What are the current treatment recommendations for COVID-19?

Current Treatment Recommendations for COVID-19

The current treatment of COVID-19 should be based on disease severity, with nirmatrelvir/ritonavir as the preferred antiviral for high-risk outpatients with mild-to-moderate disease, remdesivir for hospitalized patients, and dexamethasone as the cornerstone therapy for those requiring oxygen. 1

Disease Classification and Treatment Approach

COVID-19 treatment is stratified based on disease severity:

Outpatient (Mild Disease)

• For high-risk patients diagnosed within 7 days of symptom onset:

  • Nirmatrelvir/ritonavir is the preferred antiviral treatment for 3 days 1
  • Remdesivir can be considered as an alternative (3-day course) 2
  • Treatment should be initiated as soon as possible after diagnosis 1, 2

• Supportive care for all patients:

  • Adequate hydration, nutrition, and rest
  • Acetaminophen or ibuprofen for symptom management
  • Consider honey for cough in patients over 1 year of age 1

Hospitalized Patients (Moderate-Severe Disease)

• Not requiring mechanical ventilation/ECMO:

  • Remdesivir: 200 mg IV loading dose on day 1, followed by 100 mg IV daily for 5 days 2
  • If no clinical improvement, treatment may be extended up to 10 days 2
  • Prophylactic-dose low-molecular-weight heparin for thromboprophylaxis 3

• Requiring oxygen:

  • Dexamethasone 6 mg daily for up to 10 days 1
  • Consider tocilizumab for patients with elevated inflammatory markers who are rapidly deteriorating despite corticosteroids 1

• Requiring mechanical ventilation/ECMO:

  • Remdesivir for 10 days total 2
  • Dexamethasone 6 mg daily for 10 days 1
  • Consider tocilizumab if rapid deterioration despite corticosteroids 1

Special Considerations

Anticoagulation

• For hospitalized COVID-19 patients not in ICU receiving antiplatelet therapy for previous stroke, continue antiplatelet therapy and add prophylactic-dose LMWH 3
• For hospitalized patients with COVID-19 and new-onset atrial fibrillation, start therapeutic-dose parenteral anticoagulation regardless of CHA₂DS₂-VASc score 3

Pediatric Patients

• For pediatric patients weighing 1.5 kg to less than 40 kg, use weight-based dosing of remdesivir 2:
  • <28 days old: 2.5 mg/kg loading dose, then 1.25 mg/kg daily
  • ≥28 days old: 5 mg/kg loading dose, then 2.5 mg/kg daily

Monitoring and Testing

• Perform hepatic laboratory testing in all patients before starting and during remdesivir treatment 2
• Determine prothrombin time before starting and during remdesivir treatment 2
• Monitor for clinical deterioration signs including temperature ≥38°C, shortness of breath, tachypnea (>20 breaths/min), and hypoxia 1

Infection Prevention and Control

• Implement strict isolation protocols
• Healthcare workers should use appropriate PPE including N95/FFP2 respirators during aerosol-generating procedures 1
• Clean hands frequently with soap and water for at least 20 seconds, or use alcohol-based hand sanitizer 1
• Regularly disinfect equipment and surfaces 1

Treatments to Avoid

• Avoid empiric antibiotics unless bacterial coinfection is suspected 1
• Avoid using three or more antiviral drugs simultaneously 3
• Avoid hydroxychloroquine and azithromycin combination due to insufficient evidence 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 RT-PCR tests from respiratory tract samples 3

By following these evidence-based recommendations and tailoring treatment to disease severity, clinicians can optimize outcomes for patients with COVID-19.