How is Covid-19 (Coronavirus disease 2019) infection treated?

COVID-19 Treatment Guidelines: Current Approach

COVID-19 infection continues to be treated with targeted therapies based on disease severity, with antiviral medications recommended for high-risk patients and supportive care for those with mild disease. 1

Treatment Algorithm Based on Disease Severity

For Non-Hospitalized Patients with Mild-to-Moderate COVID-19

High-Risk Patients:

• Nirmatrelvir/ritonavir (Paxlovid) is the first-line treatment for high-risk patients, initiated as soon as possible and within 5 days of symptom onset 2
  • Dosage: 300 mg nirmatrelvir (two 150 mg tablets) with 100 mg ritonavir (one 100 mg tablet), taken together twice daily for 5 days
  • Requires dose adjustment for moderate to severe renal impairment
  • Contraindicated with certain medications due to significant drug interactions 2

Low-Risk Patients:

• Supportive care only (hydration, rest, antipyretics)
• No specific antiviral therapy recommended 1

For Hospitalized Patients

Requiring Oxygen:

• Corticosteroids (strong recommendation, moderate quality evidence) 3
  • Dexamethasone 6 mg daily for up to 10 days
  • Shown to reduce mortality in patients requiring oxygen or mechanical ventilation

Requiring Oxygen with Signs of Hyperinflammation:

• IL-6 receptor antagonist monoclonal antibody therapy (conditional recommendation, low quality evidence) 3
  • Consider tocilizumab in addition to standard care
  • Particularly beneficial in patients with elevated inflammatory markers

Requiring Mechanical Ventilation:

• Corticosteroids (strong recommendation) 3
• Prophylactic anticoagulation (strong recommendation, very low quality evidence) 3, 1
  • Standard prophylactic dosing for critically ill patients
  • Therapeutic dosing has not shown benefit in critically ill patients

What NOT to Use

• Hydroxychloroquine (strong recommendation against, moderate quality evidence) 3
• Lopinavir-ritonavir (strong recommendation against, low quality evidence) 3
• Azithromycin (conditional recommendation against, very low quality evidence) 3
• Hydroxychloroquine and azithromycin in combination (conditional recommendation against, moderate quality evidence) 3
• Colchicine for hospitalized patients (conditional recommendation against, very low quality evidence) 3
• Interferon-β (conditional recommendation against, very low quality evidence) 3

Special Considerations

Immunocompromised Patients

• May have prolonged viral shedding 3
• May benefit from monoclonal antibody prophylaxis if no serological response to vaccine 3
• Consider extending treatment duration in consultation with infectious disease specialists

Patients with Liver Disease

• No need to delay necessary treatment unless shortage of medical resources 3
• For patients on immunosuppressants, rapid exacerbation of respiratory symptoms has been reported 3

Common Pitfalls to Avoid

1. Delaying antiviral treatment - Nirmatrelvir/ritonavir must be started within 5 days of symptom onset for maximum effectiveness 2

2. Missing drug interactions - Ritonavir is a strong CYP3A4 inhibitor and has significant interactions with many medications including BTK inhibitors and BCL-2 inhibitors 3

3. Inappropriate use of corticosteroids - Not recommended for patients not requiring oxygen as they may increase mortality 3

4. Empirical antibiotics without evidence of bacterial infection - Not required in all patients with confirmed COVID-19 pneumonia 1

5. Overlooking anticoagulation - Some form of anticoagulation should be offered to all hospitalized patients 3

The management of COVID-19 continues to evolve as new evidence emerges. The current approach emphasizes early antiviral therapy for high-risk outpatients and targeted anti-inflammatory therapy for hospitalized patients requiring oxygen, with supportive care remaining the cornerstone of management for all patients.