopathy
Acute Kidney Failure
Hypoglycaemia
QT prolongation
Myocardial infarction (MI)
Heart failure
Bradycardia
Ventricular arrhythmia
Hypokalaemia
Depression
Neurological disorders
Dizziness
Headache
Nausea
Diarrhoea
Vomiting
Contraindications Retinopathy
Maculopathy (Mascular Degeneration)
GI Diseases
Psoriasis
G6PDH deficiency
Pregnancy
Breastfeeding

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IVERMECTIN
Indications Antiparasitic
Spectrum of activity Intestinal anguillulosis, Lymphatic filariasis, Scabies
Adult dosage 3 mg
Posology 3 mg to 18 mg single intake depending on the treatment of helminths (parasitic worms) or parasites
Pharmacodynamics Anthelmintics, macrocyclic lactones, causes neuromuscular paralysis of parasites
Pharmacokinetics Peak plasma at 4 hours, half-life 12 hours, faecal excretion
Interactions
Undesirable side effects or adverse drug reactions Fever
Skin rash
Hepatitis
Haematuria
Asthenia (Weakness)
State of agitation
Leukopenia
Headache
Hypotension
Diarrhoea
Tachycardia
Muscle pain
Contraindications Pregnancy

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LACTOFERRIN
Indications Mild anaemia and mild immune deficiencies
Spectrum of activity Siderophilin (transferrin), a glycoprotein involved in iron transport and concentrated mainly in the mucous membranes, where it stimulates defences as a constituent of neutrophils
Posology 200 mg/day
Interactions
Undesirable side effects or adverse drug reactions Diarrhoea
Skin rash
Lack of appetite
Asthenia
Constipation
Contraindications

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RESVERATROL
Indications Inflammatory states or mild deficits of the immune system
Spectrum of activity Phytotherapeutic, Phenol, produced by plants, including edible ones, for antibacterial and antifungal purposes. It acts by facilitating the production of antioxidant enzymes
Posology From 300 mg to 1000 mg/day
Interactions NSAIDS
Anticoagulants
Antiplatelet drugs
Antidepressants
Undesirable side effects or adverse drug reactions Nausea
Diarrhoea
Ecchymosis (bruising or purpura)
Contraindications Pregnancy
Breastfeeding

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QUERCETIN
Indications Inflammatory states or mild deficits of the immune system
Spectrum of activity Phytotherapeutic, Flavonoid. Acts by enhancing the production of antioxidant enzymes and has antiplatelet capacities
Posology 500 mg/day
Interactions NSAIDS
Antiplatelet drugs
Anticoagulants
Undesirable side effects or adverse drug reactions Dyspepsia
Nausea
Ecchymosis (bruising or purpura)
Contraindications Pregnancy
Breastfeeding

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Note:
*AIFA is the Italian Medicines Agency (Agenza Italiana del Farmaco)

  1. World Health Organization. (2021). Therapeutics and COVID-19: living guideline, 24 September 2021. World Health Organization. Available at: apps.who.int/iris/handle/10665/345356. License: CC BY-NC-SA 3.0 IGO.
  2. COVID-19 rapid guideline: Managing COVID-19. London: National Institute for Health and Care Excellence (NICE); 2021 Sep 2. PMID: 34181371.
  3. COVID-19 Treatment Guidelines Panel. Coronavirus Disease 2019 (COVID-19) Treatment Guidelines. National Institutes of Health. Available at: www.covid19treatmentguidelines.nih.gov.
  4. In Italian only: Ministero della Salute. Circolare Ministero Salute 26 aprile 2021 - Gestione domiciliare dei pazienti con infezione da SARS-CoV-2, aggiornata al 26 aprile 2021.