What are the treatment options for COVID-19?

Treatment Options for COVID-19

For patients with COVID-19, the recommended treatment approach should be based on disease severity, with remdesivir as the primary antiviral therapy for hospitalized patients, while non-hospitalized high-risk patients should receive either remdesivir, monoclonal antibodies, or oral antivirals based on availability and clinical presentation. 1, 2

Treatment Based on Disease Severity

Mild to Moderate COVID-19 (Non-hospitalized)

For patients with mild-to-moderate COVID-19 who are at high risk for progression to severe disease:

1. Antiviral Therapy Options:

   • Remdesivir: 200mg IV on day 1, followed by 100mg IV daily for 2 days (total 3-day course) 1
   • Oral Antivirals: Consider nirmatrelvir/ritonavir if available 2
   • Monoclonal Antibodies: Recommended for high-risk patients, especially those who are unvaccinated or vaccine non-responders 2

2. Symptomatic Treatment:

   • Cough: Encourage patients to avoid lying on their back; consider honey (for patients >1 year old), codeine linctus, codeine phosphate tablets, or morphine sulfate oral solution for distressing cough 2
   • Fever: Advise regular fluid intake (≤2 liters/day); acetaminophen is most commonly used and perceived as highly effective 2, 3
   • Respiratory symptoms: Benzonatate, guaifenesin, and albuterol MDIs are commonly used with high perceived efficacy 3

Moderate COVID-19 (Hospitalized, requiring oxygen)

For patients with moderate COVID-19 requiring oxygen support with saturation >90%:

1. Primary Therapies:

   • Remdesivir: 200mg IV on day 1, followed by 100mg IV daily for 4-9 days 1, 2
   • Dexamethasone: Recommended for patients requiring oxygen 2

2. Additional Considerations:

   • For seronegative patients, consider casirivimab/imdevimab or convalescent plasma 2
   • If worsening despite dexamethasone with COVID-19-related inflammation, consider adding a second immunosuppressant:
     • Anti-IL-6 (tocilizumab, sarilumab)
     • Anti-IL-1 (anakinra)
     • JAK inhibitors (baricitinib/tofacitinib) 2

Severe to Critical COVID-19

For patients with severe COVID-19 (oxygen saturation <90%, respiratory rate >30/min) or critical COVID-19 (ARDS, sepsis, shock, requiring mechanical ventilation):

1. Core Treatments:

   • Dexamethasone: Strongly recommended 2
   • Remdesivir: Recommended, especially for those not on mechanical ventilation 2, 1
   • Respiratory Support: Consider high-flow oxygen or non-invasive ventilation for hypoxemic respiratory insufficiency; proceed to intubation and invasive ventilation for severe hypoxemia or high respiratory rate 4, 5

2. Additional Therapies:

   • Anti-IL-6 agents (tocilizumab, sarilumab) for patients with evidence of systemic inflammation 2
   • Enhanced thromboprophylaxis for patients with additional risk factors (obesity, known thrombophilia, ICU treatment, elevated D-dimers) 4

Special Populations

Patients with Hematological Malignancies

• Pre-exposure prophylaxis with long-acting anti-SARS-CoV-2 monoclonal antibodies is recommended for unimmunized patients 2
• Post-exposure prophylaxis with anti-SARS-CoV-2 monoclonal antibodies is recommended for high-risk patients 2
• Treatment follows general guidelines but with closer monitoring due to higher mortality risk 2

Traditional Chinese Medicine Approaches

For regions where traditional Chinese medicine is integrated with conventional care:

• Qingfei Paidu Decoction (QPD): May be considered as an adjunct to conventional therapy 2
• Lianhua Qingwen Granules/Capsules: Suggested for patients with mild or moderate COVID-19 alongside conventional therapy 2
• Non-drug treatments: Consider Tai Chi, breathing relaxation training, mindfulness training for anxiety and mental health symptoms 2

Important Clinical Considerations

• Early Initiation: Treatment should be initiated as soon as possible after diagnosis of symptomatic COVID-19 1
• Laboratory Monitoring: Perform hepatic laboratory testing and determine prothrombin time before starting and during remdesivir treatment 1
• Treatment Duration:
  • Non-hospitalized patients: 3 days of remdesivir 1
  • Hospitalized patients not requiring mechanical ventilation: 5 days (can extend to 10 days if no clinical improvement) 1
  • Hospitalized patients requiring mechanical ventilation/ECMO: 10 days 1

Common Pitfalls to Avoid

1. Delayed Treatment Initiation: Antiviral therapy is most effective when started early in the disease course
2. Inappropriate Antibiotic Use: Antibiotics should not be used unless bacterial infection is clinically suspected 2
3. Inadequate Thromboprophylaxis: COVID-19 is associated with a prothrombotic state requiring appropriate anticoagulation 2
4. Overlooking Mental Health: Psychological support should be integrated into care plans 2
5. Premature Discharge: Ensure patients meet appropriate discharge criteria, including resolution of fever for >3 days, improvement of respiratory symptoms, and significant absorption of pulmonary lesions on imaging 2

By following these evidence-based treatment approaches and avoiding common pitfalls, clinicians can optimize outcomes for patients with COVID-19 across the spectrum of disease severity.