What are the treatments for COVID-19?

COVID-19 Treatment Approaches Based on Disease Severity

The treatment of COVID-19 should be stratified based on disease severity, with remdesivir as the primary antiviral therapy for hospitalized patients, while non-hospitalized high-risk patients should receive either nirmatrelvir/ritonavir, remdesivir, or monoclonal antibodies depending on availability and clinical factors. 1

Treatment Algorithm Based on Disease Severity

Mild-to-Moderate COVID-19 (Non-hospitalized)

• For high-risk patients:
  • First-line: Nirmatrelvir/ritonavir (Paxlovid) if available and no contraindications
  • Alternatives: Remdesivir (3-day course) or monoclonal antibodies effective against circulating variants
  • Treatment should be initiated as soon as possible after diagnosis 1, 2

Moderate COVID-19 (Hospitalized, requiring oxygen with SpO2 >90%)

• Primary therapies:
  • Remdesivir: 200mg IV loading dose on day 1, followed by 100mg IV daily for 5 days 1, 2
  • Dexamethasone: 6mg daily for 10 days 3, 1
• For seronegative patients:
  • Consider monoclonal antibodies or convalescent plasma 3
• If worsening despite dexamethasone:
  • Consider adding anti-IL-6 (tocilizumab, sarilumab) 3, 1

Severe/Critical COVID-19 (SpO2 <90%, RR >30, or requiring mechanical ventilation)

• Core therapies:
  • Dexamethasone: 6mg daily for 10 days (strongly recommended) 3, 1
  • Remdesivir: Especially for those not on mechanical ventilation 1, 2
  • Anti-IL-6 agents (tocilizumab, sarilumab): For patients with evidence of systemic inflammation 3, 1
• Treatment duration:
  • For patients requiring mechanical ventilation/ECMO: 10 days of remdesivir 2
  • For hospitalized patients not requiring mechanical ventilation: 5 days of remdesivir 2

Important Considerations for Specific Treatments

Remdesivir

• Dosing:
  • Adults and pediatric patients ≥40kg: 200mg IV on day 1, then 100mg IV daily
  • Pediatric patients <40kg: Weight-based dosing (see specific guidelines) 2
• Monitoring:
  • Perform hepatic laboratory testing before starting and during treatment
  • Monitor prothrombin time before and during treatment 2

Corticosteroids (Dexamethasone)

• Most beneficial in patients requiring oxygen therapy
• May be harmful if used in earlier viral phase without oxygen requirement 3
• Meta-analysis using random-effects model shows no significant mortality benefit (RR 0.86 [95% CI, 0.73-1.01]) 3

IL-6 Pathway Inhibitors (Tocilizumab, Sarilumab)

• Most effective when given together with corticosteroids 3
• Consider for patients with rapidly increasing oxygen needs or evidence of systemic inflammation 1
• The RECOVERY trial showed mortality benefit (31% for tocilizumab vs. 35% for usual care) 3

Special Populations

Patients with Hematological Malignancies

• Consider prolonged viral replication phase
• May benefit from extended antiviral treatment
• Monoclonal antibodies may be particularly important in seronegative patients 3

COVID-19 Prophylaxis

• Pre-exposure prophylaxis with long-acting monoclonal antibodies for high-risk unimmunized patients
• Post-exposure prophylaxis with monoclonal antibodies for high-risk patients 1

Common Pitfalls to Avoid

• Inappropriate antibiotic use: Only use when bacterial co-infection is clinically suspected 1
• Inadequate thromboprophylaxis: COVID-19 is associated with a prothrombotic state requiring appropriate anticoagulation 1
• Overlooking mental health: Integrate psychological support into care plans 1
• Premature discharge: Ensure patients meet appropriate discharge criteria including resolution of fever for >3 days and improvement of respiratory symptoms 1
• Delayed treatment initiation: Antiviral therapies are most effective when started early in the disease course 2

By following this evidence-based approach to COVID-19 treatment, clinicians can optimize patient outcomes and reduce mortality across the spectrum of disease severity.