What are the treatment approaches for COVID-19?

Treatment Approaches for COVID-19

For COVID-19 patients requiring supplemental oxygen, non-invasive or mechanical ventilation, systemic glucocorticoids should be used since they can decrease mortality, and the combination of glucocorticoids with tocilizumab should be considered as it reduces disease progression and mortality. 1

Treatment Strategy Based on Disease Severity

COVID-19 treatment should be tailored according to disease severity, with different approaches required at different stages:

1. Non-hospitalized Patients (Mild Disease)

• No immunomodulatory therapy is recommended for non-hospitalized patients with SARS-CoV-2 infection 1
• For high-risk patients with mild-to-moderate disease and symptom onset within 7 days:
  • Remdesivir may be administered for 3 days 2
  • Monoclonal antibodies against SARS-CoV-2 spike protein should be considered, especially in patients with symptom onset <5 days or those who are still seronegative 1

2. Hospitalized Patients Not Requiring Oxygen

• Currently no evidence supports immunomodulatory therapy for hospitalized patients who don't need oxygen therapy 1
• Monitor for disease progression with laboratory markers (CRP, D-dimer, ferritin) 1

3. Hospitalized Patients Requiring Oxygen

• Systemic glucocorticoids (particularly dexamethasone) should be administered as they decrease mortality 1
• Remdesivir should be initiated as soon as possible after diagnosis, with a recommended treatment duration of 5 days (can be extended up to 10 days if no clinical improvement) 2
• Combination therapy options:
  • Glucocorticoids + tocilizumab should be considered as this combination reduces disease progression and mortality 1
  • Glucocorticoids + baricitinib or tofacitinib could be considered for patients requiring oxygen therapy, non-invasive ventilation or high-flow oxygen 1

4. Critically Ill Patients (Mechanical Ventilation/ECMO)

• Systemic glucocorticoids are strongly recommended 1
• Remdesivir for a total treatment duration of 10 days 2
• Combination of glucocorticoids and tocilizumab should be considered 1

Medications to Avoid or Use with Caution

• Hydroxychloroquine should be avoided for treating any stage of SARS-CoV-2 infection as it provides no additional benefit to standard care and could worsen prognosis, particularly if co-prescribed with azithromycin 1
• Convalescent plasma should not be used in patients without hypogammaglobulinemia and with symptom onset >5 days 1
• There is no robust evidence to support the use of:
  • Anakinra or canakinumab at any disease stage 1
  • Low-dose colchicine at any disease stage 1
  • GM-CSF inhibitors (mavrilimumab, otilimab, lenzilumab) 1
  • Other immunomodulators including interferons, leflunomide, non-SARS-CoV-2 IVIg, eculizumab, cyclosporine 1

Special Considerations

Immunocompromised Patients

• Patients with hematological malignancies or hematopoietic cell transplantation may experience prolonged viral shedding 1
• For these patients, antiviral control becomes more important, and symptom-based categorization rather than time-based approach should be used 1
• Anti-inflammatory treatments should be initiated when signs of inflammatory phase are present (elevated CRP, respiratory worsening) 1

Monitoring During Treatment

• Hepatic laboratory testing should be performed before starting and during remdesivir treatment 2
• Prothrombin time should be determined before starting and monitored during remdesivir treatment 2
• Monitor inflammatory markers (CRP, D-dimer, ferritin) to guide treatment decisions 1

Recovery and Rehabilitation

• For convalescent patients, particularly those with pulmonary fibrosis, consider breathing exercises and pulmonary function recovery strategies 1

Common Pitfalls to Avoid

1. Delayed initiation of treatment - Remdesivir and monoclonal antibodies should be started as soon as possible after diagnosis
2. Inappropriate use of immunomodulatory therapy in patients who don't require oxygen
3. Using hydroxychloroquine despite evidence showing lack of benefit and potential harm
4. Failure to recognize cytokine storm - Monitor for signs of hyperinflammation that may require immunomodulatory intervention
5. Not adjusting treatment based on disease progression - Treatment duration may need extension if clinical improvement is not observed

COVID-19 treatment continues to evolve as new evidence emerges, but the staged approach based on disease severity remains the cornerstone of management, with particular focus on early antiviral therapy and appropriate immunomodulation for more severe disease.