新冠病毒感染的治疗

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新冠病毒感染的治疗 。
托法替尼药品详情:托法替尼生产厂家。新冠病毒感染的治疗这是一个非常困难的专栏。笔者参考了Uptodate临床顾问、WHO的相关指导、以及最新的临床实验等信息,并根据中国疫情控制的要求,从而提出个人的建议。请注意,笔者尽可能寻求靠谱的证据,但推荐部分是基于笔者的判断。

一,病毒暴露后的隔离与检查

对于欧美等国来说,他们并不寻求找出所有的感染者。但中国对疫情控制的需要,我们会尽可能找出所有的感染者,并集中管理。所以,所有跟病毒感染者有密切接触史,视作为新冠病毒暴露。1,接种过疫苗的对象任何疫苗都不能确保暴露于病毒后不被感染。因此,接种疫苗后有暴露于病毒的病史,也应该接受隔离。(疫情防控需求,强烈推荐)完成疫苗接种者,预测期望隔离21天为宜;时间段建议病毒核酸检查至少4次。(缺乏证据,但强烈推荐)。详细检查细节参考《新冠病毒感染的诊疗断定》。没有完成疫苗接种者,预测期望隔离28天;时间段建议病毒核酸检查至少5次。(缺乏证据,但强烈推荐)疫苗接种者,如无发热、咳嗽等疑似新冠感染后病症,不应胸部CT检查。因为胸部CT检查对预后没有提示价值[1-2]。而且,疫苗接种者的感染前置概率显著偏低。(低质量证据,强烈推荐)。在病毒暴露的隔离时间段,病毒核酸检查未发现病毒感染,则能够撤销隔离。如隔离时间段明确病毒感染,则应按照感染者处置。2,未接种疫苗的对象预测期望隔离28天;时间段建议病毒核酸检查至少5次。不反对适当增加检查频率。(缺乏证据,但强烈推荐)反对胸部CT检查,因为胸部CT疑似的诊疗断定价值不大。虽然在新冠大流行时(前置概率偏高),胸部CT检查疑似有帮助价值。(缺乏证据,强烈推荐)

二,病毒暴露后的分流处置

根据危险度选择合理的治疗措施[3-5]。(中质量证据,强烈推荐)1,高危险年龄≥65岁居住在养老院或长期医学护理机构免疫功能损害具有慢性肺病或中至重度哮喘心血管疾病(包括高血压)重度肥胖(BMI≥40kg/m2)糖尿病慢性肾病(正在接受透析)脑血管疾病慢性肝病 吸食烟草者2,中危险年龄20-64岁,无任何上述特定合并症年龄<20岁,具有上文所述疾病以外的基础病3,低危险年龄<20岁,无基础病向张文宏老师致敬

三,病毒暴露后的预先防范性治疗

目前已有药物能够减少病毒暴露后的「有病症感染」。比如,bamlanivimab和casirivimab-imdevimab这两种抗刺突蛋白单克隆抗体制剂。有研究证实,这两个药物都能够减少新冠病毒暴露后的病症发生率,甚至可能减少后续病死率[6-7]。很显然,这两个药物在中国获得困难,不宜推广使用。1,如下人群考虑使用casirivimab-imdevimab治疗,剂量为600毫克-600毫克,皮下注射或静脉注射[7]。未接种疫苗的高度危险人群,病毒暴露后的96小时内;(高质量证据,强烈推荐)未接种疫苗的中危人群,病毒暴露后的96小时内;(高质量证据,中等推荐)已接种疫苗的高度危险人群,病毒暴露后的96小时内;(高质量证据,中等推荐)已接种疫苗的中危人群,病毒暴露后的96小时内;(高质量证据,低推荐)不建议低危人群使用casirivimab-imdevimab做预先防范性治疗[7](中质量证据,低推荐);使用casirivimab-imdevimab治疗后的90天内,不宜接种新冠疫苗。(低质量证据,强烈推荐)2,因为耐受药物病毒株的流行,不再推荐使用bamlanivimab。(中质量证据,强烈推荐)3,sotrovimab也是单克隆抗体药物。因为缺乏在病毒感染后的研究数据,目前不支持用于暴露后的预先防范性治疗。中国也有若干个针对新冠病毒的单克隆抗体药物在研发中。建议中国医院积极参与研究。

四,病毒感染确诊者的一般性治疗

病毒感染确诊也应该根据危险度做分流处置[3-5];详细分流参考上述。(中质量证据,强烈推荐)1,因为新冠病毒感染者可能同时合并有流感,建议有病症的病毒感染者同时检查流感;确诊流感则予以抗流感病毒治疗。(低质量证据,强烈推荐)不建议无病症人群检查流感;因为此时的抗流感病毒治疗无意义。(低质量证据,强烈推荐)2,对新冠高度危险的感染确诊者,即便无病症,也能够胸部CT检查。(低质量证据,低推荐)3,新冠中危、低危的感染确诊者,如无病症,不建议胸部CT检查。(低质量证据,强烈推荐)4,通常不予以抗菌药物治疗,但在如下情况可酌情使用①明确肺炎,疑似新冠但未确诊时②退热后,出现新的发热且影像学有新的疑似细菌感染迹象5,确诊新冠病毒感染的肺炎患者,全部予以抗凝治疗[8-10],首选低分子肝素(高质量证据,强烈推荐)6,继续使用他汀类药物、阿司匹林。有研究发现这两个药物可能对新冠病毒感染者有益[11]。(中等质量证据,强烈推荐)从未使用他汀类药物、阿司匹林的新冠感染者,是否需要使用这两个药物来协助新冠治疗?答案尚不明确。如没有明显副反应,不反对使用这两个药物治疗新冠感染者[11-12]。(中等质量证据,中等推荐)7,能够用对乙酰氨基酚缓解发热、痛苦等相关不适[13].(高质量证据,中等推荐)

五,确诊新冠的非重症患者的治疗

存在如下任何情况之一者,能够归入重症病患:血氧饱和度≤94%其他提示需要高流量吸氧的迹象其他提示需要呼吸机通气支持的迹象非重症病患,应按照如下治疗1,casirivimab-imdevimab治疗[14-15],剂量为600毫克-600毫克,首选静脉;(高质量证据,中等推荐)2,Sotrovimab,剂量500毫克静脉注射[16]; (低质量证据,弱推荐)

六,确诊新冠的重症患者的治疗

1,所有新冠感染的肺炎患者,出现低氧血症时,或者呼吸困难时,应使用地塞米松治疗[17-18]。(高质量证据,强烈推荐)给药方法:6毫克/d,持续10日(如病情显著好能够缩短时间)没有低氧血症,呼吸困难等迹象,不建议使用地塞米松[17-18]。(高质量证据,强烈推荐)2,在启动地塞米松治疗后,患者病情继续恶化严重时,应联合巴瑞替尼治疗[19-22]。(高质量证据,强烈推荐)。托法替布的证据相对偏弱,也可选择[23]。(中等质量证据,中等推荐)巴瑞替尼的给药方法为4毫克、口服,一日1次,最多使用14日。3,在启动地塞米松治疗后,患者病情继续恶化严重时,可联合白介素6拮抗剂治疗;例如托珠单抗[24-26]。(高质量证据,中等推荐)但此时,不跟巴瑞替尼联合。4,瑞德西韦对新冠病毒感染者可能是有益的;但这种有益的阶段较为微弱[27-31](高质量证据,弱推荐)5,俯卧位通气等呼吸支持治疗,限于篇幅,本篇不讨论。
(写于2022年8月10日,如后续有更多研究资料,将视乎情况做调整)
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