What medications are given to COVID-19 positive patients?

Medications for COVID-19 Positive Patients

For COVID-19 positive patients, systemic glucocorticoids (particularly dexamethasone) and tocilizumab are the primary recommended medications for those requiring oxygen support, while remdesivir is recommended for hospitalized patients, and monoclonal antibodies against SARS-CoV-2 spike protein should be considered for high-risk outpatients with recent symptom onset. 1, 2

Treatment Based on Disease Severity

Outpatients (Mild Disease)

• For high-risk patients with symptom onset <5 days or seronegative status:

  • Monoclonal antibodies against SARS-CoV-2 spike protein 1
  • Nirmatrelvir-ritonavir (300 mg nirmatrelvir with 100 mg ritonavir twice daily for 5 days) 3
  • Remdesivir (200 mg IV on Day 1, followed by 100 mg IV daily for 2 days) 2
  • For patients with eGFR 30-59 mL/min: adjust nirmatrelvir to 150 mg with 100 mg ritonavir twice daily 3

• For symptomatic relief:

  • Paracetamol for fever
  • Adequate hydration
  • Honey for cough 3

Hospitalized Patients Not Requiring Oxygen

• Currently no evidence supports initiating immunomodulatory therapy 1
• Continue monitoring for disease progression

Hospitalized Patients Requiring Oxygen Support

• Systemic glucocorticoids (dexamethasone 6 mg daily for up to 10 days) 1
• Combination of glucocorticoids and tocilizumab (IL-6 receptor inhibitor) to reduce disease progression and mortality 1
• Remdesivir (200 mg IV on Day 1, followed by 100 mg IV daily) 1, 2
• For patients requiring high-flow oxygen or non-invasive ventilation:
  • Consider adding baricitinib or tofacitinib to glucocorticoids 1

Medications to Avoid

• Hydroxychloroquine should be avoided at any stage of SARS-CoV-2 infection as it provides no benefit and may worsen prognosis, particularly when co-prescribed with azithromycin 1
• Lopinavir/ritonavir has shown no clinical benefit in randomized trials 1
• Convalescent plasma is not recommended for patients without hypogammaglobulinemia and with symptom onset >5 days 1

Special Considerations

Monitoring

• Check baseline liver function tests in all patients on admission and monitor throughout hospitalization 1
• Monitor for potential drug-drug interactions, particularly with nirmatrelvir-ritonavir due to ritonavir's strong CYP3A4 inhibition 3

Restarting Medications for Patients with Rheumatic Diseases

• For patients with uncomplicated COVID-19 infections, consider restarting disease-modifying antirheumatic drugs (DMARDs), immunosuppressants, biologics, and JAK inhibitors within 7-14 days of symptom resolution 1
• For asymptomatic patients with positive PCR, consider restarting rheumatic disease treatments 10-17 days after the positive result 1

Medication Safety

• Remdesivir may cause elevated transaminases (23% of patients) and diarrhea (9% of patients) 2
• Tocilizumab is generally well-tolerated but should be used cautiously in patients with history of serious infections 1
• Drug interactions are a major concern with nirmatrelvir-ritonavir and may persist for several days after completing treatment 3

Discharge Criteria

• Temperature returned to normal for more than 3 days
• Significant improvement in respiratory symptoms
• Significant absorption of pulmonary lesions on CT imaging
• Two consecutive negative nucleic acid tests from respiratory samples (at least 24 hours apart) 3

The evidence strongly supports the use of dexamethasone and tocilizumab for hospitalized patients requiring oxygen, while remdesivir and monoclonal antibodies have shown benefit in specific patient populations. Hydroxychloroquine should be avoided due to lack of efficacy and potential harm.