What is the recommended treatment for an 83-year-old female with a history of well-controlled asthma/Chronic Obstructive Pulmonary Disease (COPD) and a positive COVID-19 test, presenting with cough, sore throat, and fever, with normal lung sounds and oxygen saturation?

Treatment Recommendations for 83-Year-Old Female with COVID-19 and Asthma/COPD History

For this 83-year-old female with well-controlled asthma/COPD crossover and mild COVID-19 symptoms, supportive care with symptomatic treatment is the primary recommendation, with consideration for nirmatrelvir/ritonavir (Paxlovid) due to her high-risk age group. 1, 2, 3

Initial Assessment

• Current presentation:
  • Mild COVID-19 symptoms (cough, sore throat)
  • Normal vital signs (afebrile, no tachycardia)
  • Normal oxygen saturation
  • Normal lung sounds
  • Symptoms started 3 days ago

Treatment Algorithm

1. Supportive Care (Strong Recommendation)

• Rest in bed with monitoring of vital signs 1
• Ensure adequate fluid intake (up to 2 liters per day) 2
• Nutritional support with protein-rich foods 1
• Monitor for signs of clinical deterioration, especially given age and comorbidities 2

2. Symptomatic Treatment

• For cough: Use honey as first-line treatment 2
  • If cough is distressing and honey ineffective, consider short-term codeine linctus or codeine phosphate tablets 2
  • Avoid lying on back as this makes coughing ineffective 2
• For sore throat: Warm saline gargles and over-the-counter lozenges

3. Antiviral Consideration

• Nirmatrelvir/ritonavir (Paxlovid) should be considered due to patient's age >65 years and history of respiratory disease, which place her at high risk for progression 3, 4
  • Standard dose: 300 mg nirmatrelvir (two 150 mg tablets) with 100 mg ritonavir (one 100 mg tablet) twice daily for 5 days 3
  • Must be initiated within 5 days of symptom onset (patient is currently at day 3) 3
  • Before prescribing, review all medications for potential drug-drug interactions 3
  • Recent evidence shows 39% reduction in hospitalization risk and 61% reduction in death risk, with greatest absolute benefit in patients ≥65 years 4

4. Antibiotic Consideration

• Empiric antibiotics are NOT routinely recommended for patients with confirmed COVID-19 1, 2
• Consider antibiotics only if:
  • Clinical suspicion of bacterial co-infection
  • Elevated procalcitonin
  • Clinical deterioration after initial improvement 1, 2

5. Monitoring and Follow-up

• Monitor for signs of respiratory deterioration 1
• Follow up within 24-48 hours to assess symptoms
• Instruct patient to seek immediate medical attention if developing:
  • Increased shortness of breath
  • Respiratory rate >30 breaths/min
  • Oxygen saturation <90%
  • Altered mental status

Special Considerations for Asthma/COPD History

• Continue baseline asthma/COPD medications 1
• Avoid nebulized medications as they may increase aerosol generation 2
• For increased respiratory symptoms related to underlying condition, consider:
  • Selective anticholinergic drugs to reduce airway secretions and relieve airway spasm 1
  • Controlled breathing techniques such as pursed-lip breathing 2

Pitfalls and Caveats

1. Age-related risk: Despite mild symptoms, this 83-year-old patient is at high risk for progression due to advanced age and respiratory comorbidities 1, 4

2. Drug interactions: If prescribing nirmatrelvir/ritonavir, carefully review all medications as ritonavir is a strong CYP3A inhibitor that may cause significant drug interactions 3

3. Delayed deterioration: COVID-19 can worsen around days 5-10 of illness; close monitoring is essential despite current mild presentation 1

4. Overuse of antibiotics: Avoid unnecessary antibiotics as bacterial co-infection is uncommon in COVID-19 patients 1

5. Steroid consideration: Routine corticosteroids are not recommended for mild COVID-19 without hypoxemia 1