What is the recommended treatment for a patient who is Covid-19 (Coronavirus disease 2019) positive?

Recommended Treatment for COVID-19 Positive Patients

For patients with COVID-19, nirmatrelvir/ritonavir is strongly recommended as first-line therapy for high-risk patients with non-severe disease, while dexamethasone is strongly recommended for patients requiring oxygen support. 1

Treatment Based on Disease Severity

Non-Severe COVID-19 (Outpatient)

High-Risk Patients:

1. Nirmatrelvir/ritonavir (Paxlovid)

   • First-line therapy 1
   • Start as soon as possible within 5 days of symptom onset
   • Caution: Significant drug interactions with BTK inhibitors and BCL-2 inhibitors 1
   • Monitor for diarrhea and dysgeusia (taste disturbance)

2. Remdesivir

   • Alternative if nirmatrelvir/ritonavir contraindicated 1
   • 200mg IV on Day 1, then 100mg IV daily for 2 more days (3-day course) 2
   • Requires daily intravenous administration
   • Monitor hepatic function before starting and during treatment 2

3. Monoclonal antibodies

   • Consider for unvaccinated or vaccine non-responders 1
   • Efficacy depends on activity against circulating variants

Low-Risk Patients:

• Supportive care
• Hydration
• Antipyretics
• Rest

Severe COVID-19 (Hospitalized, Requiring Oxygen)

1. Dexamethasone

   • 6mg daily for up to 10 days 1
   • Reduces mortality in patients requiring oxygen 1

2. Remdesivir

   • 200mg IV on Day 1, then 100mg IV daily 2
   • Duration: 5 days (can extend to 10 days if no clinical improvement) 2
   • Monitor hepatic function and prothrombin time 2

3. Baricitinib (JAK inhibitor)

   • Add to dexamethasone in severe/critical disease 1
   • Can be combined with IL-6 receptor blockers 1

Critical COVID-19 (ICU, Requiring Mechanical Ventilation)

1. Dexamethasone (as above)

2. IL-6 Receptor Blockers (tocilizumab)

   • For worsening disease with inflammation 1
   • Use in combination with dexamethasone

3. Anticoagulation

   • Low molecular weight heparin for thromboprophylaxis 1
   • Consider higher doses for patients with additional risk factors 1

Monitoring and Supportive Care

• Monitor oxygen saturation
• Hepatic laboratory testing before and during treatment with remdesivir 2
• For patients requiring oxygen: high-flow nasal oxygen or non-invasive CPAP before considering invasive mechanical ventilation 1
• Monitor for treatment response: resolution of fever, improvement of respiratory symptoms, absorption of pulmonary lesions on imaging 1

Important Considerations

• Start antiviral therapy as early as possible in the disease course for maximum benefit 1
• For patients with liver disease and COVID-19, standard investigations for liver diseases should be performed if persistent liver derangement is observed 3
• Patients with abnormal liver function should be closely monitored when using experimental COVID-19 treatments 3
• Off-label treatments should be withheld in cases of moderate-to-severe liver injury 3

Treatments NOT Recommended

• Hydroxychloroquine (lack of efficacy, potential harm) 1
• Azithromycin (unless bacterial infection is suspected) 1
• Lopinavir-ritonavir (no benefit beyond standard care in severe COVID-19) 4
• Ivermectin 5
• Systemic steroids for non-severe disease 5

Special Populations

Immunocompromised Patients

• Consider monoclonal antibodies for pre-exposure prophylaxis 1
• May require extended duration of antiviral therapy 1

Patients with Liver Disease

• Test liver function in hospitalized patients with COVID-19 3
• Monitor liver tests twice weekly in patients on potentially hepatotoxic medication 3
• Screen for HBsAg if systemic corticosteroids or immunosuppressants are used for ≥7 days 3

Common Pitfalls to Avoid

1. Delaying antiviral therapy in high-risk patients (should be started within 5 days of symptom onset)
2. Failing to check for drug interactions with nirmatrelvir/ritonavir
3. Using dexamethasone in patients without oxygen requirements (may be harmful)
4. Not monitoring liver function in patients receiving remdesivir
5. Using unproven therapies outside of clinical trials

By following these evidence-based recommendations and avoiding common pitfalls, clinicians can optimize outcomes for patients with COVID-19 while minimizing risks of adverse events.