Rx Care

How you can counsel patients on drug treatments for SARS

The recent outbreak of the mysterious pneumonialike infection called severe acute respiratory syndrome (SARS) is sparking worldwide jitters as the number of documented cases continues to rise. The outbreak has received extensive media coverage all over the world.

According to the Centers for Disease Control & Prevention, no specific treatment recommendations for SARS can be made at this time, because the etiology of the disease is uncertain. The cause of SARS is believed to be a previously unrecognized strain of the coronavirus. The agency is recommending that patients be treated empirically with antibacterial drugs targeting organisms associated with community-acquired pneumonia.

Robert Fowler, M.D., assistant professor of medicine, Sunnybrook and Women's College Health Sciences Centre, Toronto, said that the currently used treatment regimen also includes ribavirin. The dosing regimen for ribavirin is a 2-gm loading dose administered intravenously, followed by 1 gm intravenously every six hours for four days, then 0.5 gm intravenously every eight hours for six days, he said. The patient may then be switched to oral ribavirin, depending on the clinical circumstances.

The World Health Organization, the CDC, and the Food & Drug Administration recently contacted ICN Pharmaceuticals regarding the availability of intravenous ribavirin, which the company markets under the brand name Virazole. ICN is cooperating with the agencies, although it has not conducted any clinical research to support the use of intravenous ribavirin for the treatment of SARS.

In terms of antibacterial drugs, Fowler said the regimen in use at his institution is 500 mg of levofloxacin (Levaquin, Ortho-McNeil), either intravenously or orally once daily, or 750 mg of cefuroxime intravenously every eight hours and 500 mg of azithromycin (Zithromax, Pfizer), either intravenously or orally once daily.

Some physicians have advocated adding steroids to the regimen of ribavirin to reduce inflammation in the lungs, said Aaron Glatt, M.D., chief of infectious diseases and associate dean, St. Vincent's Catholic Medical Centers, Brooklyn and Queens, N.Y. Studies have not yet evaluated treatments for SARS in a rigorous scientific manner, however, he said.

Pharmacists have an important role in counseling patients about the adverse effects of ribavirin, Fowler said. Women who might be pregnant should take a pregnancy test prior to beginning ribavirin therapy, because the drug can cause birth defects. In addition, women who are considering pregnancy within the next six months should not use ribavirin, he cautioned.

Persons taking ribavirin should have their hemoglobin and hematocrit checked periodically, Fowler added. Bilirubin and lactate dehydrogenase levels should also be monitored regularly.

SARS appears to be spread through close contact, probably through droplet transmission, Fowler said. There appears to be minimal to no airborne transmission per se, other than what is spread through close contact, he added.

When treating patients who have SARS, it is very important to maintain full contact precautions and infection-control measures, said Fowler. These precautions include the use of gowns, gloves, and N95 respirator masks with face shields or glasses, he noted. Patients in isolation should be placed in negative pressure rooms.

Persons with SARS present with a temperature of >100.5ºF (>38ºC) and one or more respiratory symptoms such as cough, difficulty breathing, hypoxia, or shortness of breath, Fowler stated. They have a travel history to Hong Kong; the People's Republic of China; Hanoi, Vietnam; or Singapore within 10 days of symptom onset, or close contact with a person with a respiratory illness who has traveled to those places.

In an effort to educate healthcare professionals and calm the fears of the general public, CDC and WHO have set up Web pages dedicated exclusively to information about the disease. These Web pages provide answers to frequently asked questions about SARS and guidelines for the management and containment of the infection that targets both clinicians and patients. Transcripts of media briefings given by CDC and WHO leaders are also available.

The CDC Web page about SARS can be found at http://www.cdc.gov/ncidod/sars and the WHO Web page at http://www.who.int/csr/sars/en. The number of SARS cases worldwide is updated daily on the WHO page, and the number of cases in the United States is updated daily on the CDC page. The number of suspected cases under investigation in the United States had reached 148 at press time. Other information on both pages is posted as it becomes available.

Charlotte LoBuono

 

Charlotte LoBuono. How you can counsel patients on drug treatments for SARS. Drug Topics Apr. 21, 2003;147:30.