What are the treatment options for Covid-19?

COVID-19 Treatment Options

The most effective treatment approach for COVID-19 includes anti-SARS-CoV-2 monoclonal antibodies as first-line therapy for mild disease, remdesivir for hospitalized patients, dexamethasone for severe disease, and appropriate anticoagulation based on disease severity and patient risk factors. 1

Treatment Based on Disease Severity

Mild COVID-19 (Outpatient)

• First-line treatment: Anti-SARS-CoV-2 monoclonal antibodies for high-risk patients 1
• Alternative options (if monoclonal antibodies unavailable):
  • High-titer convalescent plasma (within 72 hours from symptom onset) 1
  • Inhaled IFN β-1a 1
  • Molnupiravir (oral antiviral) 1
  • Remdesivir (IV antiviral) 1, 2
    • For adults and pediatric patients (≥1.5 kg): 200 mg IV on day 1, followed by 100 mg IV daily 2
    • For pediatric patients <40 kg: Weight-based dosing (see specific guidelines) 2
  • Ritonavir/nirmatrelvir (oral antiviral) 1

Moderate to Severe COVID-19 (Hospitalized, O₂ requirement)

• Primary treatments:
  • Remdesivir 1, 2
  • Dexamethasone (only for patients requiring oxygen) 1
  • For seronegative patients: casirivimab/imdevimab or convalescent plasma 1

Critical COVID-19 (ICU, mechanical ventilation, ARDS)

• Core treatments:
  • Dexamethasone 1
  • If seronegative on non-invasive ventilation: casirivimab/imdevimab 1
  • Consider adding a second immunosuppressant if COVID-19-related inflammation is present:
    • Anti-IL-6 (tocilizumab, sarilumab) 1
    • Anti-IL-1 (anakinra) 1
    • JAK inhibitors (baricitinib/tofacitinib) 1

Anticoagulation Management

Outpatient Setting

• For patients on antiplatelet therapy for previous stroke: continue antiplatelet therapy without adding anticoagulation 3
• For patients with new-onset atrial fibrillation: start DOAC if CHA₂DS₂-VASc score ≥1 in males or ≥2 in females 3

Non-ICU Hospitalized Patients

• All patients should receive prophylactic-dose LMWH 3
• For patients on antiplatelet therapy for previous stroke: continue antiplatelet and add prophylactic-dose LMWH 3
• For patients on DAPT for recent ACS: continue DAPT if receiving prophylactic-dose anticoagulation 3
• For patients with new-onset AF: start therapeutic-dose parenteral anticoagulation regardless of CHA₂DS₂-VASc score 3

ICU Patients

• For patients on antiplatelet therapy for previous stroke: continue antiplatelet and add prophylactic-dose LMWH 3
• For patients on DAPT for recent ACS who need therapeutic anticoagulation: individualize decision based on bleeding risk 3

Symptom Management

Cough

• Position patient to avoid lying on back 3
• First-line: Honey (for patients >1 year old) 3
• For distressing cough: Consider codeine linctus, codeine phosphate tablets, or morphine sulfate oral solution 3

Fever

• Maintain adequate hydration (up to 2 liters/day) 3
• Acetaminophen (reported as highly effective for fever management) 4

Respiratory Symptoms

• Oxygen supplementation as needed 5
• For patients with asthma/reactive airway disease: albuterol MDI or nebulizer 4
• For lower respiratory symptoms: guaifenesin, benzonatate 4

Special Populations

Hematological Malignancy Patients

• For patients not immunized and at risk for severe COVID-19: pre-exposure prophylaxis with long-acting anti-SARS-CoV-2 monoclonal antibodies 3
• Post-exposure prophylaxis with anti-SARS-CoV-2 monoclonal antibodies for high-risk patients (not vaccinated, vaccine non-responders) 3

Important Considerations and Pitfalls

• Early intervention is crucial: Treatment with remdesivir should be initiated as soon as possible after diagnosis 2
• Treatment duration varies: 5 days for hospitalized patients not requiring mechanical ventilation; 10 days for those requiring mechanical ventilation/ECMO 2
• Avoid dexamethasone in mild disease: Dexamethasone should NOT be used for mild COVID-19 but is the primary treatment for severe disease 1
• Monitor for complications: Perform hepatic laboratory testing and monitor prothrombin time before starting and during remdesivir treatment 2
• Thromboprophylaxis is essential: COVID-19 is associated with a prothrombotic state requiring appropriate anticoagulation 3
• Cardiovascular medications: Continue ACE inhibitors and ARBs in patients with COVID-19, as they do not increase infection risk or mortality 3

By following these evidence-based treatment approaches and tailoring therapy to disease severity and patient characteristics, clinicians can optimize outcomes for patients with COVID-19.