What is the treatment approach for COVID-19 (Coronavirus Disease 2019)?

Treatment Approach for COVID-19

The recommended treatment for COVID-19 should be based on disease severity, with nirmatrelvir-ritonavir as first-line therapy for high-risk outpatients, remdesivir for hospitalized patients, and a combination of supportive care measures for all patients. 1

Disease Severity Classification

COVID-19 treatment should be tailored according to disease severity:

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

Treatment for Non-Hospitalized Patients

High-Risk Outpatients

• First-line: Nirmatrelvir-ritonavir (Paxlovid)

  • Dosing: 300 mg nirmatrelvir with 100 mg ritonavir twice daily for 5 days
  • For eGFR 30-59 mL/min: 150 mg nirmatrelvir with 100 mg ritonavir twice daily 1
  • Must be initiated within 5 days of symptom onset
  • Monitor for drug interactions (ritonavir is a strong CYP3A4 inhibitor)

• Alternative options (if nirmatrelvir-ritonavir is contraindicated):

  • Molnupiravir (less effective but can be used when other options unavailable) 1

Symptomatic Relief

• Maintain hydration
• Paracetamol for fever
• Honey for cough
• Early mobilization when possible 2, 1

Treatment for Hospitalized Patients

Moderate Disease

• Remdesivir (Veklury) 3
  • Adults and pediatric patients ≥40 kg: 200 mg IV on day 1, then 100 mg IV daily
  • Pediatric patients <40 kg: Weight-based dosing (see specific guidelines)
  • Duration: 5 days (may extend to 10 days if no improvement)
  • Monitor liver function and prothrombin time before and during treatment

Severe/Critical Disease

• Remdesivir as above 3
• Corticosteroids for patients requiring oxygen 1
• Anticoagulation with LMWH 2
  • Standard prophylactic dosing for most patients
  • Consider intensified VTE prophylaxis for high-risk patients (BMI >30 kg/m², history of VTE, active cancer) or those requiring ICU admission 2
  • For confirmed VTE, therapeutic dosing of LMWH is standard of care 2
• Tocilizumab for patients with rapidly increasing inflammatory markers 1

Supportive Care

• Oxygen therapy titrated to maintain SpO2 >94% (or individualized target)
• Prone positioning for patients with respiratory distress
• Venous thromboembolism prophylaxis for all hospitalized patients 2
• Multidisciplinary approach especially for ICU patients with mechanical ventilation or septic shock 2

Special Considerations

Antibiotic Use

• Antibiotics should not be routinely prescribed for COVID-19 prevention
• Use antibiotics only when bacterial co-infection is suspected
• De-escalate antibiotic therapy as early as possible based on culture results 2

Rehabilitation

• Implement rehabilitation care as soon as possible when oxygenation and hemodynamics are stable 2
• Consider pulmonary rehabilitation training for patients with impaired pulmonary function 2

Mental Health Support

• Provide psychological counseling and mental health education
• Consider non-drug treatments such as breathing relaxation training, mindfulness training, and cognitive behavioral therapy 2

Discharge Criteria

Patients can be discharged when:

• Temperature normal for >3 days
• Respiratory symptoms significantly improved
• Significant absorption of pulmonary lesions on imaging
• Two consecutive negative nucleic acid tests (≥24 hours apart) 1

Follow-up Care

• Schedule virtual follow-up 1-2 weeks after diagnosis
• Consider prolonged VTE prophylaxis after discharge for patients with persistent immobility or high inflammatory activity 2
• Monitor for potential long-term complications

Common Pitfalls to Avoid

1. Delaying treatment initiation (especially antivirals) beyond the 5-day window after symptom onset
2. Overlooking drug interactions with nirmatrelvir-ritonavir
3. Inappropriate antibiotic use without evidence of bacterial infection
4. Neglecting VTE prophylaxis in hospitalized patients
5. Failing to adjust medication doses according to renal function

The treatment approach should be initiated promptly after diagnosis and adjusted based on clinical response, with careful monitoring for complications and adverse effects of medications.