What are the treatment options for Covid-19?

Treatment Options for COVID-19

The most effective treatment approach for COVID-19 includes corticosteroids (dexamethasone 6mg daily for 10 days) for hospitalized patients requiring oxygen, anticoagulation prophylaxis for all hospitalized patients, and consideration of remdesivir based on oxygen requirements. 1

Pharmacological Interventions Based on Disease Severity

Outpatient (Mild-to-Moderate COVID-19)

• For high-risk patients:

  • Nirmatrelvir/ritonavir (Paxlovid) as first-line therapy 1, 2
  • Remdesivir: 200mg IV on day 1, followed by 100mg IV daily for 2-4 days 3, 2
  • Monoclonal antibodies (casirivimab/imdevimab) for unvaccinated or vaccine non-responders, though efficacy may vary with different variants 4, 1

• For symptom management:

  • Cough: Avoid lying on back; consider honey (for patients >1 year), codeine linctus, codeine phosphate tablets, or morphine sulfate oral solution for distressing cough 5, 6
  • Fever: Regular fluid intake (≤2 L/day) and acetaminophen 5, 6
  • Respiratory symptoms: Albuterol MDIs (highly effective), benzonatate, and guaifenesin 6

Hospitalized Patients (Moderate-to-Severe COVID-19)

• Corticosteroids:

  • Dexamethasone 6mg daily for 10 days for patients requiring oxygen 1

• Anticoagulation:

  • Low molecular weight heparin (LMWH) at prophylactic dosage for all hospitalized patients 1, 5
  • Consider higher doses for patients with additional risk factors (high BMI, history of VTE, active cancer) 1
  • For non-critically ill patients, therapeutic-dose anticoagulation may improve outcomes 5

• Antiviral therapy:

  • Remdesivir for patients with moderate COVID-19 requiring oxygen with saturation >90% 1, 3
  • Treatment duration: 5 days for non-ventilated patients; can be extended to 10 days if no improvement 3

• Immunomodulatory agents:

  • IL-6 receptor antagonists (tocilizumab) for patients requiring oxygen or ventilatory support, most effective when combined with corticosteroids 1
  • Consider baricitinib/tofacitinib for patients with worsening disease despite dexamethasone 1

Respiratory Support

• High-flow nasal cannula (HFNC) or non-invasive CPAP for patients with hypoxemic respiratory failure without immediate indication for invasive mechanical ventilation 1, 7
• Can be delivered through helmet or facemask under supervision by clinicians capable of performing endotracheal intubation if patient deteriorates 1

Special Considerations

Cardiovascular Complications

• For patients with COVID-19 and confirmed ACS, dual antiplatelet therapy (DAPT) is strongly recommended 5
• For patients with myocardial injury without ACS, DAPT is not recommended 5
• For patients already on DAPT for recent ACS who are receiving prophylactic-dose anticoagulant, continue DAPT 5

Atrial Fibrillation

• For outpatients with COVID-19 and new-onset AF: Start DOAC if CHA₂DS₂-VASc score is ≥1 in males or ≥2 in females 5
• For hospitalized patients with COVID-19 and new-onset AF: Start therapeutic-dose parenteral anticoagulation regardless of CHA₂DS₂-VASc score 5

Treatments to Avoid

• Hydroxychloroquine (with or without azithromycin) 1
• Lopinavir-ritonavir 1
• Azithromycin (unless bacterial infection is present) 1
• Colchicine 1, 2
• Ivermectin 2
• Systemic steroids for non-hospitalized patients 2

Treatment Timing and Duration

• Initiate treatment as soon as possible after diagnosis of symptomatic COVID-19 3
• For hospitalized patients requiring mechanical ventilation/ECMO: 10-day treatment course 3
• For hospitalized patients not requiring mechanical ventilation/ECMO: 5-day treatment course (may extend to 10 days if no improvement) 3

Monitoring

• Perform hepatic laboratory testing in all patients before starting and during remdesivir treatment 3
• Monitor prothrombin time before and during remdesivir treatment 3
• Assess for potential drug interactions, particularly with nirmatrelvir/ritonavir 1

COVID-19 treatment continues to evolve as new evidence emerges. The approach should be guided by disease severity, patient risk factors, and available resources, with particular attention to reducing mortality and preventing progression to severe disease.