What is the treatment for Covid-19 (Coronavirus disease 2019)?

Treatment for COVID-19

For COVID-19 treatment, corticosteroids (dexamethasone) are strongly recommended for patients requiring oxygen, while nirmatrelvir-ritonavir or remdesivir should be initiated early for high-risk patients with mild to moderate disease. 1

Disease Severity Classification and Initial Assessment

COVID-19 severity is classified as:

• 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 1

Treatment Algorithm by Disease Severity

Mild to Moderate COVID-19 (Non-hospitalized)

1. Antiviral therapy for high-risk patients:

   • First-line: Nirmatrelvir-ritonavir (300 mg/100 mg twice daily for 5 days) 1
     • For eGFR 30-59 mL/min: 150 mg/100 mg twice daily for 5 days
   • Alternative: Remdesivir (200 mg IV on Day 1, then 100 mg IV daily for 2 days) 2
   • If above contraindicated: Molnupiravir (800 mg twice daily for 5 days) 1

2. Supportive care:

   • Antipyretics for fever
   • Adequate hydration
   • Rest

Moderate to Severe COVID-19 (Hospitalized)

1. Respiratory support:

   • Oxygen therapy to maintain SpO2 ≥94%
   • Consider high-flow nasal cannula (HFNC) or non-invasive CPAP for hypoxemic respiratory failure 3
   • Awake prone positioning may improve oxygenation 1

2. Pharmacological therapy:

   • Corticosteroids: Dexamethasone 6 mg daily for up to 10 days for patients requiring oxygen 3
   • IL-6 receptor antagonists (e.g., tocilizumab) for patients with high inflammatory markers requiring oxygen or ventilatory support 3
   • Anticoagulation: Prophylactic dose for all hospitalized patients 3, 1
   • Remdesivir: 200 mg IV on Day 1, then 100 mg IV daily for 4-9 days 2

Critical COVID-19 (ICU)

1. Respiratory management:

   • Invasive mechanical ventilation for worsening hypoxemia despite non-invasive support 3
   • Consider ECMO for refractory hypoxemia 3

2. Pharmacological therapy:

   • Corticosteroids: Dexamethasone 6 mg daily for up to 10 days 3
   • IL-6 receptor antagonists 3
   • Anticoagulation: Consider intensified prophylaxis 1
   • Remdesivir: Not recommended for patients on invasive mechanical ventilation 3

Medications NOT Recommended

• Hydroxychloroquine: Strong recommendation against use 3
• Lopinavir-ritonavir: Strong recommendation against use 3
• Azithromycin: Not recommended unless bacterial infection is suspected 3
• Interferon-β: Not recommended 3

Laboratory Monitoring

• Complete blood count
• C-reactive protein (CRP)
• Prothrombin time before starting remdesivir 2
• Liver function tests before and during remdesivir treatment 2
• Arterial blood gas analysis for severe cases 3

Antibiotics and Secondary Infections

• Antibiotics are not routinely recommended unless bacterial infection is suspected 1
• For suspected bacterial co-infection:
  • Mild-moderate: Consider amoxicillin or azithromycin 3
  • Severe: Consider broader coverage including anti-pseudomonal and anti-MRSA agents 1

Special Considerations

1. Renal impairment:

   • Remdesivir can be used regardless of renal function, including patients on dialysis 2
   • Adjust nirmatrelvir-ritonavir dosing for moderate renal impairment 1

2. Liver disease:

   • Monitor liver function when using remdesivir 2
   • Use COVID-19 treatments with caution in patients with liver disease 1

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

Common Pitfalls to Avoid

1. Delaying antiviral treatment in high-risk patients
2. Using corticosteroids in mild cases not requiring oxygen
3. Inappropriate use of antibiotics without evidence of bacterial infection
4. Failing to provide thromboprophylaxis for hospitalized patients
5. Not monitoring for drug interactions with nirmatrelvir-ritonavir

The evidence strongly supports early intervention with antivirals for high-risk patients and corticosteroids for those requiring oxygen, which has been shown to reduce mortality and disease progression 3, 1, 4.