What is the recommended treatment for Covid?

Recommended Treatment for COVID-19

The recommended treatment for COVID-19 depends on disease severity, with supportive care being the cornerstone for mild cases, dexamethasone for patients requiring oxygen, and nirmatrelvir/ritonavir as the preferred antiviral for high-risk outpatients with mild-to-moderate disease. 1

Treatment Algorithm Based on Disease Severity

Mild COVID-19 (Outpatient)

• First-line approach: Supportive care with adequate hydration, nutrition, rest, and over-the-counter medications for symptom management 1

  • Acetaminophen or ibuprofen for fever and pain
  • Consider honey for cough in patients over 1 year of age
  • Albuterol MDI for patients with pre-existing asthma who develop respiratory symptoms

• For high-risk outpatients: Nirmatrelvir/ritonavir (Paxlovid) initiated within 7 days of symptom onset for a 3-day course 1

  • High-risk factors include older age, immunocompromised status, and comorbidities such as cardiovascular disease, diabetes, and obesity

• Alternative antiviral: Remdesivir can be considered for non-hospitalized patients diagnosed with mild-to-moderate COVID-19 who are at high risk for progression to severe disease 2

  • Should be initiated as soon as possible after diagnosis and within 7 days of symptom onset
  • Recommended total treatment duration is 3 days

Moderate to Severe COVID-19 (Hospitalized)

• Oxygen therapy: Provide supplemental oxygen as needed to maintain SpO2 ≥ 90-96% 1

  • Consider high-flow nasal cannula (HFNC) or noninvasive continuous positive airway pressure (CPAP) for patients with hypoxemic respiratory failure without immediate indication for invasive mechanical ventilation 3
  • Consider awake prone positioning for patients on high-flow oxygen or non-invasive ventilation

• Corticosteroids:

  • Dexamethasone 6 mg daily for up to 10 days for patients requiring oxygen, noninvasive ventilation, or invasive mechanical ventilation 3, 1
  • Do NOT offer corticosteroids to patients not requiring supplementary oxygen 3

• Anticoagulation:

  • Offer some form of anticoagulation to all hospitalized patients 3
  • For patients with COVID-19 not in the ICU who are receiving antiplatelet therapy for a previous stroke, continue the antiplatelet and add prophylactic-dose low-molecular-weight heparin (LMWH) 3

• Immunomodulators:

  • Consider tocilizumab for patients with elevated inflammatory markers who are rapidly deteriorating despite corticosteroids 1

• Remdesivir:

  • Consider for hospitalized patients not requiring invasive mechanical ventilation 3, 2
  • Not recommended for patients requiring invasive mechanical ventilation 3
  • Treatment duration: 5 days for hospitalized patients not requiring invasive mechanical ventilation; may extend up to 10 days if no clinical improvement 2
  • Treatment duration: 10 days for hospitalized patients requiring invasive mechanical ventilation and/or ECMO 2

Treatments NOT Recommended

• Hydroxychloroquine (strong recommendation against) 3, 4
• Hydroxychloroquine and azithromycin in combination 3
• Lopinavir-ritonavir 3
• Azithromycin alone (in absence of bacterial infection) 3
• Colchicine for hospitalized patients 3
• Interferon-β 3

Special Populations

Patients with Hematological Malignancies

• Deferral of chemotherapy is not advisable for patients with active cancer and asymptomatic SARS-CoV-2 infection 3
• JAK2-inhibitors and TKI/BTKi should not be discontinued, even in patients with COVID-19 3
• Defer cellular therapy such as HSCT or CAR-T in case of SARS-CoV-2 infection 3

Patients with Cardiovascular Conditions

• For patients with COVID-19 and confirmed acute coronary syndrome (ACS), dual antiplatelet therapy (DAPT) is recommended 3
• For patients with COVID-19 on DAPT for recent ACS who are receiving prophylactic-dose anticoagulant therapy, continue DAPT 3
• For patients with new-onset atrial fibrillation, start therapeutic-dose parenteral anticoagulation irrespective of CHA2DS2-VASc score 3

Infection Prevention Measures

• Implement strict infection control measures: hand hygiene, physical distancing, face masks, and ventilation of rooms 3, 5
• Place COVID-19 patients in single rooms, avoiding positive pressure rooms 3
• Healthcare workers should use appropriate PPE including N95/FFP2 respirators during aerosol-generating procedures 1

Common Pitfalls and Caveats

1. Delayed treatment initiation: Antiviral treatments should be initiated as early as possible in the disease course, ideally within 7 days of symptom onset 1, 2

2. Inappropriate antibiotic use: Avoid empiric antibiotics unless bacterial coinfection is suspected, as this contributes to antimicrobial resistance 1

3. Overlooking thromboprophylaxis: COVID-19 increases thrombotic risk, so appropriate anticoagulation is essential for hospitalized patients 3

4. Premature discontinuation of home medications: Medications such as JAK2-inhibitors and TKI/BTKi should be continued in patients with COVID-19 3

5. Overuse of corticosteroids: While beneficial in patients requiring oxygen, corticosteroids may be harmful in patients with mild disease not requiring oxygen 3

By following this evidence-based approach to COVID-19 treatment, clinicians can optimize patient outcomes while minimizing potential harms from inappropriate therapies.