What are the treatment options for Covid-19 (Coronavirus disease 2019)?

Treatment Options for COVID-19

For patients with mild-to-moderate COVID-19 who are at high risk for progression to severe disease, PAXLOVID (nirmatrelvir/ritonavir) is the recommended first-line treatment and should be initiated as soon as possible after diagnosis and within 5 days of symptom onset. 1

General Management Principles

Supportive Care (All Patients)

• Rest in bed with monitoring of vital signs (heart rate, pulse oxygen saturation, respiratory rate, blood pressure)
• Ensure sufficient energy intake and balance of water, electrolytes, and acid-base levels
• Monitor laboratory parameters: blood routine, CRP, PCT, organ function, coagulation function, arterial blood gas analysis, and chest imaging 2

Oxygen Therapy

• Provide effective oxygen therapy based on severity:
  • Mild: Nasal catheter or mask oxygen
  • Moderate-Severe: High flow nasal oxygen therapy (HFNO) or non-invasive ventilation (NIV)
  • Critical: Invasive mechanical ventilation
  • Refractory hypoxemia: Consider Extracorporeal Membrane Oxygenation (ECMO) 2

Specific Therapeutic Options

1. Antiviral Therapy

First-line therapy for high-risk patients with mild-to-moderate COVID-19:

• Nirmatrelvir/ritonavir (PAXLOVID): 300 mg nirmatrelvir (two 150 mg tablets) with 100 mg ritonavir (one 100 mg tablet), with all 3 tablets taken together twice daily for 5 days 1
  • Dosage adjustment for renal impairment:
    • Moderate renal impairment (eGFR ≥30 to <60 mL/min): 150 mg nirmatrelvir with 100 mg ritonavir twice daily for 5 days
    • Severe renal impairment (eGFR <30 mL/min): 300 mg nirmatrelvir with 100 mg ritonavir once on Day 1, then 150 mg nirmatrelvir with 100 mg ritonavir once daily for Days 2-5 1
  • Important: Review all medications for potential drug-drug interactions before prescribing PAXLOVID 1

Alternative antiviral options:

• Remdesivir: May be considered for patients with COVID-19 2
• Favipiravir: Suggested for treatment of patients with COVID-19 2
• α-interferon atomization inhalation: 5 million U per time for adults in sterile injection water, twice a day (weak recommendation) 2

2. Immunomodulatory Therapy

• Corticosteroids: For severe ARDS or rapid disease progression

  • Methylprednisolone 40-80 mg per day (not exceeding 2 mg/kg/day) 2
  • Should be used cautiously and for short courses 2

• Interleukin-6 inhibitors: May be considered when severe/critical COVID-19 patients' condition deteriorates dramatically 2

3. Antibiotic Therapy

• Avoid blind or inappropriate use of antibacterial drugs
• For mild cases with suspected bacterial co-infection: Consider antibiotics effective against community-acquired pneumonia (amoxicillin, azithromycin, or fluoroquinolones)
• For severe cases: Empirical broad-spectrum antibiotics covering all possible pathogens, with de-escalation once pathogen is identified 2

4. Management of COVID-19 Associated Complications

COVID-19 Associated Mucormycosis (CAM)

• Primary therapy: Liposomal amphotericin B IV 5 mg/kg daily (10 mg/kg daily for CNS involvement) for 4-6 weeks 2
• Alternatives:
  • Amphotericin B deoxycholate 1.0-1.5 mg/kg daily
  • Isavuconazole 200 mg IV/PO every 8 hours for 6 doses, followed by 200 mg daily
  • Posaconazole 300 mg IV/PO every 12 hours for 2 doses, followed by 300 mg daily 2
• Maintenance therapy: 3-6 months until resolution of clinical signs and symptoms 2

Prevention Strategies

Non-pharmaceutical Interventions

• Improve ventilation in indoor spaces
• Use masks or respirators indoors when community transmission is high
• Testing after exposure or when symptomatic
• Isolation for ≥5 days if infected 3

Pharmaceutical Prevention

• Vaccination to prevent severe illness
• Pre-exposure prophylaxis for immunocompromised individuals 3

Special Considerations

Drug Interactions

• PAXLOVID contains ritonavir, a strong CYP3A inhibitor, which may lead to significant drug interactions
• Prior to prescribing PAXLOVID:
  1. Review all medications to assess potential drug-drug interactions
  2. Determine if concomitant medications require dose adjustment, interruption, or additional monitoring 1

Contraindications for PAXLOVID

• History of clinically significant hypersensitivity to nirmatrelvir or ritonavir
• Co-administration with drugs highly dependent on CYP3A for clearance
• Co-administration with potent CYP3A inducers 1

Pitfalls and Caveats

1. Timing is critical: Antiviral therapy is most effective when started early (within 5 days of symptom onset)
2. Drug interactions: Carefully screen for potential interactions, especially with PAXLOVID
3. Overuse of antibiotics: Avoid unnecessary antibiotic use to prevent antimicrobial resistance
4. Corticosteroid use: Should be reserved for appropriate patients; inappropriate use may worsen outcomes
5. Monitoring for complications: COVID-19 can affect multiple organ systems; vigilant monitoring is essential

The management of COVID-19 continues to evolve as new evidence emerges. Treatment decisions should be based on disease severity, patient risk factors, and local epidemiology while considering the most recent guidelines and evidence.