What is the recommended treatment for Covid-19?

Recommended Treatment for COVID-19

The recommended treatment for COVID-19 depends on disease severity, with remdesivir being the primary antiviral therapy for hospitalized patients requiring oxygen, dexamethasone for those needing respiratory support, and nirmatrelvir-ritonavir (Paxlovid) for high-risk outpatients within 5 days of symptom onset. 1

Disease Severity Classification

COVID-19 treatment is guided by disease severity, which is categorized as:

• Mild: Various symptoms without respiratory distress
• Moderate: Lower respiratory disease with SpO2 ≥94% on room air
• Severe: SpO2 <94% on room air or other specific criteria
• Critical: Requires ICU admission or mechanical ventilation

Treatment Recommendations by Patient Setting

Non-Hospitalized Patients

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

• Nirmatrelvir-ritonavir (Paxlovid): Start within 5 days of symptom onset 1
• Remdesivir: Can be considered for high-risk outpatients, administered as a 3-day course, initiated within 7 days of symptom onset 1, 2

Hospitalized Patients

For patients requiring hospitalization:

1. Remdesivir:

   • Dosing: 200 mg IV loading dose on day 1, followed by 100 mg IV daily 1, 2
   • Duration: 5 days for patients not requiring mechanical ventilation; can be extended to 10 days if no clinical improvement 2
   • Duration for critical illness: 10 days for patients requiring mechanical ventilation or ECMO 2

2. Dexamethasone:

   • 6 mg daily for up to 10 days for patients requiring supplemental oxygen 1
   • Greatest mortality benefit observed in mechanically ventilated patients 3

3. Consider adding tocilizumab (IL-6 inhibitor) for patients with worsening respiratory status and elevated inflammatory markers 1

Pediatric Considerations

• Remdesivir is approved for pediatric patients from birth to <18 years weighing at least 1.5 kg 1, 2
• Dosing varies by weight:
  • For patients weighing 1.5 kg to less than 40 kg: Weight-based dosing applies
  • For patients weighing at least 40 kg: Adult dosing applies 2

Monitoring and Safety

• Before starting remdesivir:
  • Perform hepatic laboratory testing
  • Determine prothrombin time 2
• During treatment:
  • Monitor hepatic function
  • Monitor for potential adverse reactions (hepatic, renal, cardiovascular) 1, 2

Treatments NOT Recommended

Several treatments have been evaluated but are NOT recommended due to lack of efficacy or potential harm:

• Hydroxychloroquine
• Azithromycin
• Lopinavir-ritonavir
• Interferon-β
• Colchicine 1
• Favipiravir (despite being included in some international guidelines, more recent evidence does not support its use) 3

Supportive Care

Supportive care remains essential for all COVID-19 patients:

• Adequate hydration and proper nutrition
• Oxygen therapy for patients with SpO2 <94%
• Monitoring for respiratory distress
• Thromboprophylaxis as appropriate 1

Special Populations

• Renal impairment: No dosage adjustment of remdesivir is recommended, including for patients on dialysis 2
• Inflammatory bowel disease: Consider both COVID-19 and IBD severity when making admission decisions 1
• Liver disease: Closely monitor patients with abnormal liver function 1
• Rheumatic disease: Continue lowest effective dose of dexamethasone possible to control underlying disease 1

Discharge Criteria

Patients can be discharged when meeting all the following:

• Temperature normal for >3 days
• Significant improvement in respiratory symptoms
• Significant absorption of pulmonary lesions on CT imaging
• Two consecutive negative nucleic acid tests from respiratory samples (≥24 hours apart) 1

Common Pitfalls to Avoid

• Delaying antiviral treatment in eligible patients (remdesivir should be started as soon as possible after diagnosis)
• Using treatments with no proven benefit (hydroxychloroquine, azithromycin, etc.)
• Failing to monitor hepatic function before and during remdesivir treatment
• Not adjusting treatment based on disease severity

Remember that treatment guidelines continue to evolve as new evidence emerges, and the approach should be updated according to the latest recommendations.