What alternative medications can be used to treat COVID-19?

Alternative Medications for COVID-19 Treatment

Corticosteroids, tocilizumab, and remdesivir are the most effective alternative medications for treating COVID-19, with their use determined by disease severity and inflammatory markers. 1

First-Line Treatment Options by Disease Severity

Severe COVID-19

• Corticosteroids: Strongly recommended for severe COVID-19 with moderate evidence quality 1

  • Associated with lower all-cause mortality, reduced IMV requirements, higher disease improvement rates
  • Monitor for potential hyperglycemia as a side effect
  • Dexamethasone 6 mg daily for up to 10 days is the standard regimen 2

• Tocilizumab (TCZ): Strongly recommended for adult patients with high inflammatory markers 1

  • Most effective in patients with high CRP levels (≥100 mg/L)
  • Reduces risk of all-cause mortality and requirements for mechanical ventilation
  • Monitor liver function closely when using TCZ 1

• Remdesivir: Consider for patients receiving oxygen therapy but not on invasive mechanical ventilation 1

  • 5-day course recommended (weak recommendation, moderate evidence quality)
  • Probably increases chance of clinical improvement slightly 3
  • Decreases risk of clinical worsening within 28 days 3
  • May cause elevated transaminases; monitor liver function 1

• Intravenous Immunoglobulin (IVIg): Consider for patients who fail to respond to initial therapy 1

  • Strong recommendation with moderate evidence quality
  • Particularly useful when other treatments have failed

Mild to Moderate COVID-19

• Remdesivir: May be beneficial for non-hospitalized patients with mild COVID-19 3, 4

  • Decreases risk of hospitalization (RR 0.28,95% CI 0.11 to 0.75) 3
  • Standard dosing: 200 mg IV loading dose on day 1, followed by 100 mg IV daily maintenance dose 2

• Nirmatrelvir-ritonavir (Paxlovid): Consider for patients with risk factors for disease progression 2, 4

  • Must be started within 5 days of symptom onset
  • Preferred due to high efficacy and convenience of administration 4
  • Caution with drug interactions; adjust doses accordingly

Traditional Chinese Medicine (TCM) Options

• TCM medications based on syndrome differentiation are recommended for severe COVID-19 in combination with standard care 1
  • "Three CPMs and three decoctions" with effects of "releasing pulmonary Qi and detoxicating"
  • Chinese Patent Medicines (CPMs) like LHQW granules, JHQG granule, Tongjie Quwen granules, and XBJ injection 1
  • TCM decoctions such as Maxingshigan decoction, QFPD decoction, and others based on syndrome differentiation 1
  • Can effectively ameliorate symptoms of fever, cough, expectoration, shortness of breath, and fatigue

Medications to Avoid

• Hydroxychloroquine/Chloroquine: Not recommended due to lack of efficacy and potential harm 2, 5

  • No significant differences in viral clearance rate or clinical progression 1
  • May increase mortality among hospitalized patients 6
  • FDA has revoked authorization for use in COVID-19 patients 6

• Lopinavir-ritonavir: Not recommended for severe COVID-19 2

  • Did not improve clinical outcomes or increase viral clearance in a randomized controlled trial 1
  • Should be withheld in cases of moderate-to-severe liver dysfunction 1

Special Considerations

Liver Function

• Monitor liver function tests in all patients on admission and throughout hospitalization 1
• For patients with abnormal liver function, investigate non-COVID-19 causes of liver disease 1
• Use off-label COVID-19 treatments with caution and close monitoring in patients with abnormal liver function 1
• Consider withholding off-label treatments in cases of moderate-to-severe liver dysfunction 1

Elderly Patients

• Reduce polypharmacy and adjust drug doses according to organ function and drug interactions 1
• For patients 60-80 years old, administer 3/4-4/5 of the adult dose 1
• For patients over 80 years old, reduce dose to 1/2 of the adult dose 1
• Review medication prescriptions to prevent drug interactions and adverse events 1

Monitoring and Follow-up

• Close monitoring of clinical signs of deterioration is essential 1
• For severe patients, monitor oxygen saturation and consider respiratory support as needed
• Schedule virtual follow-up 1-2 weeks after diagnosis and report worsening symptoms immediately 2

Remember that treatment decisions should be made in consultation with infectious disease specialists whenever possible, and patients should be enrolled in clinical trials when available 1.