From the Guidelines
Current COVID-19 treatment guidelines prioritize a combination of supportive care and targeted medications, with a focus on reducing morbidity, mortality, and improving quality of life. The most recent and highest quality study, published in 2021 in the European Respiratory Review 1, supports the use of corticosteroids, particularly dexamethasone, and anti-IL-6 receptor monoclonal antibody therapy to reduce mortality in hospitalized patients.
Key Treatment Recommendations
- For mild to moderate cases in outpatients, Paxlovid (nirmatrelvir 300mg with ritonavir 100mg twice daily for 5 days) is recommended for high-risk patients within 5 days of symptom onset.
- Remdesivir (200mg IV on day 1, then 100mg daily for 2-4 more days) is an alternative for outpatients.
- For hospitalized patients requiring oxygen, dexamethasone (6mg daily for up to 10 days) is the standard treatment.
- Severely ill patients may receive remdesivir, baricitinib (4mg daily for up to 14 days), or tocilizumab (8mg/kg, single dose) in addition to dexamethasone.
- Supportive care remains essential, including oxygen supplementation, prone positioning for respiratory distress, and management of complications.
Rationale for Treatment
The medications recommended work by either inhibiting viral replication (Paxlovid, remdesivir) or modulating the inflammatory response (dexamethasone, baricitinib, tocilizumab) that causes severe COVID-19 complications. Monoclonal antibodies previously used are no longer recommended due to viral mutations affecting efficacy. Treatment should begin promptly, especially for high-risk individuals (elderly, immunocompromised, or those with underlying conditions), as supported by various clinical guidelines 1.
Clinical Guidelines
Several international and national professional bodies have issued guidelines on the management of COVID-19, including the World Health Organization (WHO), Infectious Diseases Society of America (IDSA), and Surviving Sepsis Campaign 1. These guidelines generally recommend the use of investigational treatments only within the setting of clinical trials, but some guidelines list potential adjuvant treatment options, such as chloroquine, lopinavir-ritonavir, and convalescent plasma, while cautioning against their routine use.
From the FDA Drug Label
1 INDICATIONS AND USAGE VEKLURY is indicated for the treatment of coronavirus disease 2019 (COVID-19) in adults and pediatric patients (birth to less than 18 years of age weighing at least 1.5 kg) who are [see Clinical Studies (14)]: Hospitalized, or Not hospitalized and have mild-to-moderate COVID-19, and are at high risk for progression to severe COVID-19, including hospitalization or death.
1 INDICATIONS AND USAGE 1.7 Coronavirus Disease 2019 (COVID-19) ACTEMRA® (tocilizumab) is indicated for the treatment of coronavirus disease 2019 (COVID-19) in hospitalized adult patients who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO).
The current treatment guidelines for COVID-19 include:
- Hospitalized patients:
- Remdesivir (IV) is indicated for the treatment of COVID-19 in hospitalized adults and pediatric patients 2
- Tocilizumab (IV) is indicated for the treatment of COVID-19 in hospitalized adult patients who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO) 3
- Non-hospitalized patients:
- Remdesivir (IV) is indicated for the treatment of mild-to-moderate COVID-19 in non-hospitalized adults and pediatric patients who are at high risk for progression to severe COVID-19, including hospitalization or death 2
From the Research
Current Treatment Guidelines for COVID-19
- The current treatment guidelines for COVID-19 focus on supportive care, as no antiviral agent has shown to be effective in treating the disease 4.
- Patients with severe and critical disease require full active treatment, including oxygen for hypoxaemia and ventilatory support, along with optimal management of complications and underlying co-morbidities 4.
- Determination of hospital admission should involve consideration of age, comorbidities, respiratory rate, and oxygen saturation 5.
- Patients with hypoxemia, dyspnea, or a high respiratory rate should be admitted to intensive care, and those with severe hypoxemia or high respiratory rate should undergo intubation and invasive ventilation 5.
Pharmacological Treatment
- Treatment with dexamethasone has been shown to decrease mortality among patients with severe or critical COVID-19 5.
- Combination therapy with baricitinib, remdesivir, and dexamethasone has been effective in treating severe COVID-19, with a low incidence of adverse events 6.
- High-dose steroids, remdesivir, and baricitinib have also been used in combination, with a low frequency of high-grade adverse events and a high rate of improvement in patients with moderate to severe COVID-19 7.
Supportive Care
- Standard critical care measures, including prone ventilation, avoidance of excessive tidal volumes, conservative fluid management, and antibiotic stewardship, remain at the core of management of patients with severe COVID-19 8.
- Early evaluation for extracorporeal membrane oxygenation (ECMO) is also recommended for patients with severe COVID-19 8.
- Personal protection measures, including attention to hygiene and the correct wearing of personal protective equipment, are essential for preventing transmission of the disease 5.