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COVID-19 rapid Nice guideline summary: Managing symptoms

Nice has published rapid guidelines for the care of patients with suspected and confirmed cases of COVID-19

Unplanned learning

It may be useful to print this summary as a resource for your pharmacy team – PDF available here.

Patients can be advised that the main COVID-19 symptoms include cough, fever, breathlessness, anxiety, delirium and agitation, but that they may also experience fatigue, muscle aches and headaches. Mild symptoms usually last approximately one week. Those with severe symptoms may deteriorate quickly and require hospital admission, particularly older patients or those who have underlying health conditions.

Managing coughs

Pneumonia can potentially develop in older patients who can’t clear secretions or those with underlying health conditions.

Encourage patients to sit up where possible. For adults over 18, options include:

Treatment Dosage

Initially: Non-pharmacological measures

1 teaspoon of honey

1st line: Codeine linctus/tablets

15mg to 30mg every 4 hours as required, up to 4 doses in 24 hours (max 240mg in 24 hours)

2nd line: Morphine sulfate oral solution (10mg/5ml)

2.5mg to 5mg as required every 4 hours; increase up to 5mg to 10mg every 4 hours as required

Managing fever

Fever is most common five days after exposure to the infection. Adequate fluid levels should be maintained (max 2 litres/day). Paracetamol should be used first line as it is preferred to nonsteroidal anti-inflammatory drugs for fever in COVID-19 patients.

Managing breathlessness

Symptoms can worsen in anxious patients. To manage breathlessness, advise patients to:

  • Keep the room cool
  • Sit upright
  • Breathe in through the nose with the mouth closed for several seconds, then exhale slowly through pursed lips for 4-6 seconds
  • Lean forward with arms holding a chair or knees and the upper body supported
  • Keep the room well ventilated by opening doors or windows.

End of life patients who have moderate to severe breathlessness and are distressed, may require a combination of opioids and benzodiazepine (which includes morphine sulfate, lorazepam and midazolam).

For those with symptoms of pneumonia, see our summary on managing pneumonia in the community.

Managing anxiety, delirium and agitation

Treating agitation and anxiety: a benzodiazepine such as lorazepam (0.5mg to 1mg 4 times a day as required, maximum 4mg in 24 hours with reduced doses for elderly and debilitated patients), may be used for those who can swallow. For those who cannot, subcutaneous midazolam may be used.

Treating delirium: haloperidol (0.5mg to 1mg at night and every 2 hours as required: max 10mg daily, or 5mg daily in elderly patients) may be used for those who can swallow. For those who cannot, subcutaneous levomepromazine injections may be used.

Prescribing for end of life patients

When supplying anticipatory medicines for patients near the end of life:

  • Alternative routes of administration may need to be considered
  • Smaller quantities may be prescribed
  • Long-acting formulations may be prescribed if staff shortages occur and family or carers potentially need to administer.

If medicines are returned to a pharmacy when a patient had died due to COVID-19, infection control and prevention measures should be taken.

This summary is intended as a quick resource for pharmacy teams on the Nice COVID-19 rapid guideline: managing symptoms (including at the end of life) in the community. For more detailed information, please see the full guideline here.


National Institute for health Care and Excellence (2020) COVID-19 rapid guideline: managing symptoms (including at the end of life) in the community. Nice guideline (NG163).

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